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

Justin R. Mascitelli, Michael T. Lawton, Benjamin K. Hendricks, Peter Nakaji, Joseph M. Zabramski, Robert F. Spetzler

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

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 5850292551001

Original languageEnglish (US)
Pages (from-to)622-631
Number of pages10
JournalClinical Neurosurgery
Volume85
Issue number5
DOIs
StatePublished - Nov 1 2019

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Ruptured Aneurysm
Aneurysm
Neck
Surgical Instruments
Retreatment
Middle Cerebral Artery
Internal Carotid Artery
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Keywords

  • Aneurysm
  • Barrow Ruptured Aneurysm Trial, Wide neck

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Mascitelli, J. R., Lawton, M. T., Hendricks, B. K., Nakaji, P., Zabramski, J. M., & Spetzler, R. F. (2019). Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. Clinical Neurosurgery, 85(5), 622-631. https://doi.org/10.1093/neuros/nyy439

Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. / Mascitelli, Justin R.; Lawton, Michael T.; Hendricks, Benjamin K.; Nakaji, Peter; Zabramski, Joseph M.; Spetzler, Robert F.

In: Clinical Neurosurgery, Vol. 85, No. 5, 01.11.2019, p. 622-631.

Research output: Contribution to journalArticle

Mascitelli, JR, Lawton, MT, Hendricks, BK, Nakaji, P, Zabramski, JM & Spetzler, RF 2019, 'Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial', Clinical Neurosurgery, vol. 85, no. 5, pp. 622-631. https://doi.org/10.1093/neuros/nyy439
Mascitelli JR, Lawton MT, Hendricks BK, Nakaji P, Zabramski JM, Spetzler RF. Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. Clinical Neurosurgery. 2019 Nov 1;85(5):622-631. https://doi.org/10.1093/neuros/nyy439
Mascitelli, Justin R. ; Lawton, Michael T. ; Hendricks, Benjamin K. ; Nakaji, Peter ; Zabramski, Joseph M. ; Spetzler, Robert F. / Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. In: Clinical Neurosurgery. 2019 ; Vol. 85, No. 5. pp. 622-631.
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N2 - 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 5850292551001

AB - 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 5850292551001

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