The Barrow Ruptured Aneurysm Trial

Abstract

Object The purpose of this ongoing study is to compare the safety and efficacy of microsurgical clipping and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to determine if one treatment is superior to the other by examining clinical and angiographic outcomes. The authors examined the null hypothesis that no difference exists between the 2 treatment modalities in the setting of subarachnoid hemorrhage (SAH). The current report is limited to the clinical results at 1 year after treatment. Methods The authors screened 725 patients with SAH, resulting in 500 eligible patients who were enrolled prospectively in the study after giving their informed consent. Patients were assigned in an alternating fashion to surgical aneurysm clipping or endovascular coil therapy. Intake evaluations and outcome measurements were collected by nurse practitioners independent of the treating surgeons. Ultimately, 238 patients were assigned to aneurysm clipping and 233 to coil embolization. The 2 treatment groups were well matched. There were no anatomical exclusions. Crossing over was allowed, but primary outcome analysis was based on the initial treatment modality assignment. Posttreatment care was standardized for both groups. Patient outcomes at 1 year were independently assessed using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score > 2 at 1 year. The primary outcome was based on the assigned group; that is, by intent to treat. Results One year after treatment, 403 patients were available for evaluation. Of these, 358 patients had actually undergone treatment. The remainder either died before treatment or had no identifiable source of SAH. A poor outcome (mRS score > 2) was observed in 33.7% of the patients assigned to aneurysm clipping and in 23.2% of the patients assigned to coil embolization (OR 1.68, 95% CI 1.08–2.61; p = 0.02). Of treated patients assigned to the coil group, 124 (62.3%) of the 199 who were eligible for any treatment actually received endovascular coil embolization. Patients who crossed over from coil to clip treatment fared worse than patients assigned to coil embolization, but no worse than patients assigned to clip occlusion. No patient treated by coil embolization suffered a recurrent hemorrhage. Conclusions One year after treatment, a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes than clip occlusion. Although most aneurysms assigned to the coil treatment group were treated by coil embolization, a substantial number crossed over to surgical clipping. Although a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes at 1 year, it remains important that high-quality surgical clipping be available as an alternative treatment modality.

The analysis of long - term follow - up screening in patients with surgically treated intracranial aneurysms

“…At the conclusion of the ISAT, coil embolisation appeared to be more advantageous than clip ligation regarding death and severe disability at one year, and clip occlusion had better long-term efficacy in order to prevent recurrent bleeding and to result a better long-term outcome especially in patients younger than 40 years of age (19). Recently, The Barrow Ruptured Aneurysm Trial (BRAT) reported the initial results (18). According to this trial, endovascular treatment resulted in fewer poor clinical outcomes after one year of follow-up but a substantial number of aneurysms assigned to the coil treatment crossed over to surgical clipping with the reasons of surgery required hematoma or anatomical features.…”

“…Open microsurgery or endovascular procedures have been applied to achieve the optimum results for many years. Prospective, randomised studies have been conducted to compare the efficacy of treatment modalities in terms of clinical outcome and durability of occlusion (3,18,(20)(21)(22). Late anatomic results of the occluded aneurysms by microsurgery or endovascular procedures might be possible with the follow-…”

Feasibility and Efficacy of Endovascular Therapy for Ruptured Distal Anterior Cerebral Artery Aneurysms

“…DACA aneurysms are usually located on the branching points of the pericallosal or callosomarginal arteries, are relatively rare, and make up approximately 5-6% of all intracranial aneurysms. 2,5) Although endovascular therapy of ruptured intracranial aneurysms has become an important and well-known alternative to surgical clipping, 14,16,17,28) the reports regarding the DACA aneurysms are sparse. The purpose of this article is to report the feasibility and efficacy of endovascular therapy for ruptured DACA aneurysms.…”

Diagnostic limitations in the treatment of cerebral aneurysms

“…Rerupture rates after one year were extremely low with only one event in the coiling group (8). However, better short term clinical results are achieved with endovascular coiling according to the ISAT and BRAT study (1,9,10), although this effect is lowered after 3 years of follow-up (11). The CARAT study further demonstrated that the initial occlusion degree is strongly associated with the risk of rerupture (12).…”