General neurosurgery, studies Flashcards
ISAT
The International Subarachnoid Aneurysm Trial (ISAT) of
2002 signifcantly infuenced the management of **ruptured intracranial aneurysms **[1]. The trial compared two treatment methods: neurosurgical clipping and endovascular coiling. A total of 2,143 patients with ruptured intracranial aneurysms were enrolled and randomly assigned to either of the two treatments. The primary outcome was the proportion of patients who were dependent or dead (indicated by a modifed Rankin scale score of 3–6) at one year post-treatment.
Results showed a substantial beneft in favor of **endovascular coiling, with 23.7% **of patients in the coiling group versus **30.6% in the clipping **group falling into the dependent or dead category [1]. This fnding marked a pivotal moment in the approach to treating ruptured intracranial aneurysms, suggesting a signifcant advantage of endovascular coiling over neurosurgical clipping in improving patient independence and survival rates at the one-year mark.
ISUIA
The International Study of Unruptured Intracranial Aneurysms (ISUIA) Trial of 2003 provided critical insights into the management of unruptured intracranial aneurysms [2].
This extensive study, involving 4,060 patients across various centers, focused on comparing the natural history risks of unruptured aneurysms with the risks associated with surgical or endovascular interventions. Key fndings included detailed data on rupture rates based on aneurysm size and location, revealing that small aneurysms in the anterior circulation had a very low risk of rupture, whereas larger aneurysms, particularly those in the posterior circulation, posed
a higher risk. For instance, aneurysms less than 7 mm in size located in the anterior circulation had a very low risk of rupture. The study also emphasized the importance of individualized treatment decisions, infuenced by factors such as patient age, aneurysm size, and location [2]. These fndings have signifcantly infuenced current practices, advocating for a nuanced and patient-specifc approach in the management of unruptured intracranial aneurysms.
CARAT
The Cerebral Aneurysm Rerupture After Treatment
(CARAT) study of 2008 aimed to identify predictors of rerupture following the treatment of ruptured intracranial aneurysms [3]. This study included 1,001 patients and used both coil embolization and surgical clipping as treatment methods. Key fndings indicated that the degree of aneurysm occlusion post-treatment was a strong predictor of subsequent rupture. Specifcally, the study found a graduated risk of rerupture based on the degree of occlusion: complete occlusion presented the lowest risk, while less than 70% occlusion showed the highest risk. While complete aneurysm occlusion of 100% post initial treatment did not guarantee rerupture nonoccurrence, however, the risk of rerupture was only 1.1% in their study group with all events occurring during the frst year [3]. This study underlined the importance of achieving as complete an occlusion as possible during initial treatment to reduce the risk of rerupture.
SUAVe
The Small Unruptured Intracranial Aneurysm Verifcation study (SUAVe) of 2010 focused on the natural history and optimal management of incidentally discovered small unruptured intracranial aneurysms** less than 5 mm**in diameter [4]. The study included 540 aneurysms in 446 patients, with a follow-up period averaging 41 months. Key fndings revealed the average annual risks of rupture for small unruptured aneurysms to be relatively low at 0.54% overall, with 0.34% for single aneurysms and 0.95% for multiple aneurysms. Signifcant predictive factors for rupture included patient age below 50 years, aneurysm diameter of 4.0 mm or larger, hypertension, and aneurysm multiplicity [4]. This study underscores the importance of individualized treatment decisions for small unruptured aneurysms, particularly in younger patients with hypertension and multiple aneurysms of larger size.
BRAT
The Barrow Ruptured Aneurysm Trial (BRAT) of 2012 was a signifcant study in the feld of neurosurgery that focused on comparing the efcacy and safety of microsurgical clipping and endovascular coil embolization in treating acutely ruptured cerebral aneurysms [5]. Enrolling 470 patients, the trial aimed to determine if one treatment method was superior to the other by analyzing clinical and angiographic outcomes. The study’s primary outcome was based on patient results at 1 year post-treatment, assessed using the modifed Rankin Scale (mRS). A key fnding was that patients assigned to coil embolization had fewer poor outcomes compared to those assigned to surgical clipping [5]. This result supported the growing inclination towards endovascular treatment, emphasizing the need for quality surgical clipping as an alternative treatment modality
STICH I
The Surgical Trial in Intracerebral Haemorrhage (STICH) I Trial (2005) was a landmark study in the feld of neurosurgery focusing on spontaneous supratentorial intracerebral hemorrhages [6]. This randomized trial compared early surgery (haematoma evacuation within 24 h of randomization) with initial conservative treatment. The study involved 1,033 patients from 83 centers across 27 countries. The primary outcome measured was the **sixmonth prognosis using the Glasgow outcome scale. **The results showed no signifcant overall beneft from early surgery compared to initial conservative treatment [6]. The trial’s fndings have been infuential in guiding treatment approaches for spontaneous supratentorial intracerebral hemorrhages, highlighting the complexity and need for individualized patient assessment in these cases.
STICH II
The STICH II Trial (2013) followed up on the STICH I
Trial to further investigate the efcacy of early surgery
for spontaneous supratentorial lobar intracerebral hemorrhages [7]. This randomized trial involved 601 patients, comparing **early surgical hematoma evacuation within 12 h **of randomization plus medical treatment against initial conservative treatment. The primary outcome was based on the Extended Glasgow Outcome Scale (GOSE) at 6 months. The fndings showed that **early surgery did not signifcantly increase the rate of death or disability at 6 months compared to conservative treatment, **suggesting a small potential survival advantage for patients with superfcial intracerebral hemorrhage without intraventricular hemorrhage [7].
