Clipping ist weiterhin wichtig nach aneurysmatischer Subarachnoidalblutung: Eine Re-Analyse der Earlydrain-Studie

A recent US national cohort study comprising of more than 100.000 patients showed still a preference for clipping over coiling in patients with aneurysmal subarachnoid hemorrhage (1). As such databases lack a granular level of clinical data, features associated with each method in contemporary practice are unknown.

We performed a secondary analysis of the Earlydrain trial, which investigated the use of an additional lumbar drain in patients with aneurysmal subarachnoid hemorrhage (2). Deidentified patient data is freely available on the internet. Aneurysm treatment choice was at the discretion of the local physicians and not mandated by the study protocol.

Earlydrain recruited 287 patients with aneurysmal subarachnoid hemorrhage of all severity grades in 19 centers in Germany, Switzerland, and Canada from 2011 to 2016. Overall, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess / WFNS grades and radiological criteria were similar. Clipping was more used for aneurysms in the anterior circulation (55%), while most posterior circulation aneurysms were coiled (86%, p< 0.001).

Infarction on postoperative imaging was seen in 16% of clipped vs 8% of coiled patients (p=0.03). Postprocedural hemorrhages had a higher frequency after coiling (7% vs 10%). 60% of clipped vs 42% of coiled patients showed signs of elevated TCD criteria (p < 0.005), which was reflected in the rates of angiographic vasospasm (51% vs 38%, p= 0.03). The rates of severe angiographic vasospasm (10% vs 11%) and the use of endovascular rescue techniques (9% vs 8%) were similar.

In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in all others. No trend in preference of clipping or coiling was notable during the six year of study duration. In contrast to the Earlydrain main results establishing the superiority of the use of a lumbar drain additional to standard of care, outcome rates after clipping and coiling measured by secondary infarctions, mortality and the modified Rankin score at six months were without statistically significant difference.

In clinical practice, aneurysm clipping is still a required and frequently used method. Further development of periprocedural clipping techniques is warranted.

References:

Shah VA, et al: Front Neurol 2022; 16:13:908609 Wolf S, et al: JAMA Neurol 2023; 80(8):833-842