The Neurosurgery Signal — Signal, Not Noise

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

10.1016/S0140-6736(14)60975-2

PMID

25465111

PICO

Population

Patients with ruptured intracranial aneurysms anatomically suitable for either treatment, enrolled in UK centers of ISAT.

Intervention

Endovascular coiling.

Comparator

Neurosurgical clipping.

Outcomes

Death, dependency (modified Rankin scale 0-2), recurrent subarachnoid hemorrhage, independent survival at 10 years.

Design

Type

Randomized controlled trial

Randomized

Yes

Multicenter

Yes

Blinded

Not applicable: treatment assignment not blinded due to procedural nature.

Follow-up

10.0–18.5 years (median not specified).

Primary endpoint

Independent survival (alive with mRS 0-2) at 10 years.

Secondary endpoints

Overall survival at 10 years
Dependency (mRS 0-2) at 10 years
Recurrent subarachnoid hemorrhage >1 year after initial hemorrhage

Practice impact

What this means

This 18-year follow-up of ISAT's UK cohort shows endovascular coiling leads to better independent survival at 10 years compared to clipping for ruptured aneurysms suitable for either treatment. Coiling had higher survival (83% vs 79%) and similar independence rates (82% vs 78%), with a small increased rebleeding risk. The evidence supports coiling as first-line for eligible patients, though individual aneurysm anatomy and patient factors remain crucial.

Bottom line

Endovascular coiling provides better long-term independent survival at 10 years compared to clipping for ruptured aneurysms suitable for both treatments.

Strength of evidence

high

Recommendation

consider change

Why it matters

Randomized trial with long follow-up shows significant benefit in independent survival.
Higher re-treatment risk with coiling but no detriment to outcome.
Results support coiling as first-line for eligible patients.

What would change my mind

New RCT with modern endovascular techniques (e.g., flow diversion) showing different durability.
Longer-term data (>20 years) showing loss of coiling advantage.
Subgroup analyses revealing specific aneurysm types where clipping outperforms.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

Low risk: randomized, intention-to-treat analysis, high follow-up rates (96% at 10 years), CONSORT adherence.

Confounding

Minimal: randomization balanced baseline characteristics, though some loss to follow-up occurred (10 patients after 2 months).

Missing data

Handled with sensitivity analyses using alternative year mRS scores for missing 10-year data.

Multiplicity

Multiple outcomes reported but primary endpoint clearly defined; no adjustment for multiple comparisons mentioned.

Notes

Self-reported mRS may introduce measurement bias.
Long-term follow-up via questionnaires and national death registry.

Stats check

NNT

Not reported: absolute risk reduction for independent survival not provided.

Effect sizes

OR 1.34 (95% CI 1.07-1.67) for independent survival at 10 years favoring coiling
OR 1.35 (95% CI 1.06-1.73) for survival at 10 years favoring coiling
OR 1.25 (95% CI 0.92-1.71) for independence (mRS 0-2) at 10 years

Absolute effects

83% (674/809) alive at 10 years in coiling group vs 79% (657/835) in clipping group
82% (435/531) independent in coiling group vs 78% (370/472) in clipping group at 10 years
33 patients had recurrent SAH >1 year after initial hemorrhage

Concerns

Confidence intervals for independence (mRS 0-2) include 1.0.
Self-reported outcomes may lack clinician assessment.

External validity

Who it applies to

Patients with ruptured aneurysms suitable for both coiling and clipping, similar to ISAT eligibility.

Who it does not

Patients with aneurysms not suitable for both treatments, unruptured aneurysms, or non-UK populations.

Generalizability notes

UK cohort only; other ISAT centers not included in this analysis.
Evolving endovascular techniques may affect durability.

Evidence trace

Source trace and metadata

Citations (3)

claim_id

methods_critique.risk_of_bias

locator

p. 3 Methods

quote

We followed up 1644 patients in 22 UK neurosurgical centres for death and clinical outcomes for 10·0–18·5 years.

claim_id

stats_check.effect_sizes

locator

Table 1

quote

Patients in the endovascular treatment group were more likely to be alive and independent at 10 years than were patients in the neurosurgery group (OR 1·34, 95% CI 1·07–1·67).

claim_id

practice_impact.bottom_line

locator

p. 4 Results

quote

The probability of disability-free survival was significantly greater in the endovascular group than in the neurosurgical group at 10 years.

Metadata

Generated at

2026-03-06T13:39:36.775Z

Version

top 100 cited in past 20 years