The Barrow Ruptured Aneurysm Trial: 6-year results

Abstract

obJect The authors report the 6-year results of the Barrow Ruptured Aneurysm Trial (BRAT). This ongoing randomized trial, with the final goal of a 10-year follow-up, compares the safety and efficacy of surgical clip occlusion and endovascular coil embolization in patients presenting with subarachnoid hemorrhage (SAH) from a ruptured aneurysm. The 1- and 3-year results of this trial have been previously reported. methods In total, 500 patients with an SAH met the entry criteria and were enrolled in the study. Of these patients, 471 were randomly assigned to the treatments: 238 to surgical clipping and 233 to endovascular coiling. Six patients who died before treatment and 57 patients with nonaneurysmal SAHs were excluded, leaving a total of 408 patients who underwent clipping (209 assigned) or coiling (199 assigned). Whether to treat patients within the assigned group or to cross over patients to the other group was at the discretion of the treating physician; 38% (75/199) of the patients assigned to coiling were crossed over to clipping and 1.9% (4/209) assigned to clipping were crossed over to coiling. The outcome data were collected by a dedicated nurse practitioner. The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. Six years after randomization, 336 (82%) of 408 patients who had been treated were available for examination. results On the basis of an mRS score of > 2, and similar to the results at the 3-year follow-up, no significant difference in outcomes (p = 0.24) was detected between the 2 treatment groups. Complete aneurysm obliteration at 6 years was achieved in 96% (111/116) of the clipping group and in 48% (23/48) of the coiling group (p < 0.0001). In the period between the 3- and 6-year follow-ups, 3 additional patients assigned to coiling and none assigned to clipping received retreatment, for overall retreatment rates of 4.6% (13/280) for clipping and 16.4% (21/128) for coiling (p < 0.0001). When aneurysm location was considered, the 6-year results continued to match the previously reported results, with no difference in outcome for anterior circulation aneurysms at most time points. Of the anterior circulation aneurysms assigned to coiling treatment, 42% (70/168) were crossed over to clipping treatment. The outcomes for posterior circulation aneurysms continued to favor coiling. The randomization process was unexpectedly skewed, with 18 of 21 treated aneurysms of the posterior inferior cerebellar artery (PICA) being assigned to clipping, but even when PICA aneurysms were removed from the analysis, outcomes for the posterior circulation aneurysms still favored coiling. coNclusioNs Although BRAT was statistically underpowered to detect small differences, these results suggest little difference in outcome between the 2 treatments for anterior circulation aneurysms. This was not the case for the posterior circulation aneurysms, where coil embolization appeared to provide a sustai...

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136�cases

“…The International Subarachnoid Aneurysm Trial in 2015 indicated that these two methods were effective for the treatment of intracranial aneurysms (15). Currently, the surgical clipping of intracranial aneurysms is a popular treatment (16). Neurosurgical clipping can be affected by numerous factors, including the age and sex of the patient, the location and size of the aneurysm, and the extent of calcification or sclerosis of the aneurysm and parent artery (14).…”

The principles for choosing a surgical technique for patients with acute cerebral aneurysm rupture

“…Эндова-скулярная окклюзия является предпочтительной даже в тех случаях, когда анатомические условия не позволяют выключить аневризму полностью. В этих условиях частичная окклюзия аневризмы может снизить риск повторного разрыва и создать условия для безопасного проведения консервативной тера-пии [7]. Радикальное микрохирургическое вмеша-тельство может быть проведено вторым этапом в холодном периоде после стабилизации состояния больного.…”

“…При этом существует опре-деленная конкуренция между этими направления-ми, что может приводить к недостаточно обосно-ванному использованию или, напротив, неисполь-зованию того или иного метода. Между тем много-численные публикации свидетельствуют о том, что ни микрохирургия, ни эндовазальная хирургия не могут самостоятельно решить все сложные пробле-мы хирургического лечения больных с разорвавши-мися аневризмами [1][2][3][4][5][6][7][8]. В этой связи поиск опти-мального выбора лечения и путей кооперации раз-личных методов не теряет своей актуальности.…”

How do we maintain competence in aneurysm surgery

“…A case was made for surgical treatment for anterior circulation aneurysms, given the similar outcomes, higher obliteration rate (98 vs. 48 %), lower retreatment rate (4 vs. 13 %), and high crossover from the coil to clip arm (38 %). For posterior circulation aneurysms, outcomes were definitely better for endovascular [11].…”

“…A significant number of aneurysms are still treated with surgical clipping in a more efficacious and long-lasting manner. On a paper presented at the AANS meeting earlier this year [11], Spetzler et al discussed the 6-year results of the BRAT study. A case was made for surgical treatment for anterior circulation aneurysms, given the similar outcomes, higher obliteration rate (98 vs. 48 %), lower retreatment rate (4 vs. 13 %), and high crossover from the coil to clip arm (38 %).…”