Outcomes of Early Endovascular Versus Surgical Treatment of Ruptured Cerebral Aneurysms: A Prospective Randomized Study

Abstract

Background and Purpose —This prospective study was conducted to compare the outcomes of surgical clipping and endovascular treatment in acute (<72 hours) aneurysmal subarachnoid hemorrhage (SAH). Methods —One hundred nine consecutive patients were randomly assigned to either surgical (n=57) or endovascular (n=52) treatment. Clinical and neuropsychological outcome was assessed at 3 and 12 months after treatment; MRI of the brain was performed at 12 months. Follow-up angiography was scheduled after clipping and 3 and 12 months after endovascular treatment. Results —One year postoperatively, 43/41 (surgical/endovascular) patients had good or moderate recovery, 5/4 had severe disability or were in a vegetative state, and 9/7 had died (NS) according to intention to treat. Patients with good clinical recovery did not differ in their neuropsychological test scores. Symptomatic vasospasm (OR 2.47; 95% CI 1.45 to 4.19; P <0.001), poorer Hunt and Hess grade (OR 2.50; 95% CI 1.31 to 4.75; P =0.005), need for permanent shunt (OR 8.90; 95% CI 1.80 to 44.15; P =0.008), and larger size of the aneurysm (OR 1.22; 95% CI 1.02 to 1.45; P =0.032) independently predicted worsened clinical outcome regardless of the treatment modality. In MRI, superficial brain retraction deficits ( P <0.001) and ischemic lesions in the territory of the ruptured aneurysm ( P =0.025) were more frequent in the surgical group. Kaplan-Meier analysis (mean±SD follow-up 39±18 months) revealed equal survival in both treatment groups. No late rebleedings have occurred. Conclusions —One-year clinical and neuropsychological outcomes seem comparable after early surgical and endovascular treatment of ruptured intracranial aneurysms. The long-term efficacy of endovascular treatment in preventing rebleeding remains open.