http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960975-2/fulltext
Summary
Background
Previous
analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort
have reported on the risks of recurrent subarachnoid haemorrhage and
death or dependency for a minimum of 5 years and up to a maximum of 14
years after treatment of a ruptured intracranial aneurysm with either
neurosurgical clipping or endovascular coiling. At 1 year there was a 7%
absolute and a 24% relative risk reduction of death and dependency in
the coiling group compared with the clipping group, but the medium-term
results showed the increased need for re-treatment of the target
aneurysm in the patients given coiling. We report the long-term
follow-up of patients in this UK cohort.
Methods
In
ISAT, patients were randomly allocated to either neurosurgical clipping
or endovascular coiling after a subarachnoid haemorrhage, assuming
treatment equipoise, between Sept 12, 1994, and May 1, 2002. We followed
up 1644 patients in 22 UK neurosurgical centres for death and clinical
outcomes for 10·0—18·5 years. We assessed dependency as self-reported
modified Rankin scale score obtained through yearly questionnaires. Data
for recurrent aneurysms and rebleeding events were collected from
questionnaires and from hospital and general practitioner records. The
Office for National Statistics supplied data on deaths. This study is
registered, number ISRCTN49866681.
Findings
At
10 years, 674 (83%) of 809 patients allocated endovascular coiling and
657 (79%) of 835 patients allocated neurosurgical clipping were alive
(odds ratio [OR] 1·35, 95% CI 1·06—1·73). Of 1003 individuals who
returned a questionnaire at 10 years, 435 (82%) patients treated with
endovascular coiling and 370 (78%) patients treated with neurosurgical
clipping were independent (modified Rankin scale score 0—2; OR 1·25; 95%
CI 0·92—1·71). Patients in the endovascular treatment group were more
likely to be alive and independent at 10 years than were patients in the
neurosurgery group (OR 1·34, 95% CI 1·07—1·67). 33 patients had a
recurrent subarachnoid haemorrhage more than 1 year after their initial
haemorrhage (17 from the target aneurysm).
Interpretation
Although
rates of increased dependency alone did not differ between groups, the
probability of death or dependency was significantly greater in the
neurosurgical group than in the endovascular group. Rebleeding was more
likely after endovascular coiling than after neurosurgical clipping, but
the risk was small and the probability of disability-free survival was
significantly greater in the endovascular group than in the
neurosurgical group at 10 years.
No comments:
Post a Comment