1051. Coiling vs Clipping in poor grade aneurysmal subarachnoid haemorrhage: A single centre analysis of outcome and complications
Authors: ANKIT SANJAYKUMAR SHAH; DALJIT SINGH; ANITA JAGETIA (Vadodara, India)
Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. Endovascular treatment has been established as an alternative to surgical clipping for SAH with ruptured aneurysm. This study aimed to evaluate functional outcomes and postoperative complications between the two treatment modalities in this group of patients treated at a single centre by a dual trained cerebrovascular surgeon.
A retrospective analysis of 88 patients presenting with poor grade SAH associated with ruptured aneurysms between August 2013 and July 2018.was done. An aggressive policy of initial resuscitation followed by either endovascular coiling or clipping by the senior dual trained neurovascular surgeons was undertaken. Modified rankin scale was used to determine outcome immediately after discharge and at 3 and 6 months.
Eighty eight poor-grade SAH patients (18.18% of all 484 aneurismal SAH patients) were operated and studied. Treatment was microsurgical in 63 (71.59%) and endovascular in 25 (28.41%) patients. Four (4.5%) were lost to follow-up. Good outcome (mRS 0-3) at 6 months was found in 27 microsurgical patients (45 %) and 13 endovascular patients (54.16%). Inspite of significant initial good outcome at discharge in patients undergoing coiling, there was no statistically significant difference at 6 months. A significant risk of hydrocephalus was noted among patients undergoing endovascular coiling. (OR: 3.60, CI: 1.00-13.37, p=0.04)
With an aggressive early treatment policy approximately half of the poor-grade SAH patients demonstrated a good clinical outcome. No significant differences in functional outcome were noted between two arms. Clipping and coiling being two complementary arms, treatment should be individualized based on clinical presentation and aneurysm characteristics. The risk of symptomatic vasospasm was higher after clipping while that of hydrocephalus was higher after coiling in treatment of poor grade ruptured aneurysms.