Superiority of Endovascular Coiling Over Surgical Clipping for Clinical Outcomes at Discharge in Patients With Poor-Grade Subarachnoid Hemorrhage: A Registry Study in Japan

Tatsuya Ishikawa; Fusao Ikawa; Nao Ichihara; Koji Yamaguchi; Takayuki Funatsu; Hirofumi Nakatomi; Yoshiaki Shiokawa; Takatoshi Sorimachi; Yuichi Murayama; Kaima Suzuki; Hiroki Kurita; Hitoshi Fukuda; Tetsuya Ueba; Norihito Shimamura; Hiroki Ohkuma; Jun Morioka; Ichiro Nakahara; Minami Uezato; Masaki Chin; Takakazu Kawamata

doi:10.1227/neu.0000000000002782

Superiority of Endovascular Coiling Over Surgical Clipping for Clinical Outcomes at Discharge in Patients With Poor-Grade Subarachnoid Hemorrhage: A Registry Study in Japan

Neurosurgery. 2023 Dec 1. doi: 10.1227/neu.0000000000002782. Online ahead of print.

Authors

Tatsuya Ishikawa¹, Fusao Ikawa², Nao Ichihara^{3

4}, Koji Yamaguchi¹, Takayuki Funatsu¹, Hirofumi Nakatomi⁵, Yoshiaki Shiokawa⁵, Takatoshi Sorimachi⁶, Yuichi Murayama⁷, Kaima Suzuki⁸, Hiroki Kurita⁸, Hitoshi Fukuda⁹, Tetsuya Ueba⁹, Norihito Shimamura^{10

11}, Hiroki Ohkuma^{10

11}, Jun Morioka¹², Ichiro Nakahara¹², Minami Uezato¹³, Masaki Chin¹³, Takakazu Kawamata¹

Affiliations

¹ Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
² Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan.
³ Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan.
⁴ Department of Cardiovascular Surgery, Jikei University, Tokyo, Japan.
⁵ Department of Neurosurgery, Kyorin University, Mitaka, Tokyo, Japan.
⁶ Department of Neurosurgery, Tokai University, Isehara, Kanagawa, Japan.
⁷ Department of Neurosurgery, The Jikei University School of Medicine, Minato, Tokyo, Japan.
⁸ Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
⁹ Department of Neurosurgery, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan.
¹⁰ Department of Neurosurgery, Hirosaki University, Hirosaki, Aomori, Japan.
¹¹ Department of Neurosurgery, Hirosaki General Medical Center, National Hospital Organization, Hirosaki, Aomori, Japan.
¹² Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan.
¹³ Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.

PMID: 38038438
DOI: 10.1227/neu.0000000000002782

Abstract

Background and objectives: The differences in clinical outcomes between endovascular coiling (EC) and surgical clipping (SC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are controversial. Therefore, this study aimed to evaluate whether EC is superior to SC and identify risk factors in patients with poor-grade aSAH.

Methods: We used data from the "Predict for Outcome Study of aneurysmal SubArachnoid Hemorrhage." World Federation of Neurological Societies (WFNS) grade III-V aSAH was defined as poor-grade aSAH, and unfavorable clinical outcomes (modified Rankin Scale scores 3-6) were compared between SC and EC after propensity score matching (PSM). In-hospital mortality was similarly evaluated. Predictors of unfavorable clinical outcomes were identified using multivariable analysis.

Results: Ultimately, 1326 (SC: 847, EC: 479) and 632 (SC: 316, EC: 316) patients with poor-grade aSAH were included before and after PSM, respectively. Unfavorable clinical outcomes at discharge were significantly different between SC and EC before (72.0% vs 66.2%, P = .026) and after PSM (70.6% vs 63.3%, P = .025). In-hospital mortality was significantly different between groups before PSM (10.5% vs 16.1%, P = .003) but not after PSM (10.4% vs 12.7%, P = .384). Predictors of unfavorable clinical outcomes in both SC and EC were WFNS grade V, older than 70 years, and Fisher computed tomography (CT) grade 4. Predictors of unfavorable clinical outcomes only in SC were WFNS grade IV (odds ratio: 2.46, 95% CI: 1.22-4.97, P = .012) and Fisher CT grade 3 (4.90, 1.42-16.9, P = .012). Predictors of unfavorable clinical outcome only in EC were ages of 50s (3.35, 1.37-8.20, P = .008) and 60s (3.28, 1.43-7.52, P = .005).

Conclusion: EC resulted in significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without clear differences in in-hospital mortality. The benefit of EC over SC might be particularly remarkable in patients with WFNS grade IV and Fisher CT grade 3.