Stroke: Clipped aneurysm linked to higher risk of complications

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A large registry-based study that compared clipping with coiling of patients hospitalized with aneurysmal subarachnoid hemorrhage (SAH) found that clipping increases the risk of in-hospital complications, which results in a longer length of stay and worse functional outcomes. Patients who are suitable for either procedure should receive endovascular treatment, the authors recommended in their study in the November issue of Stroke.

Mervyn D.I. Vergouwen, MD, PhD, of the Utrecht Stroke Center at the University Medical Center Utrecht in Utrecht, the Netherlands, and colleagues used data from the Registry of the Canadian Stroke Network (RCSN) to expand on previous studies that have associated clipping with a higher incidence of neurocognitive deficits and seizures when compared with coiling. Using RCSN, a registry of patients presenting with an acute stroke or a transient ischemic attack at 11 regional stroke hospitals in Ontario, the researchers compared in-hospital complications between clipped and coiled patients.

They identified patients who were admitted for aneurysmal SAH between July 1, 2003, and March 31, 2008 who received either a coiled or clipped treatment of the aneurysm. They excluded patients who received both treatments, who died within two days of admission or whose final diagnosis was nonstroke, ischemic stroke or intracerebral hemorrhage. They included documented complications that occurred within 30 days.

They abstracted data on baseline characteristics (age, sex, Hunt and Hess score, Charlson comorbidity index, systolic and diastolic blood pressure and nonfasting blood glucose); in-hospital complications within 30 days after admission (urinary tract infection, pneumonia, sepsis, seizure, deep vein thrombosis, pulmonary embolism, cardiac/respiratory arrest, MI, gastrointestinal hemorrhage, decubitus ulcer and falls with injury); modified Rankin Scale at discharge; death during hospitalization; and 30-day and 90-day overall mortality.

The study group included 931 patients, 548 with a clipped aneurysm and 383 with a coiled aneurysm. The two groups had no differences in baseline characteristics.

Vergouwen and colleagues found that clipping increased risk of in-hospital complications, poor functional outcome, mortality and increased length of stay compared with coiling. The incidence of in-hospital complications in patients with clipped aneurysms was 37.2 percent compared with 24.5 percent for patients with coiled aneurysms. The incidence of poor functional outcome at discharge was 69.4 percent in the clipped group compared with 51.4 percent in the coiled group.

The incidences of mortality at discharge, 30 days after SAH and 90 days after SAH were all higher in the clipped group. The median length of stay was 17 days in the clipped group and 13 days in the coiled group.

The clipped group had higher incidences of urinary tract infection, pneumonia, cardiac and respiratory arrest, seizure and decubitus ulcer. All but decubitus ulcer were found to be independent predictors of poor functional outcomes.

“The results of our study have implications for daily practice,” Vergouwen and colleagues wrote. “Because clipped patients had a higher incidence of complications including decubitus ulcer, our data suggest that efforts should be done to shorten the period of immobilization. Future studies should focus on the efficacy of strategies that prevent complications.”

The researchers noted that the incidence of in-hospital complications could be affected by interoperator bias, the data collected was limited to what was captured on charts and the study was not randomized.

They pointed out that their study and others have identified urinary tract infection, pneumonia, cardiac and respiratory arrest and seizure as independent predictors of poor functional outcomes. For clipped patients in particular, they recommended, aggressive strategies be designed to prevent and treat these complications.

“In patients with aneurysms that are suitable for both clipping and coiling, endovascular treatment should be the preferred treatment option,” they concluded.