INTRODUCTION – since the first publication of ISAT
study the treatment strategy of ruptured aneurysms has changed in a
large proportion of Centres due to alleged better results achieved with
endovascular treatment. Much criticism was made to this study, not only
due to its methodology but also to its influence on the surgical
training of the new neurosurgical generation. Our study was done to
evaluate our surgical treatment results, and to compare them not only
with the results of the clipped patients on the ISAT study, but also to
compare the results of coiled patients in ISAT study and a equivalent
group of clipped patients in our study.
MATERIAL AND METHODS – 319 consecutive, non-selected
patients, with a ruptured sacular aneurysm were operated on during an 8
years period (2000-2007). Patients were clinically evaluated using WFNS
scale. For CT grade Fisher scale was used. Gender, age, clinical grade,
aneurysm number and location and complications (neurological and
“extra-neurological”) were analysed in order to establish a hypothetical
relationship with treatment results. Results were evaluated using GOS
scale, partially with a stratification (GOS 1-2 = good results; 3-5 =
bad results) to allow to compare with ISAT results which used a
stratification of the Rankin scale (0-2 = good results; 3-6 = bad
results). To compare our surgical results with ISAT coiled patients our
“sub-group” was selected in order to have equivalent WFNS scale keeping
the GOS percentage for each of its grade in the very same proportion it
had in the original group of patients. Additionally gender, age and
number of aneurysms were used to have the most equilibrium as possible
between groups. For statistics χ2 test, the Spearman’s
correlation coefficient, and a logistic regression analysis were used
(Microsoft® Office Excel 2007 and SPSS Statistics® 17.0).
RESULTS – 228 were female (71%) and 91 were male
(29%). Age varied among 18 and 86 years old, with an average of 55,8 (±
14,9). 48,3% presented with a WFNS scale of 1, 25,4% of 2, 8,5% of 3,
14,4% of 4 and 3,4% of 5. 394 aneurysms were found (19,1% of the
patients with multiple aneurysms). 70,5% had Fisher 3, 18,2% Fisher 2,
5,3% Fisher 1, 5,3% Fisher 4 and in 0,7% there is no Fisher grade
registration. 36,5% of the aneurysms were located on the anterior
communicating artery, 23,1% on the middle cerebral artery bifurcation,
18,5% on the posterior communicating artery and the rest was widely
distribute on both anterior and posterior circulation. 37% of the
patients had “early” surgery and 63% had “late” surgery. Vasospasm was
diagnosed in 44,5% of the patients, hydrocephalus in 25,1%, infarction
in 21%, re-bleeding in 9,7% and epilepsy in 5,6%. From the
“extra-neurological” complications pneumonia (15,4%), hyponatremia
(12,2%), anaemia (11,3%) and arterial hypertension (11,3%) were the most
frequent. At discharge 41,4% of the patients had a GOS of 1, 14,1% of 2,
31% of 3, 6% of 4 and 7,5% died. At 1 year 65.1% had GOS 1, 9% had GOS
2, 9, 9% had GOS 3, 1% had GOS 4 and 15,1% had died.
Age, clinical grade, vasospasm, hydrocephalus,
infarction and epilepsy depicted a statistically significant value (p<0,05)
on GOS, but among them only age, clinical grade, infarction,
hydrocephalus, epilepsy and pneumonia had an independent value. At 1
year 26% of our patients had a “bad result” (GOS 3-5) and 74% had a
“good result” (GOS 1-2). ISAT clipped patients at 1 year had a “bad
result” in 30,9% (mRS 3-6) and a “good result” in 69,1% (mRS 0-2). ISAT
coiled patients had a “bad result” in 23,5% and a “good result” in
76,5%. In the 246 patients “sub-group” of our study, at 1 year 79,5% had
a “good result” and 20,5% had a “bad result”.
DISCUSSION AND CONCLUSION – our surgical results are
better than ISAT surgical results and not very different from ISAT
coiled patients, but our patients were not selected. In a comparable
group our surgical results are better than coiled patients in ISAT, even
if, at the time the study started, the surgical policy was of a “late”
one. Despite being studies with a different design (retrospective versus
prospective; institutional versus multicenter) it shows that surgery may
still be the best treatment modality for ruptured aneurysms, specially
if one considers efficacy as a meaning not only of complete exclusion
but also as a definitive one. Surgery must be done in referral
Departments and training the new neurosurgical generation is necessary
in order to achieve better results.