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Journal Club

Cerebrovascular

The Barrow Ruptured Aneurysm Trial: 6-year results

Journal of Neurosurgery | 2015

Rapid review note

Journal Club is a rapid, AI-assisted appraisal layer. It highlights study design, effect estimates, and practice relevance, but it is still a briefing, not a replacement for the paper.

For education only. Not medical advice.

Paper snapshot

Rapid study overview

Open paper

DOI

10.3171/2014.9.JNS141749

PMID

N/A

PICO

Population

Patients presenting with subarachnoid hemorrhage from ruptured aneurysm at a single center, randomized to clip or coil intent in the BRAT trial.

Intervention

Endovascular coil embolization.

Comparator

Surgical clip occlusion.

Outcomes

Poor functional outcome by modified Rankin Scale, long-term obliteration, retreatment, and aneurysm-location subgroup outcomes.

Design

Type

Single-center randomized pragmatic trial

Randomized

Yes

Multicenter

No

Blinded

Outcome nurse independently adjudicated mRS

Follow-up

6 years

Primary endpoint

Poor outcome defined as modified Rankin Scale score greater than 2.

Secondary endpoints

  • Aneurysm obliteration at follow-up
  • Retreatment rates
  • Anterior versus posterior circulation subgroup outcomes

Practice impact

What this means

BRAT is important because it shows that aneurysm treatment is not just a clipping-versus-coiling popularity contest. Coiling looked better for posterior circulation functional outcomes, but clipping was far more durable and required fewer retreatments. The mature lesson is to choose the modality that fits the aneurysm and circulation territory, not to force every case into one camp.

Bottom line

BRAT supports a nuanced aneurysm strategy: coiling appears to maintain a long-term functional advantage for posterior circulation aneurysms, while clipping remains much more durable and overall anterior circulation outcomes were broadly similar.

Strength of evidence

moderate

Recommendation

consider change

Why it matters

  • This is randomized long-term evidence rather than another retrospective aneurysm series.
  • Functional outcomes and durability point in different directions, which argues against oversimplified modality preference.
  • High crossover and location imbalance prevent a stronger blanket recommendation.

What would change my mind

  • Long-term randomized or high-quality registry data showing that modern coiling eliminates the durability gap without sacrificing outcomes.
  • Contemporary comparative evidence showing that posterior circulation benefit no longer favors coiling after current device improvements.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

Randomization strengthens the design, but the trial was pragmatic and treatment crossover was extreme, especially from coil assignment to clipping, which diluted intention-to-treat contrasts.

Confounding

Posterior circulation randomization was skewed by many PICA aneurysms landing in the clipping arm, and this imbalance complicated location-specific comparisons.

Missing data

At 6 years, only 336 of 408 treated patients (82%) were available for examination, although the authors also performed sensitivity analyses using the most recent available mRS score.

Multiplicity

The paper reports several subgroup and as-treated analyses by location and crossover status, so the cleanest read still comes from the main randomized comparison.

Notes

  • Thirty-eight percent of coil-assigned patients crossed over to clipping.
  • The trial is most informative for the long-term tradeoff between functional outcome and durability.
  • Posterior circulation findings favored coiling more consistently than the overall trial did.

Stats check

NNT

N/A

Effect sizes

  • There was no significant overall difference in poor outcome at 6 years between treatment groups (p=0.24).
  • Complete aneurysm obliteration at 6 years was 48% after coiling versus 96% after clipping (p<0.0001).
  • Overall retreatment was 16.4% after coiling versus 4.6% after clipping (p<0.0001).

Absolute effects

  • At 6 years, 60 of 177 coil-assigned patients (34%) and 73 of 188 clip-assigned patients (39%) had poor outcome in the last-available analysis.
  • Six-year follow-up was available for 336 of 408 treated patients (82%).
  • Posterior circulation outcomes favored coiling at every measured time point, whereas anterior circulation outcomes were largely similar.

Concerns

  • The 38% crossover from coil assignment to clipping weakens the trial's ability to detect a true treatment effect.
  • Durability clearly favored clipping, but that did not translate into a major overall functional difference in the intention-to-treat analysis.
  • Location-specific conclusions are partly confounded by skewed posterior circulation randomization.

External validity

Who it applies to

Patients with ruptured intracranial aneurysms evaluated in centers where both clipping and coiling are realistic treatment options.

Who it does not

Settings where anatomy makes one modality clearly impossible, or modern endovascular environments very different from the trial era.

Generalizability notes

  • The pragmatic enrollment strategy makes the cohort broader than highly selective aneurysm trials.
  • The single-center design and dated devices limit direct transfer to current endovascular durability expectations.
  • The strongest practical message is about location-specific nuance rather than a universal winner.

Evidence trace

Source trace and metadata

Citations (4)

claim_id

methods_critique.missing_data

locator

p. 1

claim_id

stats_check.effect_sizes

locator

p. 1

claim_id

stats_check.absolute_effects

locator

p. 3

claim_id

practice_impact.bottom_line

locator

p. 9

Metadata

Generated at

2026-03-08T16:15:00-05:00

Version

manual-pdf-repair-v1