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Andrew J. Molyneux - One of the best experts on this subject based on the ideXlab platform.

  • the durability of Endovascular Coiling versus neurosurgical clipping of ruptured cerebral aneurysms 18 year follow up of the uk cohort of the international subarachnoid aneurysm trial isat
    The Lancet, 2015
    Co-Authors: Andrew J. Molyneux, Mary Sneade, Jacqueline Birks, Alison Clarke, Richard S. C. Kerr
    Abstract:

    Summary Background Previous analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on the risks of recurrent subarachnoid haemorrhage and death or dependency for a minimum of 5 years and up to a maximum of 14 years after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or Endovascular Coiling. At 1 year there was a 7% absolute and a 24% relative risk reduction of death and dependency in the Coiling group compared with the clipping group, but the medium-term results showed the increased need for re-treatment of the target aneurysm in the patients given Coiling. We report the long-term follow-up of patients in this UK cohort. Methods In ISAT, patients were randomly allocated to either neurosurgical clipping or Endovascular Coiling after a subarachnoid haemorrhage, assuming treatment equipoise, between Sept 12, 1994, and May 1, 2002. We followed up 1644 patients in 22 UK neurosurgical centres for death and clinical outcomes for 10·0–18·5 years. We assessed dependency as self-reported modified Rankin scale score obtained through yearly questionnaires. Data for recurrent aneurysms and rebleeding events were collected from questionnaires and from hospital and general practitioner records. The Office for National Statistics supplied data on deaths. This study is registered, number ISRCTN49866681. Findings At 10 years, 674 (83%) of 809 patients allocated Endovascular Coiling and 657 (79%) of 835 patients allocated neurosurgical clipping were alive (odds ratio [OR] 1·35, 95% CI 1·06–1·73). Of 1003 individuals who returned a questionnaire at 10 years, 435 (82%) patients treated with Endovascular Coiling and 370 (78%) patients treated with neurosurgical clipping were independent (modified Rankin scale score 0–2; OR 1·25; 95% CI 0·92–1·71). Patients in the Endovascular treatment group were more likely to be alive and independent at 10 years than were patients in the neurosurgery group (OR 1·34, 95% CI 1·07–1·67). 33 patients had a recurrent subarachnoid haemorrhage more than 1 year after their initial haemorrhage (17 from the target aneurysm). Interpretation Although rates of increased dependency alone did not differ between groups, the probability of death or dependency was significantly greater in the neurosurgical group than in the Endovascular group. Rebleeding was more likely after Endovascular Coiling than after neurosurgical clipping, but the risk was small and the probability of disability-free survival was significantly greater in the Endovascular group than in the neurosurgical group at 10 years. Funding UK Medical Research Council.

  • effect of antiplatelet therapy for Endovascular Coiling in aneurysmal subarachnoid hemorrhage
    Stroke, 2009
    Co-Authors: Walter M Van Den Bergh, Ale Algra, Gabriel J E Rinkel, Richard S. C. Kerr, Andrew J. Molyneux
    Abstract:

    Background and Purpose— Antiplatelets are frequently used during or after Endovascular Coiling of aneurysm in patients with subarachnoid hemorrhage (SAH). This strategy is based on uncontrolled case series including also patients with unruptured aneurysms or other lesions. We collected data on effectiveness of antiplatelets in patients with SAH. Methods— All 43 participating centers in the International Subarachnoid Aneurysm Trial (ISAT) were sent a questionnaire whether they never, sometimes, or always prescribed antiplatelets during or after Coiling. Based on individual patient data, the relative risks (RRs) of Coiling versus clipping were calculated separately for patients treated in hospitals with standard prescription during or after Coiling versus patients treated in hospitals with no standard prescription of antiplatelets. We calculated ratios of RRs for standard versus not standard prescription of antiplatelets during Coiling and for standard versus not standard prescription after Coiling. Results...

  • international subarachnoid aneurysm trial of neurosurgical clipping versus Endovascular Coiling subgroup analysis of 278 elderly patients
    Stroke, 2008
    Co-Authors: Mats Ryttlefors, Richard S. C. Kerr, Per Enblad, Andrew J. Molyneux
    Abstract:

    Background and Purpose— It is often thought that elderly patients in particular would benefit from Endovascular aneurysm treatment. The aim of this analysis was therefore to compare the efficacy and safety of Endovascular Coiling (EVT) with neurosurgical clipping (NST) in the subgroup of elderly SAH patients in the International Subarachnoid Aneurysm Trial (ISAT). Methods— In the ISAT cohort 278 SAH patients, 65 years or older, were enrolled. The patients were randomly allocated EVT (n=138) or NST (n=140). The primary outcome was the proportion of patients with a modified Rankin scale score of 0 to 2 (independent survival) at 1 year after the SAH. The rates of procedural complications and adverse events were also recorded. Results— 83 of 138 (60.1%) patients allocated EVT were independent compared to 78 of 140 (56.1%) allocated NST (N.S.). 36 of 50 (72.0%) patients with internal carotid and posterior communicating artery aneurysms allocated EVT were independent compared to 26 of 50 (52.0%) allocated NST (...

  • Treatment Pathways, Resource Use, and Costs of Endovascular Coiling Versus Surgical Clipping After aSAH
    Stroke, 2007
    Co-Authors: Jane Wolstenholme, Oliver Rivero-arias, Alastair Gray, Andrew J. Molyneux, Richard S. C. Kerr, Julia A. Yarnold, Mary Sneade
    Abstract:

    Background and Purpose— The International Subarachnoid Aneurysm Trial (ISAT) reported that Endovascular Coiling yields better clinical outcomes than surgical clipping at 1 year. The high cost of the consumables associated with the Endovascular Coiling procedure (particularly the coils) led health care purchasers to conclude that Coiling was a more costly procedure overall. To examine this assumption and provide evidence for future policy, accurate and comprehensive data are required on the overall resource usage and cost of each strategy. Methods— We provide detailed results of patient treatment pathways, resource utilization, and costs up to 24 months postrandomization for Endovascular and neurosurgical treatment of aSAH. We report data on costs related to initial and subsequent procedures (ward days, ITU, equipment, staff, consumables, etc), adverse events, complications, and follow up. The data are based on a subsample of all patients randomized in ISAT, containing all patients across 22 UK centers (n=...

  • international subarachnoid aneurysm trial isat of neurosurgical clipping versus Endovascular Coiling in 2143 patients with ruptured intracranial aneurysms a randomised comparison of effects on survival dependency seizures rebleeding subgroups and ane
    The Lancet, 2005
    Co-Authors: Andrew J. Molyneux, Mike Clarke, Richard S. C. Kerr, Mary Sneade, Lymee Yu, Julia Yarnold, Peter Sandercock
    Abstract:

    Summary Background Two types of treatment are being used for patients with ruptured intracranial aneurysms: Endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment. Methods 2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or Endovascular Coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3–6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment. Findings We report the 1-year outcomes for 1063 of 1073 patients allocated to Endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23·5%) of 1063 patients allocated to Endovascular treatment were dead or dependent at 1 year, compared with 326 (30·9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7·4% (95% CI 3·6–11·2, p=0·0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0·03). The risk of epilepsy was substantially lower in patients allocated to Endovascular treatment, but the risk of late rebleeding was higher. Interpretation In patients with ruptured intracranial aneurysms suitable for both treatments, Endovascular Coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after Endovascular Coiling than after neurosurgical clipping.

Gabriel J E Rinkel - One of the best experts on this subject based on the ideXlab platform.

  • Endovascular Coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage
    2018
    Co-Authors: Lindgren Antti, Mervyn D I Vergouwen, Van Der Schaaf Irene, Algra Ale, Wermer Marieke, Clarke, Mike J., Gabriel J E Rinkel
    Abstract:

    Background: Around 30% of people who are admitted to hospital with aneurysmal subarachnoid haemorrhage (SAH) will rebleed in the initial month after the haemorrhage if the aneurysm is not treated. The two most commonly used methods to occlude the aneurysm for prevention of rebleeding are microsurgical clipping of the neck of the aneurysm and occlusion of the lumen of the aneurysm by means of Endovascular Coiling. This is an update of a systematic review that was previously published in 2005. Objectives: To compare the effects of Endovascular Coiling versus neurosurgical clipping in people with aneurysmal SAH on poor outcome, rebleeding, neurological deficit, and treatment complications. Search methods: We searched the Cochrane Stroke Group Trials Register (March 2018). In addition, we searched CENTRAL (2018, Issue 2), MEDLINE (1966 to March 2018), Embase (1980 to March 2018), US National Institutes of Health Ongoing Trials Register (March 2018), and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (last searched March 2018). We also contacted trialists. Selection criteria: We included randomised trials comparing Endovascular Coiling with neurosurgical clipping in people with SAH from a ruptured aneurysm. Data collection and analysis: Two review authors independently extracted data, and assessed trial quality and risk of bias using the GRADE approach. We contacted trialists to obtain missing information. We defined poor outcome as death or dependence in daily activities (modified Rankin scale 3 to 6 or Glasgow Outcome Scale (GOS) 1 to 3). In the special worst-case scenario analysis, we assumed all participants in the group with better outcome with missing follow-up information had a poor outcome and those in the other group with missing data a good outcome. Main results: We included four randomised trials involving 2458 participants (range per trial: 20 to 2143 participants). Evidence is mostly based on the largest trial. Most participants were in good clinical condition and had an aneurysm on the anterior circulation. None of the included trials was at low risk of bias in all domains. One trial was at unclear risk in one domain, two trials at unclear risk in three domains, and one trial at high risk in one domain. After one year of follow-up, 24% of participants randomised to Endovascular treatment and 32% of participants randomised to the surgical treatment group had poor functional outcome. The risk ratio (RR) of poor outcome (death or dependency) for Endovascular Coiling versus neurosurgical clipping was 0.77 (95% confidence interval (CI) 0.67 to 0.87; 4 trials, 2429 participants, moderate-quality evidence), and the absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome, the RR for Endovascular Coiling versus neurosurgical clipping was 0.80 (95% CI 0.71 to 0.91), and the absolute risk reduction was 6% (95% CI 2% to 10%). The RR of death at 12 months was 0.80 (95% CI 0.63 to 1.02; 4 trials, 2429 participants, moderate-quality evidence). In a subgroup analysis of participants with an anterior circulation aneurysm, the RR of poor outcome was 0.78 (95% CI 0.68 to 0.90; 2 trials, 2157 participants, moderate-quality evidence), and the absolute risk decrease was 7% (95% CI 3% to 10%). In subgroup analysis of those with a posterior circulation aneurysm, the RR was 0.41 (95% CI 0.19 to 0.92; 2 trials, 69 participants, low-quality evidence), and the absolute decrease in risk was 27% (95% CI 6% to 48%). At five years, 28% of participants randomised to Endovascular treatment and 32% of participants randomised to surgical treatment had poor functional outcome. The RR of poor outcome for Endovascular Coiling versus neurosurgical clipping was 0.87 (95% CI 0.75 to 1.01, 1 trial, 1724 participants, low-quality evidence). At 10 years, 35% participants allocated to Endovascular and 43% participants allocated to surgical treatment had poor functional outcome. At 10 years RR of poor outcome for Endovascular Coiling versus neurosurgical clipping was 0.81 (95% CI 0.70 to 0.92; 1 trial, 1316 participants, low-quality evidence). The RR of delayed cerebral ischaemia at two to three months for Endovascular Coiling versus neurosurgical clipping was 0.84 (95% CI 0.74 to 0.96; 4 trials, 2450 participants, moderate-quality evidence). The RR of rebleeding for Endovascular Coiling versus neurosurgical clipping was 1.83 (95% CI 1.04 to 3.23; 4 trials, 2458 participants, high-quality evidence) at one year, and 2.69 (95% CI 1.50 to 4.81; 1 trial, 1323 participants, low-quality evidence) at 10 years. The RR of complications from intervention for Endovascular Coiling versus neurosurgical clipping was 1.05 (95% CI 0.44 to 2.53; 2 trials, 129 participants, low-quality evidence). Authors' conclusions: The evidence in this systematic review comes mainly from one large trial, and long-term follow-up is available only for a subgroup of participants within that trial. For people in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation the data from randomised trials show that, if the aneurysm is considered suitable for both neurosurgical clipping and Endovascular Coiling, Coiling is associated with a better outcome. There is no reliable trial evidence that can be used directly to guide treatment in people with a poor clinical condition

  • effect of antiplatelet therapy for Endovascular Coiling in aneurysmal subarachnoid hemorrhage
    Stroke, 2009
    Co-Authors: Walter M Van Den Bergh, Ale Algra, Gabriel J E Rinkel, Richard S. C. Kerr, Andrew J. Molyneux
    Abstract:

    Background and Purpose— Antiplatelets are frequently used during or after Endovascular Coiling of aneurysm in patients with subarachnoid hemorrhage (SAH). This strategy is based on uncontrolled case series including also patients with unruptured aneurysms or other lesions. We collected data on effectiveness of antiplatelets in patients with SAH. Methods— All 43 participating centers in the International Subarachnoid Aneurysm Trial (ISAT) were sent a questionnaire whether they never, sometimes, or always prescribed antiplatelets during or after Coiling. Based on individual patient data, the relative risks (RRs) of Coiling versus clipping were calculated separately for patients treated in hospitals with standard prescription during or after Coiling versus patients treated in hospitals with no standard prescription of antiplatelets. We calculated ratios of RRs for standard versus not standard prescription of antiplatelets during Coiling and for standard versus not standard prescription after Coiling. Results...

  • Direct Costs of Surgical Clipping and Endovascular Coiling of Unruptured Intracranial Aneurysms
    Cerebrovascular diseases (Basel Switzerland), 2006
    Co-Authors: Patricia H.a. Halkes, Marieke J H Wermer, Gabriel J E Rinkel, Erik Buskens
    Abstract:

    Background: Unruptured intracranial aneurysms can be preventively treated by surgical clipping or Endovascular Coiling. We determined in detail the costs of these treatments.

  • Endovascular Coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid hemorrhage
    Stroke, 2006
    Co-Authors: Irene C Van Der Schaaf, Andy Molyneux, Ale Algra, Marieke J H Wermer, Mike Clarke, J Van Gijn, Gabriel J E Rinkel
    Abstract:

    Section Editor: Graeme J. Hankey MD, FRCP Patients who have had an aneurysmal subarachnoid hemorrhage (SAH) are at very high risk of rebleeding if the aneurysm is not treated. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm. In recent years, an alternative, the introduction of detachable coils to occlude the aneurysm, has become more common. The goal was to compare the effects of Endovascular Coiling versus neurosurgical clipping in patients with aneurysmal SAH. ### Search Strategy We searched the Cochrane Stroke Group Trials Register (last searched in February 2005). In addition, we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to …

  • Endovascular Coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage
    Cochrane Database of Systematic Reviews, 2005
    Co-Authors: Antti E Lindgren, Mervyn D I Vergouwen, Irene C Van Der Schaaf, Ale Algra, Marieke J H Wermer, Mike Clarke, Gabriel J E Rinkel
    Abstract:

    Background: Around 30% of people who are admitted to hospital with aneurysmal subarachnoid haemorrhage (SAH) will rebleed in the initial month after the haemorrhage if the aneurysm is not treated. The two most commonly used methods to occlude the aneurysm for prevention of rebleeding are microsurgical clipping of the neck of the aneurysm and occlusion of the lumen of the aneurysm by means of Endovascular Coiling. This is an update of a systematic review that was previously published in 2005. Objectives: To compare the effects of Endovascular Coiling versus neurosurgical clipping in people with aneurysmal SAH on poor outcome, rebleeding, neurological deficit, and treatment complications. Search methods: We searched the Cochrane Stroke Group Trials Register (March 2018). In addition, we searched CENTRAL (2018, Issue 2), MEDLINE (1966 to March 2018), Embase (1980 to March 2018), US National Institutes of Health Ongoing Trials Register (March 2018), and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (last searched March 2018). We also contacted trialists. Selection criteria: We included randomised trials comparing Endovascular Coiling with neurosurgical clipping in people with SAH from a ruptured aneurysm. Data collection and analysis: Two review authors independently extracted data, and assessed trial quality and risk of bias using the GRADE approach. We contacted trialists to obtain missing information. We defined poor outcome as death or dependence in daily activities (modified Rankin scale 3 to 6 or Glasgow Outcome Scale (GOS) 1 to 3). In the special worst-case scenario analysis, we assumed all participants in the group with better outcome with missing follow-up information had a poor outcome and those in the other group with missing data a good outcome. Main results: We included four randomised trials involving 2458 participants (range per trial: 20 to 2143 participants). Evidence is mostly based on the largest trial. Most participants were in good clinical condition and had an aneurysm on the anterior circulation. None of the included trials was at low risk of bias in all domains. One trial was at unclear risk in one domain, two trials at unclear risk in three domains, and one trial at high risk in one domain. After one year of follow-up, 24% of participants randomised to Endovascular treatment and 32% of participants randomised to the surgical treatment group had poor functional outcome. The risk ratio (RR) of poor outcome (death or dependency) for Endovascular Coiling versus neurosurgical clipping was 0.77 (95% confidence interval (CI) 0.67 to 0.87; 4 trials, 2429 participants, moderate-quality evidence), and the absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome, the RR for Endovascular Coiling versus neurosurgical clipping was 0.80 (95% CI 0.71 to 0.91), and the absolute risk reduction was 6% (95% CI 2% to 10%). The RR of death at 12 months was 0.80 (95% CI 0.63 to 1.02; 4 trials, 2429 participants, moderate-quality evidence). In a subgroup analysis of participants with an anterior circulation aneurysm, the RR of poor outcome was 0.78 (95% CI 0.68 to 0.90; 2 trials, 2157 participants, moderate-quality evidence), and the absolute risk decrease was 7% (95% CI 3% to 10%). In subgroup analysis of those with a posterior circulation aneurysm, the RR was 0.41 (95% CI 0.19 to 0.92; 2 trials, 69 participants, low-quality evidence), and the absolute decrease in risk was 27% (95% CI 6% to 48%). At five years, 28% of participants randomised to Endovascular treatment and 32% of participants randomised to surgical treatment had poor functional outcome. The RR of poor outcome for Endovascular Coiling versus neurosurgical clipping was 0.87 (95% CI 0.75 to 1.01, 1 trial, 1724 participants, low-quality evidence). At 10 years, 35% participants allocated to Endovascular and 43% participants allocated to surgical treatment had poor functional outcome. At 10 years RR of poor outcome for Endovascular Coiling versus neurosurgical clipping was 0.81 (95% CI 0.70 to 0.92; 1 trial, 1316 participants, low-quality evidence). The RR of delayed cerebral ischaemia at two to three months for Endovascular Coiling versus neurosurgical clipping was 0.84 (95% CI 0.74 to 0.96; 4 trials, 2450 participants, moderate-quality evidence). The RR of rebleeding for Endovascular Coiling versus neurosurgical clipping was 1.83 (95% CI 1.04 to 3.23; 4 trials, 2458 participants, high-quality evidence) at one year, and 2.69 (95% CI 1.50 to 4.81; 1 trial, 1323 participants, low-quality evidence) at 10 years. The RR of complications from intervention for Endovascular Coiling versus neurosurgical clipping was 1.05 (95% CI 0.44 to 2.53; 2 trials, 129 participants, low-quality evidence). Authors' conclusions: The evidence in this systematic review comes mainly from one large trial, and long-term follow-up is available only for a subgroup of participants within that trial. For people in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation the data from randomised trials show that, if the aneurysm is considered suitable for both neurosurgical clipping and Endovascular Coiling, Coiling is associated with a better outcome. There is no reliable trial evidence that can be used directly to guide treatment in people with a poor clinical condition.

Enju Lee - One of the best experts on this subject based on the ideXlab platform.

  • Endovascular Coiling versus neurosurgical clipping in patients with unruptured intracranial aneurysm a systematic review
    BMC Neurology, 2012
    Co-Authors: Jin Seub Hwang, Min Kyung Hyun, Hyun Joo Lee, Ji Eun Choi, Jonghee Kim, Na Rae Lee, Jinwon Kwon, Enju Lee
    Abstract:

    Background To compare the effects of Endovascular Coiling and neurosurgical clipping in patients with unruptured intracranial aneurysm.

  • Endovascular Coiling versus neurosurgical clipping in patients with unruptured intracranial aneurysm a systematic review
    BMC Neurology, 2012
    Co-Authors: Jin Seub Hwang, Min Kyung Hyun, Hyun Joo Lee, Ji Eun Choi, Jonghee Kim, Na Rae Lee, Jinwon Kwon, Enju Lee
    Abstract:

    To compare the effects of Endovascular Coiling and neurosurgical clipping in patients with unruptured intracranial aneurysm. Sixteen electronic databases were searched for articles published between 1950 and July 2010 to compare clinical outcomes of clipping and Coiling. Researchers reviewed all searched articles and extracted data independently. The quality of studies and evidence were evaluated using MINORS and GRADEprofiler, respectively. The odds ratio (OR) was calculated using the inverse variance meta-analysis method for each study outcome. To assess heterogeneity of ORs across cohorts, Cochran’s Q statistic and I2 were used. Of 4160 studies, 24 were identified (n  =  31865). Clipping resulted in significantly higher disability using the Glasgow Outcome Scale (OR, 2.38; 95% CI, 1.33–4.26) and Modified Rankin Scale (OR, 2.83; 95% CI, 1.42–5.63) when compared with Coiling. ORs for complications were also higher with clipping (ORs for neurological and cardiac complications were 1.94 with a 95% confidence interval [CI] of 1.09–3.47 and 2.51 with a 95% CI of 1.15–5.50). Clipping resulted in significantly greater disability in the short term (≤6 m)(OR on the Glasgow Outcome Scale, 2.72; 95% CI, 1.16–6.34), but not in the long term (>6 m)(OR for Glasgow Outcome Scale, 2.12; 95% CI, 0.93–4.84). Coiling was a better procedure for treatment of unruptured intracranial aneurysm in terms of disability, complications, especially in the short term. Because of the limitations of the reviewed studies, further studies are required to support the present results.

Richard S. C. Kerr - One of the best experts on this subject based on the ideXlab platform.

  • the durability of Endovascular Coiling versus neurosurgical clipping of ruptured cerebral aneurysms 18 year follow up of the uk cohort of the international subarachnoid aneurysm trial isat
    The Lancet, 2015
    Co-Authors: Andrew J. Molyneux, Mary Sneade, Jacqueline Birks, Alison Clarke, Richard S. C. Kerr
    Abstract:

    Summary Background Previous analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on the risks of recurrent subarachnoid haemorrhage and death or dependency for a minimum of 5 years and up to a maximum of 14 years after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or Endovascular Coiling. At 1 year there was a 7% absolute and a 24% relative risk reduction of death and dependency in the Coiling group compared with the clipping group, but the medium-term results showed the increased need for re-treatment of the target aneurysm in the patients given Coiling. We report the long-term follow-up of patients in this UK cohort. Methods In ISAT, patients were randomly allocated to either neurosurgical clipping or Endovascular Coiling after a subarachnoid haemorrhage, assuming treatment equipoise, between Sept 12, 1994, and May 1, 2002. We followed up 1644 patients in 22 UK neurosurgical centres for death and clinical outcomes for 10·0–18·5 years. We assessed dependency as self-reported modified Rankin scale score obtained through yearly questionnaires. Data for recurrent aneurysms and rebleeding events were collected from questionnaires and from hospital and general practitioner records. The Office for National Statistics supplied data on deaths. This study is registered, number ISRCTN49866681. Findings At 10 years, 674 (83%) of 809 patients allocated Endovascular Coiling and 657 (79%) of 835 patients allocated neurosurgical clipping were alive (odds ratio [OR] 1·35, 95% CI 1·06–1·73). Of 1003 individuals who returned a questionnaire at 10 years, 435 (82%) patients treated with Endovascular Coiling and 370 (78%) patients treated with neurosurgical clipping were independent (modified Rankin scale score 0–2; OR 1·25; 95% CI 0·92–1·71). Patients in the Endovascular treatment group were more likely to be alive and independent at 10 years than were patients in the neurosurgery group (OR 1·34, 95% CI 1·07–1·67). 33 patients had a recurrent subarachnoid haemorrhage more than 1 year after their initial haemorrhage (17 from the target aneurysm). Interpretation Although rates of increased dependency alone did not differ between groups, the probability of death or dependency was significantly greater in the neurosurgical group than in the Endovascular group. Rebleeding was more likely after Endovascular Coiling than after neurosurgical clipping, but the risk was small and the probability of disability-free survival was significantly greater in the Endovascular group than in the neurosurgical group at 10 years. Funding UK Medical Research Council.

  • effect of antiplatelet therapy for Endovascular Coiling in aneurysmal subarachnoid hemorrhage
    Stroke, 2009
    Co-Authors: Walter M Van Den Bergh, Ale Algra, Gabriel J E Rinkel, Richard S. C. Kerr, Andrew J. Molyneux
    Abstract:

    Background and Purpose— Antiplatelets are frequently used during or after Endovascular Coiling of aneurysm in patients with subarachnoid hemorrhage (SAH). This strategy is based on uncontrolled case series including also patients with unruptured aneurysms or other lesions. We collected data on effectiveness of antiplatelets in patients with SAH. Methods— All 43 participating centers in the International Subarachnoid Aneurysm Trial (ISAT) were sent a questionnaire whether they never, sometimes, or always prescribed antiplatelets during or after Coiling. Based on individual patient data, the relative risks (RRs) of Coiling versus clipping were calculated separately for patients treated in hospitals with standard prescription during or after Coiling versus patients treated in hospitals with no standard prescription of antiplatelets. We calculated ratios of RRs for standard versus not standard prescription of antiplatelets during Coiling and for standard versus not standard prescription after Coiling. Results...

  • international subarachnoid aneurysm trial of neurosurgical clipping versus Endovascular Coiling subgroup analysis of 278 elderly patients
    Stroke, 2008
    Co-Authors: Mats Ryttlefors, Richard S. C. Kerr, Per Enblad, Andrew J. Molyneux
    Abstract:

    Background and Purpose— It is often thought that elderly patients in particular would benefit from Endovascular aneurysm treatment. The aim of this analysis was therefore to compare the efficacy and safety of Endovascular Coiling (EVT) with neurosurgical clipping (NST) in the subgroup of elderly SAH patients in the International Subarachnoid Aneurysm Trial (ISAT). Methods— In the ISAT cohort 278 SAH patients, 65 years or older, were enrolled. The patients were randomly allocated EVT (n=138) or NST (n=140). The primary outcome was the proportion of patients with a modified Rankin scale score of 0 to 2 (independent survival) at 1 year after the SAH. The rates of procedural complications and adverse events were also recorded. Results— 83 of 138 (60.1%) patients allocated EVT were independent compared to 78 of 140 (56.1%) allocated NST (N.S.). 36 of 50 (72.0%) patients with internal carotid and posterior communicating artery aneurysms allocated EVT were independent compared to 26 of 50 (52.0%) allocated NST (...

  • Treatment Pathways, Resource Use, and Costs of Endovascular Coiling Versus Surgical Clipping After aSAH
    Stroke, 2007
    Co-Authors: Jane Wolstenholme, Oliver Rivero-arias, Alastair Gray, Andrew J. Molyneux, Richard S. C. Kerr, Julia A. Yarnold, Mary Sneade
    Abstract:

    Background and Purpose— The International Subarachnoid Aneurysm Trial (ISAT) reported that Endovascular Coiling yields better clinical outcomes than surgical clipping at 1 year. The high cost of the consumables associated with the Endovascular Coiling procedure (particularly the coils) led health care purchasers to conclude that Coiling was a more costly procedure overall. To examine this assumption and provide evidence for future policy, accurate and comprehensive data are required on the overall resource usage and cost of each strategy. Methods— We provide detailed results of patient treatment pathways, resource utilization, and costs up to 24 months postrandomization for Endovascular and neurosurgical treatment of aSAH. We report data on costs related to initial and subsequent procedures (ward days, ITU, equipment, staff, consumables, etc), adverse events, complications, and follow up. The data are based on a subsample of all patients randomized in ISAT, containing all patients across 22 UK centers (n=...

  • international subarachnoid aneurysm trial isat of neurosurgical clipping versus Endovascular Coiling in 2143 patients with ruptured intracranial aneurysms a randomised comparison of effects on survival dependency seizures rebleeding subgroups and ane
    The Lancet, 2005
    Co-Authors: Andrew J. Molyneux, Mike Clarke, Richard S. C. Kerr, Mary Sneade, Lymee Yu, Julia Yarnold, Peter Sandercock
    Abstract:

    Summary Background Two types of treatment are being used for patients with ruptured intracranial aneurysms: Endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment. Methods 2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or Endovascular Coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3–6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment. Findings We report the 1-year outcomes for 1063 of 1073 patients allocated to Endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23·5%) of 1063 patients allocated to Endovascular treatment were dead or dependent at 1 year, compared with 326 (30·9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7·4% (95% CI 3·6–11·2, p=0·0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0·03). The risk of epilepsy was substantially lower in patients allocated to Endovascular treatment, but the risk of late rebleeding was higher. Interpretation In patients with ruptured intracranial aneurysms suitable for both treatments, Endovascular Coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after Endovascular Coiling than after neurosurgical clipping.

Todd A. Mackenzie - One of the best experts on this subject based on the ideXlab platform.

  • surgical clipping versus Endovascular Coiling for elderly patients presenting with subarachnoid hemorrhage
    Journal of NeuroInterventional Surgery, 2016
    Co-Authors: Kimon Bekelis, Daniel J. Gottlieb, Nicos Labropoulos, Alistair J Omalley, Phillip Goodney, Todd A. Mackenzie
    Abstract:

    Background The comparative effectiveness of the two treatment options (surgical clipping and Endovascular Coiling) for ruptured cerebral aneurysms has not been studied in real-world practice in the USA. We investigated the association between the treatment method for ruptured cerebral aneurysms and outcomes. Methods We performed a retrospective cohort study of elderly patients who underwent treatment for ruptured cerebral aneurysms from 2007 to 2012 using a 100% sample of Medicare fee-for-service claims data. An instrumental variable analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. In sensitivity analysis, controlling only for measured confounding, we used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. Results During the study period 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had Endovascular Coiling. Instrumental variable analysis demonstrated no difference between Coiling and clipping in 1-year postoperative mortality (OR 1.04; 95% CI 0.70 to 1.54), likelihood of discharge to rehabilitation (OR 1.07; 95% CI 0.72 to 1.58), or 30-day readmission rate (OR 1.44; 95% CI 0.70 to 1.87). However, clipping was associated with 2.7 days longer length of stay (LOS) (95% CI 0.45 to 4.99). The same associations were present in propensity score adjusted and inverse probability weighted models. Conclusions In a cohort of Medicare patients, we did not demonstrate a difference in mortality, rate of discharge to rehabilitation, and readmissions between clipping and Coiling of ruptured cerebral aneurysms. Clipping was associated with a slightly longer LOS.

  • The impact of hybrid neurosurgeons on the outcomes of Endovascular Coiling for unruptured cerebral aneurysms
    Journal of neurosurgery, 2016
    Co-Authors: Kimon Bekelis, Daniel J. Gottlieb, Nicos Labropoulos, Stavropoula Tjoumakaris, Pascal Jabbour, Todd A. Mackenzie
    Abstract:

    OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm Coiling remains an issue of debate. The authors investigated the association of combined open and Endovascular expertise with the outcomes of unruptured cerebral aneurysm Coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent Endovascular Coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent Endovascular Coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only Endovascular Coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58-1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66-1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83-1.38), and length of stay (adjusted difference, 0.41; 95% CI -0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only Endovascular Coiling.