Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

Area of Science:

• Neurosurgery
• Interventional Neuroradiology
• Clinical Trials

Background:

• Subarachnoid hemorrhage (SAH) is a critical condition often caused by ruptured aneurysms.
• Randomized trials comparing surgical clipping and endovascular coiling for aneurysms are limited, particularly for saccular types.
• The Barrow Ruptured Aneurysm Trial (BRAT) provides data for this comparison.

Purpose of the Study:

• To compare the efficacy and safety of clipping versus coiling for saccular aneurysms within the BRAT cohort.
• To analyze long-term outcomes, including aneurysm obliteration and retreatment rates.
• To assess functional outcomes using the modified Rankin Scale.

Main Methods:

• A prospective, randomized trial (BRAT) comparing clipping and coiling for nontraumatic SAH.
• Post hoc analysis of BRAT data focusing on the subgroup of patients with saccular aneurysms.
• Independent adjudication of aneurysm obliteration by a neuroradiologist.
• Follow-up for up to 6 years, assessing outcomes and retreatment needs.

Main Results:

• Of 471 BRAT patients, 362 had saccular aneurysms, equally randomized to clipping (181) or coiling (181).
• No significant difference in poor functional outcome (modified Rankin Scale > 2) between groups at any time point up to 6 years.
• Clipping resulted in significantly higher complete obliteration rates (95% vs. 40%) and lower retreatment rates (0.4% vs. 18%) at 6 years (p < 0.001).

Conclusions:

• For saccular aneurysms, clipping and coiling yield similar functional outcomes in the long term (intent-to-treat analysis).
• Surgical clipping demonstrates superior durability, evidenced by significantly higher obliteration rates and reduced need for retreatment compared to coiling at 6-year follow-up.
• The findings support clipping as a more durable treatment for saccular aneurysms, despite comparable initial functional outcomes.