The Source for Neurovascular News and Education

August 23, 2019

 

A meta-analysis of data from more than 500 patients has shown comparable efficacy in ruptured and unruptured cases.

 

Open surgical and endovascular approaches yield similar outcomes for treatment of ruptured and unruptured aneurysms in the pediatric setting, according to a recent institutional evaluation and meta-analysis. The findings were published online August 12, 2018, ahead of print in the Journal of NeuroInterventional Surgery.

 

“Children with brain aneurysms pose unique challenges,” senior author Akash P. Kansagra, MD (Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, MO), told Neurovascular Exchange in an email. “Compared to adults, children generally have longer life expectancies and may even have different types of brain aneurysms [than adults]. . . . In addition, not every hospital has combined expertise in pediatrics and neurovascular disease.”

 

While there are good data to guide decision-making for treatment of aneurysms in adults, similar data are lacking in the pediatric setting.

 

To help fill the gap, Kansagra and colleagues identified 42 pediatric patients with 57 aneurysms who were evaluated at their institution. Of the 57 aneurysms, 25 (44%) were treated using endovascular methods, including coil embolization, Pipeline embolization, liquid embolization, and endovascular vessel sacrifice. Another 13 (23%) were treated using surgical methods, including clipping with or without vascular bypass. The final 19 (33%) were treated conservatively with observation. Treatment-specific outcomes were available for 41 patients, with 37 (90%) having a favorable clinical outcome.

 

The investigators also performed a meta-analysis of the literature, looking at treatment-specific outcome data on 560 pediatric patients from 12 studies. Among these patients, the overall rate of favorable clinical outcome was 84.5%.

 

Kansagra noted that “this research is the product of a collaborative group of endovascular and open vascular experts. This sort of interdisciplinary expertise and collaboration is good not only for research, but . . .  may be an important part of caring for children with neurovascular disease.”

 

The combined data revealed that rates of long-term favorable outcome, defined as an mRS 0-2 or Glasgow Outcome Scale 4-5, were similar for both endovascular and surgical approaches. This was true for children with either ruptured or unruptured aneurysms.

 

Long-Term Favorable Outcome by Treatment Type

 

Endovascular

Surgical

P Value

All Patients

88.3%

82.7%

0.097

Unruptured Aneurysms

96%

97%

1.000

Ruptured Aneurysms

75%

83%

0.357

 

“We found no evidence that either endovascular or open microsurgical treatment was superior to the other when treating children with brain aneurysms,” concluded Kansagra. “Choosing between these options requires considerable expertise, but as a whole, both treatment strategies seem reasonable.”

 

He pointed out, however, that since the trial was not randomized,  “one cannot take expert judgment out of the equation when choosing a treatment strategy.”

 

“While this research represents an important step forward, real-world treatment of pediatric brain aneurysms is more nuanced than simply endovascular vs open microsurgical treatment,” Kansagra continued. “Ultimately, I would like to see a deeper understanding of the roles of the many different kinds of endovascular and microsurgical treatment, and how these recommendations might change for different aneurysm types.”

 

 


Source:

Yasin JT, Wallace AN, Madaelil TP, et al. Treatment of pediatric intracranial aneurysms: case series and meta-analysis. J NeuroInterv Surg. 2018;Epub ahead of print.

 

Disclosures:

Kansagra reports receiving support from MicroVention and Penumbra.