The Journal of International Medical Research

2012; 40: 2145 – 2151

Outcomes of Endovascular Coiling versus

Surgical Clipping in the Treatment of
Ruptured Intracranial Aneurysms
Z-Q LI1,2,a, Q-H WANG3,a, G CHEN4, AND Z QUAN
1
Department of Neurosurgery, Fengxian District Central Hospital (Branch Hospital of
Shanghai Sixth People’s Hospital), Shanghai Jiaotong University, Shanghai, China;
2
Shanghai Neurological Research Institute of Ahui University of Science and Technology,
Shanghai, China; 3Department of Neurosurgery, Shanghai Ruijin Hospital, Shanghai
Jiaotong University, Shanghai, China; 4Department of Neurosurgery, Huashan Hospital,
Fudan University, Shanghai, China

OBJECTIVE: The effects of treatment surgical group. Demographics and severity

modality (endovascular coiling or surgical of aSAH were comparable between the
clipping) on incidence of cerebral groups. Incidence of symptomatic
vasospasm and infarction following vasospasm, cerebral infarction and
aneurysmal subarachnoid haemorrhage complete occlusion were significantly
(aSAH) remain controversial. This study lower in the endovascular coiling group
compared outcomes between endovascular than in the surgical clipping group. Good
coiling versus surgical clipping to treat clinical recovery 12 months after aSAH
patients with acute (< 72 h) aSAH. was seen in 75.0% and 69.7% of surviving
METHODS: Patients with aSAH were patients in the endovascular versus coiling
randomized to receive endovascular or group, respectively. CONCLUSIONS: In this
surgical treatment. All patients underwent study, coiling yielded less symptomatic
clinical assessments, angiography and vasospasm, cerebral infarction and
brain computed tomography. RESULTS: complete occlusion than surgical clipping,
Data from 186 patients were analysed: 94 with no between-group differences in
in the endovascular group and 92 in the clinical outcome.

KEY WORDS: ANEURYSM; CEREBRAL INFARCTION; ENDOVASCULAR COILING, INTRACRANIAL ANEURYSM;

SUBARACHNOID HAEMORRHAGE; SURGICAL CLIPPING; VASOSPASM

Introduction Although a few cases of unruptured

Subarachnoid haemorrhage (SAH) caused intracranial aneurysm have been reported to
by the rupture of intracranial aneurysms resolve spontaneously, direct treatment is
remains a serious healthcare problem1 with usually recommended. In cases involving
approximately one half of survivors ruptured aneurysm, patients should be
sustaining irreversible brain damage.2 treated routinely.3,4 Early treatment (< 72 h)
is recommended for ruptured aneurysms as
a
Z-Q Li and Q-H Wang contributed equally to this work. ~20% of patients experience another rupture

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Coiling vs clipping in ruptured intracranial aneurysms

within the first 2 weeks following SAH.5 the following times: on admission; on the day
Despite developments in the treatment of (24 – 48 h) after treatment; on the day of
SAH, the case fatality rate remains stable,6 discharge. To evaluate the occurrence of
with cerebral vasospasm and infarction angiographic vasospasm, digital subtraction
being the two major causes of death and angiography was performed at a mean ± SD
disability.3,7 The treatment of aneurysmal day 9 ± 2 (between day 4 and 14)11 following
SAH (aSAH) continues to be a matter of aSAH, or earlier when clinical or transcranial
debate, with one study suggesting that doppler ultrasonography data suggested the
surgical treatment itself could produce presence of vasospasm. If angiographic
neurological morbidity, cognitive vasospasm was confirmed, hypervolaemic
impairment and increased mortality.8 hypertensive haemodilution therapy was
Treating recently ruptured cerebral initiated.
aneurysms with endovascular coiling avoids The study protocol was approved by the
the difficulties encountered during early Fengxian Central Hospital Ethics Committee
surgical clipping on swollen brain tissue, (No. FH2005032203), and signed informed
and might carry lower risk of morbidity and consent was obtained from each patient or
mortality.9 Few comparative studies of the family before treatment.
long-term outcome of surgical versus
endovascular treatment in acute aSAH have ASSESSMENT OF SYMPTOMATIC
been reported. VASOSPASM AND CEREBRAL
The present study evaluated differences in INFARCTION
terms of clinical, angiographical and All imaging material was evaluated by two
computed tomography (CT) scan outcomes independent blinded reviewers. Symptomatic
between treatment with endovascular vasospasm was defined as follows: (i) new
coiling or surgical clipping, in patients with neurological deficit occurring between days 4
acute aSAH. and 14 following aSAH; (ii) no other
identifiable cause for neurological
Patients and methods deterioration as demonstrated on CT scan,
STUDY POPULATION rebleeding, acute or worsening
Consecutive patients with acute aSAH, hydrocephalus, electrolyte disturbances,
admitted to the Department of Neurosurgery, hypoxia or seizures; (iii) vasospasm on
Fengxian District Central Hospital (Branch cerebral angiography.
Hospital of Shanghai Sixth People’s Cerebral infarction was diagnosed on the
Hospital), Shanghai Jiaotong University, discharge CT scan as a newly detected focal
Shanghai, China, between April 2005 and hypodense region, when compared with the
February 2009, were enrolled into the study 24 – 48 h postaneurysm treatment CT scan,
and assigned (according to a computer- that was not attributable to intracerebral
generated randomization schedule) to haemorrhage, ventricular drain placement
undergo either endovascular coiling or or another nonvascular aetiology. In this
surgical clipping treatment. Each patient’s way, lesions related to the initial bleeding or
age, sex and aneurysm site was recorded. The to the intervention could be excluded.
clinical status of the patient was rated using
the Hunt and Hess scale.10 In order to FOLLOW-UP
diagnose SAH, CT scans were performed at Follow-up imaging was performed by digital

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Coiling vs clipping in ruptured intracranial aneurysms

subtraction angiography, CT angiography to treatment. In both groups, all surgeries were

evaluate the occurrence of angiographic carried out by the same team, which was
vasospasm or CT for detection of infarction. experienced in performing both surgical
Following endovascular coil treatment, procedures. Two patients in the endovascular
imaging follow-up was routinely performed treatment group and four patients in the
at 3 and 12 months. In cases of increasing surgical treatment group were not treated for
coil compaction, angiographic follow-up their ruptured aneurysm. Thus, baseline
was performed more frequently. Following characteristics were available for 186 treated
surgical clipping, imaging follow-up was patients. There were no statistically
performed if the neurosurgeon considered it significant between-group differences in
necessary. terms of age, sex, Hunt and Hess scale
Clinical follow-up was performed in both grades,10 location of target aneurysm or time
groups during outpatient clinic visits. A interval between aSAH and treatment
structured telephone interview was procedure (Table 1).
performed with outpatients or family who Symptomatic vasospasm was documented
missed the clinic visits; a close relative was in 22/94 (23.4%) of the endovascular coiling
contacted in cases where the patient was patients and 34/92 (37.0%) of the surgical
unavailable. Patients with a follow-up clipping patients (P < 0.05). Surgical clipping
period of < 1 year were considered to be lost increased the risk of symptomatic vasospasm
to follow-up. Clinical outcome status was compared with coiling (odds ratio 1.24, 95%
assessed with use of the modified Rankin confidence intervals 1.01, 1.51). There were
Scale (score 0 – 6)12 at 12 months. Poor significantly fewer new cerebral infarctions
outcome was defined as a modified Rankin in the endovascular coiling group compared
Scale score of ≥ 3. Earlier follow-up visits were with the surgical clipping group (12/94
scheduled if changes in the morphological [12.8%] versus 20/92 [21.7%], respectively,
features of the aneurysm were noted. P < 0.05). Of the patients experiencing new
cerebral infarctions, the incidence of
STATISTICAL ANALYSES symptomatic vasospasm-related infarctions
All statistical procedures were performed was significantly lower in those undergoing
with SPSS® software, version 13.0 (SPSS Inc., endovascular treatment (eight of 12 patients
Chicago, IL, USA) for Windows®. [66.7%]), compared with surgical treatment
Quantitative data were presented as mean ± (17/20 patients [85.0%]) (P < 0.05).
SD, and qualitative data as percentages or Imaging follow-up was performed in all
absolute numbers. Between-group patients. In those who had received surgical
comparisons were performed using Student’s clipping, imaging showed complete
t-test for quantitative data and Pearson’s χ2- occlusion in 77/92 (83.7%), a residual neck
test for qualitative variables. A P-value in 11/92 (12.0%), and a residual aneurysm
< 0.05 was considered to be statistically in four of 92 patients (4.3%). In those who
significant. had received endovascular coiling,
complete occlusion was demonstrated in
Results 61/94 (64.9%), a residual neck in 21/94
Of the 192 patients entered in the study, 96 (22.3%), and a residual aneurysm in 12/94
were randomized to receive endovascular patients (12.8%). The differences between
treatment and 96 to receive surgical the two groups were statistically significant

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Coiling vs clipping in ruptured intracranial aneurysms

TABLE 1:
Baseline characteristics of patients treated with endovascular coiling or surgical clipping
following acute aneurysmal subarachnoid haemorrhage (aSAH)
Endovascular coiling group Surgical clipping group
Characteristic n = 94 n = 92
Age, years 54.7 ± 14.2 53.7 ± 13.8
Sex, male 68 (72.3) 62 (67.4)
Hunt and Hess Scale10
1–2 56 (59.6) 61 (66.3)
3 30 (31.9) 23 (25.0)
4–5 8 (8.5) 8 (8.7)
Aneurysm site
ICA 18 (19.1) 20 (21.7)
MCA 16 (17.0) 19 (20.7)
ACA-AComA 46 (48.9) 44 (47.8)
BA-bifurcation 1 (1.1) 0 (0)
PCoA 13 (13.8) 9 (9.8)
Mean time from aSAH to treatment (days) 3.0 ± 4.5 3.0 ± 4.9
Data presented as n (%) patients or mean ± SD.
There were no statistically significant between-group differences (P ≥ 0.05); Student’s t-test and Pearon’s χ2-test.
ICA, internal carotid artery; MCA, middle cerebral artery; ACA, anterior cerebral artery; AComA, anterior
communicating artery; BA, basilar artery; PCoA, Posterior communicating artery; aSAH, acute aneurysmal
subarachnoid haemorrhage.

for residual aneurysm only (P < 0.05). Discussion

Incidence of complete aneurysm occlusion The primary goal in treating ruptured
was significantly lower following aneurysms is to prevent haemorrhage,
endovascular coiling compared with thereby decreasing the rate of mortality and
surgical treatment (P < 0.05). Rebleeding dependency. Endovascular coiling has
occurred in three of 94 (3.2%) patients become an effective treatment option, with a
following endovascular coiling treatment, good safety profile for ruptured intracranial
and three of 92 (3.3%) patients following aneurysms, since Guglielmi et al.13
surgical treatment, with no significant revolutionized this technique with the
between-group difference. introduction of electrolytically detachable
At the end of the 1-year follow-up, 10/94 coils. The present study investigated coiling
(10.6%) and 14/92 (15.2%) patients died and clipping procedures to treat intracranial
after endovascular and surgical treatment, aneurysms. After a follow-up period of 12
respectively, with no significant between- months, death rates of 10.6% (coiled
group difference. Clinical follow-up was patients) and 15.2% (clipped patients), were
completed in all 162 surviving patients: similar to those reported by the International
63/84 (75.0%) and 53/78 (67.9%) surviving Subarachnoid Aneurysm Trial after 5 years
patients in the endovascular and surgical of follow-up.14 One-year outcome did not
treatment groups, respectively, achieved a differ significantly between the groups, with
good outcome (modified Rankin Scale score12 67.9 – 75.0% of surviving patients achieving
0 – 2); no significant between-group a good recovery (modified Rankin Scale score
differences were observed. 0 – 2). These results were in accordance with

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another study describing good clinical coiling, rather than surgical clipping, to treat
outcomes (modified Rankin Scale score 1 – 2) a ruptured aneurysm.
in 79% and 75% of the surviving patients, In accordance with other research,20 the
(coiled or clipped, respectively) treated present study revealed an association
within 3 days following SAH.15 Symptomatic between symptomatic vasospasm and
vasospasm, requirement for permanent cerebral infarction. Cerebral infarctions due
shunt creation, size of the ruptured to symptomatic vasospasm significantly
aneurysm and Hunt and Hess grade were influence morbidity and mortality following
shown to be independent predictors of aSAH, and lead to poor clinical outcomes.21
clinical outcome.15 Though medical and The incidence of symptomatic vasospasm-
surgical advances have reduced the impact related infarctions, out of the total infarction
of cerebral vasospasm on outcome following rate in the present study, was significantly
SAH, it remains a major cause of morbidity lower in the coiled patients than in the
and mortality.16,17 Whether the coiling or clipped patients (66.7 versus 85%,
clipping procedure increases the risk of respectively).
symptomatic vasospasm is debatable.3,10,18 Several studies have reported that the rate
One meta-analysis compared the rate of of incomplete occlusion is higher in coiling
symptomatic vasospasm after coiling or than in clipping treatments, but it remains
clipping and suggested a trend towards less unclear how incomplete coil occlusion affects
symptomatic vasospasm after coiling than the bleeding rate.3,14,22 Coiling resulted in a
after clipping.19 The studies included were, significantly lower incidence of complete
however, limited by their retrospective occlusion compared with clipping in the
nature, differences in study design, lack of present study. Post-treatment imaging
angiographic diagnosis of vasospasm and revealed a significant difference in residual
varying definitions of symptomatic aneurysm in the coiled patients (12.8%)
vasospasm. In addition, patients treated by compared with the clipped patients (4.3%).
coiling in this analysis were older than those Rebleeding occurred with approximately
treated with clipping, with a poor clinical equal frequency in both treatment groups.
prognosis and an aneurysm more often Published studies suggest that rebleeding
located in the posterior circulation, so the rates depended on the occlusion rates and on
two treatment groups were not comparable; the follow-up period after clipping or
in addition, only one study was prospective coiling.14,22,23 Following ruptured aneurysms,
and randomized.19 retreatment rates were similar in patients
Patient characteristics in the present with a neck remnant, and in those with
prospective randomized study were similar complete occlusion.24 A perfect angiographic
in both groups (including age, sex, severity result was not strived for in the present study,
of subarachnoid bleeding, clinical grade and which may have increased the complication
aneurysm location). The study suggested rate in attempting to achieve the ideal
that the type of procedure used to treat a occlusion.
ruptured aneurysm was significantly The present study was a randomized
associated with the risk of symptomatic controlled trial, in which basic between-
vasospasm or cerebral infarction, and group patient characteristics were
provides supportive evidence for the current comparable. These enabled the study of
practice of electing to perform endovascular differences in symptomatic vasospasm

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between coiled and clipped patients treatment CT scans (which were used to detect
independent of confounding factors. cerebral infarcts) were performed in the
Angiographic vasospasm or ischaemic coiling group in the present study, which may
lesions revealed on the CT scan were used to have affected the results (data not shown).
define symptomatic vasospasm. Moreover, In conclusion, this randomized,
no surviving patients missed follow-up. prospective study revealed that patients who
These factors strengthen the theory that received endovascular coiling following
between-group differences in occurrence of aSAH experienced significantly lower
symptomatic vasospasm, infarction, incidences of symptomatic vasospasm,
rebleeding and clinical outcome were due to cerebral infarction and complete occlusion,
the mode of treatment. compared with patients who received
The present study was limited by the small surgical clipping. In addition, coiled patients
sample size and, as a result, outcome events showed modest (although not significant)
could have been the result of chance. In the improvements in clinical outcome,
clipped patients, surgery-related damage compared with clipped patients.
might have been diagnosed as symptomatic
vasospasm, which may have led to different Conflicts of interest
diagnoses of symptomatic vasospasm The authors had no conflicts of interest to
between different physicians. More post- declare in relation to this article.

• Received for publication 2 June 2012 • Accepted subject to revision 17 June 2012
• Revised accepted 20 September 2012
© SAGE Publications Ltd 2012

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Author’s address for correspondence

Dr Z Quan
Department of Neurosurgery, Fengxian Central Hospital, 9588 Nanfeng Road, Nanqiao
Town, Fengxian District, Shanghai 201400, China.
E-mail: zequan2012@126.com

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