A comparative assessment of the results of the treatment of patients with a rupture of cerebral aneurysm in the acute period of subarachnoid hemorrhage with endovascular and microsurgical methods (continued Russian study of aneurysm surgery)

SUMMARY: In the last decade, there has been a paradigm shift in the treatment of patients with intracranial aneurysms: in neurosurgical practice, the endovascular technique of cerebral aneurysm embolization is becoming increasingly common.

PURPOSE OF THE STUDY: to analyze the factors affecting postoperative mortality in two regional centers with different priority methods of surgical treatment of aneurysms (endovascular and microsurgical) in the first 14 days after the rupture of cerebral aneurysms.

METHODS: The results of treatment of 902 patients from 01/01/2013 to 12/31/2018 were analyzed: 443 patients after microsurgical treatment (group I) and 459 patients after endovascular surgery (group II). Postoperative mortality was analyzed in the first month after surgery.

RESULTS: In patients operated on in a compensated state (I and II degrees according to the Hunt Hess scale), the results of treatment in both groups were comparable (mortality 18 % in the first group and 17 % in the second group). In patients operated on with the severity of condition III–IV on the H-H scale, mortality was lower in the endovascular group (24 %) compared to the “microsurgical” group (31 %). In patients operated on in a serious condition of grade V according to H-H, in the “microsurgical” group, mortality was almost 2 times lower than in the “endovascular” group (44 % and 79 %, respectively).

CONCLUSION: the data obtained suggest further introduction of endovascular methods of aneurysm treatment into the practice of RCC, further development of microsurgical skills in surgeons and development of methods for the prevention and treatment of vascular spasm and cerebral ischemia.

1. Krylov VV, Dash’yan VG, Shatokhin TA, Shetova IM, Eliava ShSh, Belousova OB, Orlov KYu et al. Surgical treatment of cerebral aneurysms in the Russian Federation, Voprosy neirokhirurgii im. N. N. Budenko. 2018;82(6):5–14. (In Russ.)

2. Krylov VV, Dash'yan VG, Shatokhin TA, Shafullin FA, Solodov AA, Prirodov AV, Levchenko OV, Tokarev A S, Khamidova LT, Kuksova NS, Airapetyan AA, Kalinkin AA. Timing of open surgical treatment of patients with ruptured cerebral aneurysms complicated by massive basal subarachnoid hemorrhage (Fisher 3). Neirokhirurgiya. 2015;3:11–17 (In Russ.) https://doi.org/10.17650/1683‑3295‑2015‑0‑3‑11‑17

3. Shetova IM, Shtadler VD, Matveev PD, Luk’yanchikov VA, Krylov VV. Long-term results of surgical treatment of cerebral aneurysms in the acute period of hemorrhage. Emergency medical care. Zhurnal im. N. V. Sklifosovskogo. 2021;10(2):328–336. (In Russ.) https://doi.org/10.23934/2223‑9022‑2021‑10‑2‑328‑336

4. Karpov S, Belokon O, Ermakov S, Vyshlova I. Possibilities of using the method of chemical angioplasty of cerebral vasospasm as complications of subarachnoid hemorrhage of aneurysmatic etiology to reduce poor outcomes. Journal of the Neurological Sciences. 2019;405(S);74. https://doi.org/10.1016/j.jns.2019.10.566

5. Luther E, McCarthy DJ, Brunet MC, Sur S, Chen SH, Sheinberg D, Hasan D, Jabbour P, Yavagal DR , Peterson EC, Starke RM . Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes. J Neurointerv Surg. 2020;12(7):682–687. https://doi.org/10.1136/neurintsurg‑2019–015418 Epub 2020 Jan 20. PM ID: 31959634.

6. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809–817. https://doi.org/10.1016/S 0140–6736 (05) 67214‑5

7. Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Nakaji P, Karis JP , Wallace RC. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2019;132(3):771–776. https://doi.org/10.3171/2018.8.JNS181846

8. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J. Neurosurg. 1968;28:14–20. https://doi.org/10.3171/jns.1968.28.1.0014

9. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by CT scanning. Neurosurgery. 1980;6(1):1–9. https://doi.org/10.1227/00006123‑198001000‑00001

10. Raymond J, Roy D. Safety and efficacy of endovascular treatment of acutely ruptured aneurysms. Neurosurgery. 1997;41:1235–1244. https://doi.org/10.1161/hs0901.095600

11. Drake CG, Vanderlinden RG. The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg. 1967;27(3):226–238. https://doi.org/10.3171/jns.1967.27.3.0226

12. Graeb DA, Robertson WD, Lapointe JS, Nugent RA, Harrison P.B. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982;143(1):91–96. https://doi.org/10.1148/radiology.143.1.6977795

13. Koivisto T, Vanninen R, Hurskainen H, et al. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. 2000;31:2369–2377. https://doi.org/10.1161/01.str.31.10.2369

14. Hanalioglu S, Sahin B, Sayyahmelli S, Ozaydin B, Erginoglu U, Aycan A, Baskaya MK. The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era. Acta Neurochir (Wien). 2022;164(3):781–793. https://doi.org/10.1007/s00701‑022‑05112‑1

15. Sindou M, Acevedo JC, Turjman F. Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir (Wien). 1998;140(11):1153–1159. https://doi.org/10.1007/s007010050230

16. Becske T, Brinjikji W, Potts MB, et al. Long term clinical and angiographic outcomes following Pipeline Embolization Device treatment of complex internal carotid artery aneurysms: five-year results of the Pipeline for U ncoilable or Failed Aneurysms trial. Neurosurgery. 2017;80:40–48. https://doi.org/10.1093/neuros/nyw014

17. Ringer AJ, Rodriguez-Mercado R, Veznedaroglu E, Levy EI, Hanel RA, Mericle RA, Lopes DK, Lanzino G, Boulos AS. Defining the risk of retreatment for aneurysm recurrence or residual after initial treatment by endovascular coiling: a multicenter study. Neurosurgery. 2009;65(2):311–315. https://doi.org/10.1227/01.NEU.0000349922.05350.96

18. Munich SA, Cress MC, Rangel-Castilla L, et al. Neck remnants and the risk of aneurysm rupture after endovascular treatment with coiling or stent-assisted coiling: much ado about nothing? Neurosurgery. 2019;84:421–427, https://doi.org/10.1093/neuros/nyy056

19. Rahal JP, Malek AM. Clip occlusion versus coil embolization for the treatment of cerebral aneurysms. J Neurosurg Sci. 2012;56(3):175–190. PM ID: 22854586

20. Ermakov SV, Karpov SM, Baturin VA, Belokon OS, Mozheiko RA. Neuroimmune predictors of outcome after aneurysmal subarachnoid hemorrhage. Kazan medical journal. 2020;101(5):754–759. (In Russ.) https://doi.org/10.17816/KMJ2020–754

21. Belokon OS, Ermakov SV, Karpov SM, Mozheiko RA, Kosygin VA, Kornev AP, Baturin VA. To the choice of surgical treatment of cerebral angiospasm in patients with aneurismatic subarachnoid hemorrhage. Medical news of north caucasus. 2020;15(1):119–120. (In Russ.) https://doi.org/10.14300/mnnc.2020.15028