Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals

Objective: To compare complications of surgical clipping and coil embolizat ion in the treatment of unruptured aneurysms. Background: Surgical clipping has been the preferred treatment for unruptured cerebral aneurysms but end ovascular coil embolization is an increasingly employed alternative. No dir ect comparisons of the techniques are available to guide clinical decision making. Methods: We performed a cohort study of patients treated for unrupt ured cerebral aneurysms at 60 university hospitals from January 1994 throug h June 1997 using the University Health System Consortium database. The dat abase was validated by chart review from one of the participant universitie s. The main outcome measures were in-hospital mortality and adverse outcome s, defined as in-hospital deaths and discharges to nursing homes or rehabil itation hospitals. Results: The primary treatment modality was surgical in 2,357 cases and endovascular in 255 cases. Adverse outcomes were significan tly more common in surgical cases (18.5%) compared to endovascular cases (1 0.6%) (p = 0,002), and the difference was not altered after adjusting for a ge, sex, race, transfer admissions, emergency room admissions, and year of treatment (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4 to 3.3; p = 0.001). In-hospital mortality was also increased in surgical cases (2.3% versus 0.4%; p = 0.039), but the difference was not significant in the mult ivariable model (OR 6.3, 95% CI 0.9 to 46.1; p = 0.07). Length of stay and hospital charges were significantly greater for surgical cases (p < 0.0001 for each), and these differences were not affected by risk adjustment. Conc lusion: Endovascular coil embolization resulted in fewer adverse outcomes t han surgery for unruptured cerebral aneurysms treated at the university hos pitals studied. Although these results should be seen as preliminary, the m agnitude of difference and current predominance of surgery appear to justif y a randomized trial.