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Comparison between clipping and coiling on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

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Abstract

Cerebral vasospasm is one of the most important complications of aneurysmal subarachnoid hemorrhage. The effect of aneurysm occlusion technique on incidence of vasospasm is not exactly known. The objective was to analyze surgical clipping versus endovascular coiling on the incidence of cerebral vasospasm and its consequences. Using the MEDLINE PubMed (1966–present) database, all English-language manuscripts comparing patients treated by surgical clipping with patients treated by endovascular coiling, regarding vasospasm incidence after aneurysmal subarachnoid hemorrhage, were analyzed. Data extracted from eligible studies included the following outcome measures: incidence of total vasospasm, symptomatic vasospasm, ischemic infarct vasospasm-induced and delayed ischemic neurological deficit (DIND). A pooled estimate of the effect size was computed and the test of heterogeneity between studies was carried out using The Cochrane Collaboration’s Review Manager software, RevMan 4.2. Nine manuscripts that fulfilled the eligibility criteria were included and analyzed. The studies differed substantially with respect to design and methodological quality. The overall results showed no significant difference between clipping and coiling regarding to outcome measures. According to the available data, there is no significant difference between the types of technique used for aneurysm occlusion (clipping or coiling) on the risk of cerebral vasospasm development and its consequences.

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Authors and Affiliations

  1. Department of Neurosurgery, Neurocenter, Johann Wolfgang Goethe University, Frankfurt am Main, Germany

    Jean G. de Oliveira, Jürgen Beck, Christian Ulrich, Julian Rathert, Andreas Raabe & Volker Seifert

  2. Rua Sena Madureira, 1123 Apto.61, 04021-051, São Paulo-SP, Brazil

    Jean G. de Oliveira

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Comments

R. Loch Macdonald, Chicago, Ill., USA

The authors have done a state-of-the-art review of an issue of substantial interest recently; that is, whether there is a difference in the incidence of cerebral vasospasm among patients undergoing neurosurgical clipping compared with those treated by endovascular coiling. They searched the English language literature and used the software available from the Cochrane group, which allows a very structured, comprehensive and rigorous review to be conducted. They concluded, based on review of nine manuscripts, that there is no difference between the treatments in the incidence of vasospasm, symptomatic vasospasm, delayed ischemic neurological deficits or infarction due to vasospasm.

Some of the limitations need to be addressed. The comparison is not based on randomization between clipping and coiling. When the patients are not randomized to clipping or coiling one cannot exclude differences in baseline characteristics that could affect the incidence of vasospasm. Indeed these were present. More posterior circulation aneurysms that may have a lower risk of vasospasm and more poor grade patients in whom vasospasm may be more difficult to detect, were treated by coiling. The diagnosis of large-artery vasospasm is in doubt also because of the methods used in most studies. The gold standard digital subtraction angiography was seldom used. Transcranial Doppler ultrasound is inaccurate and SPECT does not measure vasospasm, it measures cerebral blood flow.

In the end, it is the clinical outcome of the patient that matters. Considering the randomized trials of clipping compared with coiling, there was better outcome in coiled patients in the larger study, although the magnitude of the difference was remarkably small and the follow-up too short to rule out the possibility that long-term complications in the coiled group would negate the early beneficial effects [2, 3]. The studies include only the subset of aneurysms for which both treatments could be applied. Detailed analysis of delayed ischemia has not been presented. Therefore, for suitable aneurysms that can be well-coiled, whether or not delayed ischemia and vasospasm is different between the two treatments does not depend on vasospasm but on the experience of the individuals who do the two treatments at the center where the patient is. Endovascular treatment in experienced hands for small necked aneurysms is at least equal to, if not superior to, surgery. The interesting point is whether the difference between clipping and coiling is due to early or delayed complications of surgery. Vasospasm develops in relation to the volume, persistence and density of subarachnoid blood clot. It is this reviewer’s hypothesis that clot clearance actually may be more rapid after coiling than after surgery and that ventricular drainage may be detrimental with regard to clot clearance.

As an aside, Bryce Weir called my attention to a paper published in Japan in 1978 by Takemae and co-workers [4]. This was probably one of the earliest observations of the relationship between initial subarachnoid clot volume after subarachnoid hemorrhage and the risk of vasospasm, preceding Dr. Fisher’s widely cited publication by 2 years [1].

References

1. Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9

2. Koivisto T, Vanninen R, Hurskainen H, Saari T, Hernesniemi J, Vapalahti M (2000) Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. Stroke 31:2369–2377

3. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274

4. Takemae T, Mizukami M, Kin H, Kawase T, Araki G (1978) [Computed tomography of ruptured intracranial aneurysms in acute stage-relationship between vasospasm and high density on CT scan (author’s transl)]. No To Shinkei (Brain Nerve) 30:861–866

Comments

Tetsuyoshi Horiuchi, Kazuhiro Hongo, Matsumoto, Japan

This publication by Dr. de Oliveira and co-workers reviews the incidence of cerebral vasospasm after aneurysmal obliteration with clips or coils. The authors summarized nine articles and concluded that there were no significant differences in symptomatic and asymptomatic vasospasm, vasospasm-induced infarction, and delayed ischemic neurological deficit between clipping and coiling, although the incidence was inclined to be relatively high (RR 1.2; 95% CI 0.99–1.48) after clipping compared with coiling. Theoretically, removal of subarachnoid blood clots through craniotomy can reduce the vasospasm. The authors discussed that this discrepancy would be caused by surgical manipulation; the surgical manipulation may act as the trigger of vasospasm. We agree with this possibility, because a small number of patients who underwent clipping surgery for unruptured intracranial aneurysms developed vasospasm. Neurosurgeons must keep minimum and gentle surgical manipulation, so as not to induce vasospasm.

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de Oliveira, J.G., Beck, J., Ulrich, C. et al. Comparison between clipping and coiling on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 30, 22–31 (2007). https://doi.org/10.1007/s10143-006-0045-5

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