Saccular aneurysms in the post-Barrow Ruptured Aneurysm Trial era

Area of Science:

• Neurosurgery
• Interventional Neurology
• Vascular Neurology

Background:

• The Barrow Ruptured Aneurysm Trial (BRAT) compared endovascular coiling and microsurgical clipping for aneurysmal subarachnoid hemorrhage (aSAH).
• Advances in endovascular techniques since the BRAT raise questions about its contemporary relevance.
• This study investigates if technical improvements have reduced retreatment rates for endovascular interventions.

Purpose of the Study:

• To compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the post-BRAT (PBRAT) era.
• To examine the influence of BRAT results on current neurosurgical practices.
• To analyze neurological outcomes and retreatment rates for both treatment modalities across different time periods.

Main Methods:

• Retrospective cohort study of patients with saccular aSAHs treated between August 1, 2007, and July 31, 2019.
• Patients were divided into microsurgery and endovascular intervention groups.
• Primary outcome: poor neurological outcome (modified Rankin Scale > 2); Secondary outcomes: retreatment rates.

Main Results:

• No significant difference in neurological outcomes at 1-year follow-up between microsurgery (n=451) and endovascular (n=347) groups (p=0.51).
• Significantly higher retreatment rates for endovascular treatment (9%) compared to microsurgery (1%) (p < 0.001).
• Endovascular retreatment rate in the PBRAT era (9%) was lower than in the original BRAT (18%).

Conclusions:

• Neurological outcomes remain equivalent between endovascular embolization and microsurgery for aSAH.
• Retreatment rates are higher with endovascular embolization but have decreased significantly with modern techniques.
• The study highlights the evolving efficacy of endovascular treatments for aSAH.