Endovascular intervention versus surgery in ruptured intracranial aneurysms in equipoise: a systematic review

Chung Liang Chai, Jin Pyeong Jeon, Yi-Hsin Tsai, Paula Whittaker, R Loch Macdonald, Antti E Lindgren, Oliver GS Ayling, Acioly Marcus Andre, Aaron Cohen-Gadol, Yu-Hua Huang

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Background and Purpose
The benefits of endovascular intervention over surgery in the treatment of ruptured aneurysms of anterior circulation remains uncertain. Recently published studies did not find superiority of endovascular intervention, challenging earlier evidence from a clinical trial. The earlier evidence also had a higher than average proportion of patients in good clinical status, leading to uncertainty about external validity of earlier trials.

We performed a systematic review of studies after 2005 under a protocol published in the International Prospective Register of Systematic Reviews (PROSPERO). Primary outcomes were post-treatment rebleeding and adverse events (procedural complications). Secondary outcomes were dependency at 3-6 months and 12 months, delayed cerebral ischemia and seizures.

Rebleeding was more frequent after endovascular intervention (Peto OR 2.18 95% CI 1.29 to 3.70; 3104 participants; 15 studies; I2 = 0%, GRADE: very low certainty of evidence). Fewer adverse events were reported with the endovascular intervention (RR 0.71 95% CI 0.53 to 0.95; 1661 participants; 11 studies; I2 = 14%, GRADE: low certainty of evidence). Three-to-six months dependency (RR 0.82 95% CI 0.73 to 0.93; 4081 participants; 18 studies; I2 = 15%, GRADE: low certainty of evidence) and twelve-month dependency (RR 0.76 95% CI 0.66 to 0.86; 1981 participants; 10 studies; I2 = 0%, GRADE: low certainty of evidence) were lower after endovascular intervention.

This study found consistent results between recent studies and the earlier evidence, in that endovascular intervention results in lower chance of dependency compared to surgery for repair of ruptured anterior circulation aneurysms. A lower proportion of patients in good clinical status in this review supports the application of the earlier evidence.

Original languageEnglish
JournalStroke; a journal of cerebral circulation
Early online date13 May 2020
Publication statusPublished - 2020


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