[en] OBJECTIVE: There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials.
METHODS: Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded.
RESULTS: There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling.
CONCLUSIONS: Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
Disciplines :
Surgery Neurology
Author, co-author :
Darsaut, Tim E; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Keough, Michael B; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Sagga, Abdelaziz; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Chan, Vivien K Y; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Diouf, Ange; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Boisseau, William; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Magro, Elsa; Service of Neurosurgery, CHU Cavale Blanche, InsermUMR 1101 LaTIM, Brest, France
Kotowski, Marc; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Roy, Daniel; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Weill, Alain; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Iancu, Daniela ; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Bojanowski, Michel W; Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Chaalala, Chiraz; Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Bilocq, Alain; Centre Hospitalier Régional de Trois-Rivières Service of Neurosurgery, Trois-Rivières, Quebec, Canada
Estrade, Laurent; Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
Lejeune, Jean-Paul; Department of Neurosurgery, Centre Hospitalier Universitaire de Lille, Lille, France
Bricout, Nicolas ; Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
Scholtes, Félix ; Université de Liège - ULiège > Département des sciences biomédicales et précliniques > Neuro-anatomie ; Centre Hospitalier Universitaire de Liège - CHU > > Service de neurochirurgie
MARTIN, Didier ; Centre Hospitalier Universitaire de Liège - CHU > > Service de neurochirurgie
OTTO, Bernard ; Centre Hospitalier Universitaire de Liège - CHU > > Service médical de radiodiagnostic
Findlay, J Max ; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Chow, Michael M ; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
O'Kelly, Cian J; Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Ashforth, Robert A; Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Rempel, Jeremy L ; Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
Lesiuk, Howard; Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Sinclair, John; Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Altschul, David J; Department of Neurological Surgery and Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
Arikan, Fuat ; Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
Guilbert, Francois; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Chagnon, Miguel; Department of Mathematics and Statistics, Université de Montréal, Montréal, Quebec, Canada
Farzin, Behzad; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Gevry, Guylaine ; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
Raymond, Jean; Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada, Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada. Electronic address: jean.raymond@umontreal.ca
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