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Original Investigation
December 28, 2018

Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 2Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
  • 3Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
  • 4Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 5Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
JAMA Neurol. Published online December 28, 2018. doi:10.1001/jamaneurol.2018.4165
Key Points

Question  What is the 30-day clinical complication risk and case-fatality rate of endovascular treatment and neurosurgical treatment of unruptured intracranial aneurysms?

Findings  In this systematic review and meta-analysis of 114 studies and 106 433 patients, among the 74 studies of endovascular treatment, the risk of procedural clinical complications was 4.96% (95% CI, 4.00%-6.12%), and the case-fatality rate was 0.30% (95% CI, 0.20%-0.40%). In 54 studies of neurosurgical treatment, the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the case-fatality rate was 0.10% (95% CI, 0.00%-0.20%).

Meaning  The complication risks were particularly dependent on detailed and standardized recording of complications, method of outcome assessment, and region and varied according to several patient-level, aneurysm-level, and treatment-associated risk factors.

Abstract

Importance  The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors.

Objective  To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications.

Data Sources  We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017.

Study Selection  Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible.

Data Extraction and Synthesis  Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models.

Main Outcomes and Measures  Clinical complications within 30 days and the CFR.

Results  We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]).

Conclusions and Relevance  This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.

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