The Barrow Ruptured Aneurysm Trial: 3-year results

Area of Science:

• Neurosurgery
• Interventional Neurology
• Vascular Neurology

Background:

• Aneurysmal subarachnoid hemorrhage (aSAH) remains a critical cause of neurological morbidity and mortality.
• Microsurgical clip occlusion and endovascular coil embolization are primary treatment modalities for ruptured cerebral aneurysms.
• Comparative long-term outcome data are essential for guiding treatment decisions.

Purpose of the Study:

• To compare the safety, efficacy, and functional outcomes of microsurgical clipping versus endovascular coiling for acutely ruptured cerebral aneurysms.
• To report the 3-year results of the randomized Barrow Ruptured Aneurysm Trial (BRAT).

Main Methods:

• A randomized trial comparing clip occlusion (n=238) and coil embolization (n=233) for ruptured cerebral aneurysms.
• Primary outcome analysis based on initial treatment assignment; modified Rankin Scale (mRS) used for outcome assessment (poor outcome defined as mRS > 2).
• 3-year follow-up data available for 349 treated patients, with analysis considering aneurysm location.

Main Results:

• No significant difference in poor outcome rates between clipping and coiling at 3 years (35.8% vs 30%, p=0.25).
• Clipping demonstrated significantly higher aneurysm obliteration rates and lower recurrence and retreatment rates (p=0.0001 and p=0.01, respectively).
• Anterior circulation aneurysms showed no significant outcome difference between groups; posterior circulation aneurysms had better outcomes with coiling after 1 year, persisting at 3 years.

Conclusions:

• While not statistically significant, coil embolization showed a favorable trend in outcomes at 3 years.
• Clip occlusion achieved superior aneurysm obliteration and reduced recurrence and retreatment rates.
• Anterior circulation aneurysms had comparable outcomes regardless of treatment modality; posterior circulation aneurysms favored coiling at long-term follow-up.