Saturday, June 15, 2024

Study Reveals Coiling Reduces Hydrocephalus Risk Compared to Clipping After Aneurysmal Subarachnoid Hemorrhage

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Hydrocephalus is a common and severe complication following aneurysmal subarachnoid hemorrhage (aSAH), often necessitating cerebrospinal fluid (CSF) diversion surgery. A recent study aimed to elucidate the relationship between the initial treatment method for aSAH—specifically, clipping versus coiling—and the occurrence of hydrocephalus requiring CSF diversion. Utilizing a target trial approach for causal inference, the study offers valuable insights for both clinicians and patients navigating treatment options.

The research utilized US administrative health claims data from the Clinformatics Data Mart, encompassing a period from January 1, 2004, to February 28, 2023. The cohort study included 5816 patients, with 1794 undergoing clipping and 4022 receiving coiling as primary treatments for aSAH. The primary outcome measured was hydrocephalus necessitating CSF diversion surgery, while secondary outcomes included mortality rates.

Study Methodology

To control for potential confounders, researchers employed multivariable regression and 1:1 propensity score (PS) matching. Both crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. A 1:1 PS matched cohort was created, comprising 1794 participants in each treatment arm, to ensure balanced comparison.

Key Findings

The results indicated that clipping was associated with a higher risk of shunt-dependent hydrocephalus compared to coiling. In the multivariable Fine-Gray model, clipping had a hazard ratio of 1.39 (95% CI 1.19 to 1.62), and this association remained consistent in the PS matched cohort (HR 1.39, 95% CI 1.16 to 1.66). Mortality analysis initially suggested a lower risk with clipping (HR 0.78, 95% CI 0.69 to 0.88); however, this advantage diminished after adjusting for confounders, with coiling showing slightly better outcomes (HR 1.13, 95% CI 1.00 to 1.29 in the multivariable model and HR 1.11, 95% CI 0.95 to 1.29 in the PS matched cohort).

Practical Implications

– Coiling may be preferable for reducing the risk of hydrocephalus requiring CSF diversion post-aSAH.
– Initial mortality benefits observed with clipping may be less significant after adjusting for confounders.
– Clinicians should consider these findings in shared decision-making with patients.

These findings challenge previous smaller observational studies and highlight the importance of comprehensive data analysis in medical decision-making. They suggest that coiling could be a more favorable option for patients at risk of developing hydrocephalus after aSAH.

Original Article: J Neurointerv Surg. 2024 Jun 5:jnis-2024-021852. doi: 10.1136/jnis-2024-021852. Online ahead of print.

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