Lessons to be learnt from the International Subarachnoid Haemorrhage Trial (ISAT)

Kirkpatrick, P. J.; Kirollos, R. W.; Higgins, Nick; Matta, Basil F.

doi:10.1080/0268869031000093636

Cited by 5 publications

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“…This point generates criticism due to selection bias [ 7 ]. Another point that should be considered in the ISAT that endovascular coiling was done by highly experienced radiologists, and therefore, results cannot be generalized to other operators [ 8 ]. Other limitations of the ISAT were the lack of patients with poor clinical condition (94% of the patients had World Federation of Neurosurgical Societies grades 1–3) and the limited number of patients with posterior circulation aneurysms (more than 90% patients had small anterior circulation aneurysms).…”

Section: Discussionmentioning

confidence: 99%

Endovascular coiling for cerebral aneurysm: single-center experience in Egypt

Elewa

2018

Egypt J Neurol Psychiatry Neurosurg

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BackgroundEndovascular management for cerebral saccular aneurysm has evolved in the last decade with evolution in both equipment and material. Coiling is still the mainstay of cerebral aneurysm endovascular management. In Egypt, practice outcome needs evaluation especially at low-volume centers.PurposeTo discuss the technical and management outcomes of our first symptomatic and asymptomatic cerebral saccular aneurysm case series treated with simple coiling.Patients and methodsClinical, treatment, and outcome variables of consecutive symptomatic and asymptomatic cerebral aneurysm cases treated with simple coiling between January 2011 and June 2016 in one center were analyzed.ResultsIn 31 patients, 35 aneurysms were found, 34 aneurysms (97.1%) were treated by endovascular coiling, and only one aneurysm (2.9%) was not fit for endovascular treatment. Total occlusion was achieved in 29 aneurysms (82.9%). Neck remnants were present in 4 aneurysms (11.4%). Partial coiling (incomplete occlusion) was achieved in 1 aneurysm (2.9%). Regarding functional outcome (mRS at discharge), 25 patients had good outcome (mRS = 0, 1, 2, 3) and 6 patients had poor outcome (mRS = 4, 5, 6).ConclusionThe endovascular coiling could be used as a first-choice option for treatment of saccular cerebral aneurysms at our center despite the low case rate.

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Section: Discussionmentioning

confidence: 99%

Endovascular coiling for cerebral aneurysm: single-center experience in Egypt

Elewa

2018

Egypt J Neurol Psychiatry Neurosurg

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“…However, the ISAT was criticized due to selection bias. [ 24 25 26 27 28 29 ] Only aneurysms considered treatable by both techniques were randomized, resulting in only 22% of patients presenting with a ruptured aneurysm being included in the study. There were doubts raised about the experience of the neurosurgeons involved in the trial.…”

Section: Discussionmentioning

confidence: 99%

A decade after International Subarachnoid Aneurysm Trial: Coiling as a first choice treatment in the management of intracranial aneurysms - Technical feasibility and early management outcomes

Goel¹,

Gupta²,

Chinchure³

et al. 2014

Asian J Neurosurg

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Purpose:The technique of coiling has evolved in the last decade with evolution in both equipment and material. The preferable treatment of intracranial aneurysms at our center is endovascular coiling. We discuss the technical and management outcomes of consecutive patients treated with this approach and compare our results with a decade old International Subarachnoid Aneurysm Trial.Materials and Methods:Between January 2006 and November 2011, a total of 324 aneurysms in 304 consecutive patients were treated. Endovascular treatment was done in 308 aneurysms (95.0%) in 288 patients while 16 patients (5%) underwent surgical clipping. Of the 308 aneurysms treated endovascularly, 269 (87.3%) were ruptured, and 39 (12.7%) were unruptured aneurysms.Results:The endovascular coiling was feasible in all (99.6%) but 1 case. The immediate postoperative occlusion status was complete occlusion in 240 aneurysms (77.9%), neck remnant in 57 aneurysms (18.5%), and aneurysm remnant in 11 aneurysms (3.6%). Technical issues – with or without clinical effect–were encountered in 20 patients (6.9%). They included 18 thromboembolic events (6.2%) and intraprocedural aneurysmal rupture in 2 cases (0.7%). In “good grade” patients, H and H grade 1-3, a good outcome (modified Rankin score [mRS] 0-2) was in 87.6% patients while the bad outcome (mRS 3-5) was in 10.2% patients and mortality of 2.2%. In “bad grade” patients, H and H grade 3-5, a good outcome was in 29.2%, and bad outcome was in 41.7% patients with mortality was 29.1%. In the unruptured aneurysm group, the good outcome was seen in 97.7% and bad outcome in 2.3% with no mortality.Conclusions:In the current era, the favorable results of coiling demonstrated in previous studies may be applicable to the larger proportion of patients. In our series of consecutively treated patients using latest advances, such as three-dimensional imaging and the interventional material, endovascular management as first choice was feasible in 95% of patients with good technical and management outcomes.

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“…Publication of the results of this trial has sparked heated debate over the best current treatment for ruptured intracranial aneurysms. 5,8,11,13,14,16 As often happens in large multicenter trials, only a minority of the patients screened at the participating centers were actually enrolled in the ISAT. Of the 9559 patients assessed for eligibility at the participating centers during the enrollment period, 7416 were not enrolled.…”

Section: Discussionmentioning

confidence: 99%

Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies

Lanzino

Fraser

Kanaan

et al. 2006

JNS

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Object. The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery.Methods. One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome-indicated by mRS scores of 0 to 2 after at least 6 months-was achieved in 71% of patients.Conclusions. Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination. KEY WORDS • intracranial aneurysm• subarachnoid hemorrhage • surgery • endovascular embolization • outcome J. Neurosurg. / Volume 104 / March, 2006 See the Editorial and the Response in this issue, pp 341-343.ESULTS of the ISAT 15 have sparked heated debate over the best treatment modality for ruptured intracranial aneurysms: endovascular coil occlusion or surgical clip application. The ISAT was halted prematurely after data from an interim analysis showed better functional outcome at 1 year posttreatment in patients who had undergone endovascular embolization compared with those who had undergone surgical clip ligation. In Europe, particularly the United Kingdom, the study has had a profound effect on the management of ruptured intracranial aneurysms. 13 On the other hand, the ISAT has not had such a significant impact on neurosurgical vascular practices in the US. A major criticism of the ISAT is that only a minority of the patients evaluated at the participating centers were indeed enrolled in the trial. For inclusion in the study, the patient in question had to have an aneurysm judged by both a neurosurgeon and a neurointerventionalist to be equally amenable to surgery or endovascular embolization...

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Lessons to be learnt from the International Subarachnoid Haemorrhage Trial (ISAT)

Cited by 5 publications

References 0 publications

Endovascular coiling for cerebral aneurysm: single-center experience in Egypt

Endovascular coiling for cerebral aneurysm: single-center experience in Egypt

A decade after International Subarachnoid Aneurysm Trial: Coiling as a first choice treatment in the management of intracranial aneurysms - Technical feasibility and early management outcomes

Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies

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