Object: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with substantial morbidity and mortality, with better outcomes reported following endovascular coiling compared with neurosurgical clipping of the aneurysm. The authors evaluated the contribution of perioperative complications and neurological decline to patient outcomes after both aneurysm-securing procedures.
Methods: A post hoc analysis of perioperative complications from the Clazosentan to Overcome Neurological iSChemia and Infarction Occurring after Subarachnoid hemorrhage (CONSCIOUS-1) study was performed. Glasgow Coma Scale (GCS) scores for patients who underwent neurosurgical clipping and endovascular coiling were analyzed preoperatively and each day following the procedure. Complications associated with a decline in postoperative GCS scores were identified for both cohorts. Because patients were not randomized to the aneurysm-securing procedures, propensity-score matching was performed to balance selected covariates between the 2 cohorts. Using a multivariate logistic regression, the authors evaluated whether a perioperative decline in GCS scores was associated with long-term outcomes on the extended Glasgow Outcome Scale (eGOS).
Results: Among all enrolled subjects, as well as the propensity-matched cohort, patients who underwent clipping had a significantly greater decline in their GCS scores postoperatively than patients who underwent coiling (p = 0.0024). Multivariate analysis revealed that intraoperative hypertension (p = 0.011) and intraoperative induction of hypotension (p = 0.0044) were associated with a decline in GCS scores for patients undergoing clipping. Perioperative thromboembolism was associated with postoperative GCS decline for patients undergoing coiling (p = 0.03). On multivariate logistic regression, postoperative neurological deterioration was strongly associated with a poor eGOS score at 3 months (OR 0.86, 95% CI 0.78-0.95, p = 0.0032).
Conclusions: Neurosurgical clipping following aSAH is associated with a greater perioperative decline in GCS scores than endovascular coiling, which is in turn associated with poorer long-term outcomes. These findings provide novel insight into putative mechanisms of improved outcomes following coiling, highlighting the potential importance of perioperative factors when comparing outcomes between clipping and coiling and the need to mitigate the morbidity of surgical strategies following aSAH.
Keywords: CONSCIOUS-1 = Clazosentan to Overcome Neurological iSChemia and Infarction Occurring after Subarachnoid hemorrhage; DCI = delayed cerebral ischemia; DIND = delayed ischemic neurological deterioration; GCS = Glasgow Coma Scale; ISAT = International Subarachnoid Aneurysm Trial; WFNS = World Federation of Neurosurgical Societies; aSAH = aneurysmal subarachnoid hemorrhage; clipping; coiling; complications; eGOS = extended Glasgow Outcome Scale; subarachnoid hemorrhage; vascular disorders.