Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial

BACKGROUND: Ruptured wide-neck aneurysms (WNAs) are difficult to treat and few publications have compared clipping to coiling. OBJECTIVE: To determine, using Barrow Ruptured Aneurysm Trial (BRAT) data: (1) How many aneurysms had a wide neck? (2) Did wide-neck status influence treatment? (3) How did clipping compare to coiling for WNAs? METHODS: A post hoc analysis was conducted of saccular WNAs in the BRAT. A WNA was defined as maximum neck width ≥ 4 mm or maximum aneurysm dome-diameter-to-neck-width ratio < 2. Both intent-to-treat and as-treated analyses were performed. RESULTS: Of the 327 patients analyzed, 177 (54.1%) had a WNA. WNAs were more likely to occur in older patients (P =. 03) with worse presenting clinical grade (P =. 02), were more likely to arise from the middle cerebral artery, basilar tip, or internal carotid artery other than the junction with the posterior communicating artery (P =. 001) and were associated with worse clinical outcomes at all time points (P ≤. 01). WNAs were equally distributed in assigned treatment groups (clip 56.6% vs coil 51.8%; P =. 38), but were overrepresented in the actual clipping group (clip 62.4% vs coil 37.6%, P <. 001). Most patients (76.7%) in the coil-to-clip crossover group had a WNA. Comparing clipping to coiling, there was no difference in clinical outcomes at any time point in either analysis (P ≥. 33). The aneurysm obliteration rate was lower (P <. 001) and the retreatment rate higher (P <. 001) in the actual coiling group. CONCLUSION: Wide-neck status significantly impacted treatment strategy in the BRAT, favoring clipping. Clipping and coiling of ruptured WNAs resulted in statistically similar long-term clinical outcomes. 10.1093/neuros/nyy439 Video Abstract 10.1093.neuros.nyy439