Introduction: Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are two well-established techniques for the treatment of complex and wide-necked intracranial aneurysms. Most clinicians are reluctant to perform SAC in the setting of subarachnoid hemorrhage (SAH) because of the need for dual antiplatelet therapy. We present the results of the first study comparing the safety and efficacy of SAC and BAC in acutely ruptured complex and wide-necked aneurysms.
Methods: Between 2008 and 2012, 44 patients underwent SAC and 40 underwent BAC for complex and wide-necked aneurysms in the setting of SAH. Patients treated with SAC received 600 mg of clopidogrel intra-operatively and were maintained on daily doses of clopidogrel (75 mg) and aspirin (81 mg). Peri-operative adverse events and clinical outcomes were analyzed and compared.
Results: The two groups were statistically comparable with respect to all baseline characteristics except for older age in SAC patients (65.6 versus 56.5 years, p=0.009). A higher proportion of SAC patients had also poor Hunt and Hess grades (III-V) compared to BAC patients (70.5% versus 55%, p=0.l4). Hemorrhagic, thrombo-embolic, and overall procedural complications occurred respectively in 6.8%, 11.4%, and 18.2% of the SAC group versus 2.5%, 7.5%, and 10% of the BAC group (p=0.5, p=0.64, p=0.35, respectively). Clinical follow-up was available in 95.3% of patients at an average of 7.4 months. Favorable outcomes (Modified Rankin Scale 0-3) were seen in 73.2% of the SAC group versus 79.4% of the BAC group (p=0.5). Recurrences requiring retreatment occurred in 4.2% and 7.7% of SAC and BAC patients, respectively (p=0.5). In multivariate analysis, after controlling for differences in baseline characteristics, the type of treatment was not a predictor of procedural complications or clinical outcome.
Conclusions: BAC may have a lower complication rate in ruptured aneurysms compared to SAC. Both techniques are feasible and effective and can be safely applied in clinical practice.
Patient Care: Our study is the first to provide comparative data between SAC and BAC in complex and wide-necked ruptured intracranial aneurysms. Practice thus far has been based on operator’s preferences and experience. The data provided will help neurosurgeons make evidence-based clinical decisions and optimize the care of patients with complex ruptured aneurysms that require balloon or stent assistance.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the advantages and limitations of SAC in acutely ruptured intracranial aneurysms. 2) Discuss the advantages and limitations of BAC in acutely ruptured intracranial aneurysms.