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"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature

  • Clinical Article - Vascular
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Abstract

Background

The results of microsurgical treatment for middle cerebral artery (MCA) aneurysms (ANs) have been highly satisfying for decades, notoriously posing a challenge for interventional neuroradiologists. Following the International Subarachnoid Aneurysm Trial (ISAT) study results, most centres across Europe and the USA switched to a "coil first" policy. The purpose of this study is to evaluate and critically review the substantiation of this change.

Methods

The authors conducted a single-institution retrospective study of MCA AN treatment between January 2000 and December 2013 maintaining a “clip first” policy. The results are supplied with a literature review.

Results

A total of 315 MCA ANs were treated in 288 consecutive patients (209 females, 79 males). Microsurgical treatment was performed for 238 AN patients (116 ruptured, 122 unruptured) and 77 AN patients (46 ruptured, 31 unruptured) who underwent a coiling procedure. Treatment-related morbidity and mortality (MM) for unruptured ANs was 2.8 % in the microsurgical group and 10.3 % in the endovascular group. The percentage of patients with no/minor permanent neurological deficits after SAH in a good initial clinical state (HH 1–2) was 93 % in the microsurgical and 76 % in the endovascular group. A literature review identified 21 studies concerning MCA AN treatment with a specified decision-making algorithm. Microsurgery seemed superior to endovascular management regarding both clinical and radiological outcomes, although several aspects of the analysed reports might appear questionable.

Conclusion

Although this study has its inherent limitations, the effect brought about by microsurgical clipping of MCA ANs remains superior to that of endovascular embolisation and it should be sustained as the first treatment choice. The decision about the treatment strategy should be made by a multi-disciplinary team consisting of specialists from both teams, bearing in mind the higher occlusion rate and longevity of the surgical treatment.

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Abbreviations

AN:

Aneurysm

aSDH:

Acute subdural haemorrhage

CTA:

CT angiography

DSA:

Digital subtraction angiography

EV:

Endovascular

EVD:

External ventricular drainage

FD:

Flow diverter

GOS:

Glasgow outcome scale

ICH:

Intracerebral haemorrhage

LD:

Lumbar drainage

MRA:

MR angiography

MCA:

Middle cerebral artery

MM:

Morbidity and mortality

SAH:

Subarachnoid haemorrhage

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Authors and Affiliations

  1. Department of Neurosurgery and Neurooncology, Military University Hospital and First Medical Faculty, Charles University, Prague, Czech Republic

    Anna Steklacova, Ondrej Bradac & Vladimir Benes

  2. Department of Neuroradiology, Military University Hospital, Prague, Czech Republic

    Frantisek Charvat

  3. Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK

    Patricia De Lacy

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  1. Anna Steklacova
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Correspondence to Ondrej Bradac.

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Funding

Czech Ministry of Defense grant MO1012 provided financial support in the form of congress fee funding. The sponsor had no role in the design or conduct of this research.

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All authors certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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Comments

This study represents a large, single-centre, retrospective analysis of a prospectively collected database of patients treated for middle cerebral artery (MCA) intracranial aneurysms (IAs) comparing outcomes after microsurgical (MS) or endovascular (EV) treatment of both ruptured and unruptured IAs. The study period was 14 years, and during this period, the centre treated an average of 22–23 MCA IAs per year. The authors find that MS seemed superior to endovascular EV regarding both the clinical and radiological outcomes.

This is a well-written article with many nice details. The authors describe all patients seen during the study period and lay out the data in informative tables and figures. The methodology is clear and the results convincing. There might be, inherently, a huge selection bias disfavouring EV since the neuroradiologists seem to be left with the “leftovers”, but the authors studied this and concluded that statistical analysis did not confirm such a prediction and there was no difference in pre-treatment patient conditions or in the final outcome between both groups. However, many poor-grade patients also underwent MS as many of them presented with an ICH volume >10 cc.

The surgical results are very good and in line with those published in the literature. That being said, a publication bias may exist here.

The literature review was performed well and I think the crucial points are addressed.

The study mixes ruptured and unruptured IAs, which makes the paper less accessible for the reader, but is sadly also a reflection of the fact that many of our current discussions about aneurysm treatment are based on extrapolations of the ISAT study results since we do not have proper RCTs regarding unruptured IAs.

Torstein Meling

Oslo, Norway

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Steklacova, A., Bradac, O., Charvat, F. et al. "Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature. Acta Neurochir 158, 533–546 (2016). https://doi.org/10.1007/s00701-015-2687-y

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