Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial
Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial
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DOI：
10.3171/2018.8.jns181846
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发表时间：
2020-03-01
影响因子：
4.1
通讯作者：
Wallace, Robert C.
中科院分区：
文献类型：
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作者：
Spetzler, Robert F.;McDougall, Cameron G.;Wallace, Robert C.
目的作者介绍了巴罗破裂动脉瘤试验（BRAT）治疗囊状动脉瘤的10年结果。之前已报告了该试验的1年、3年和6年结果，以及囊状动脉瘤的6年结果。本最终报告比较了夹闭术与弹簧圈栓塞术的安全性和有效性，仅限于对囊状动脉瘤破裂导致蛛网膜下腔出血（SAH）的患者进行分析，在该研究中，362例囊状动脉瘤患者随机分为夹闭术和弹簧圈栓塞术两组（各181例）。主要结局分析基于分配的治疗组;不良结局定义为改良兰金量表（mRS）评分> 2，并独立判定。动脉瘤闭塞的程度由非治疗神经放射学家判定。结果在10年的随访中，这两个治疗组之间的不良结局（mRS评分> 2）或死亡率没有统计学显著差异。在178例分配的囊性动脉瘤患者中，1例（< 1%）交叉至弹簧圈栓塞术，64例（36%）交叉至夹闭术。初次住院后，2/241例（0.8%）夹闭的囊状动脉瘤和23/115例（20%）弹簧圈栓塞的囊状动脉瘤需要再次治疗（p < 0.001）。在10年随访时，93%（50/54）的夹闭动脉瘤完全闭塞，而弹簧圈栓塞动脉瘤仅为22%（5/23）（p < 0.001）。2例患者记录到再出血，均死亡，均在分配和治疗的弹簧圈栓塞队列中（2/83）;夹闭队列中无患者（0/175）死亡（p = 0.04）。在这2例患者中的1例中，出血不是来自靶动脉瘤，而是来自偶然的基底动脉动脉瘤，该动脉瘤同时被盘绕。弹簧圈栓塞术组1年时后循环动脉瘤患者的临床结局更好，但1年后该差异不再具有统计学显著性。与接受弹簧圈栓塞术的患者相比，动脉瘤完全闭塞率和再治疗率更有利于接受夹闭术的患者。
OBJECTIVE The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm.METHODS In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.RESULTS There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip- assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow- up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time.CONCLUSIONS There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.