Selection Bias in Patients Proposed for Neurosurgical versus Endovascular Treatment of Aneurysms of the Posterior Communicating Artery.

Abstract

Background: Microsurgical clipping and endovascular coiling are viable treatment options for posterior communicating artery (PComA) aneurysms, but there are still major limitations to evidence-based decisions regarding standard-of-care treatment. In this study, we aimed at assessing potential selection biases that may influence our ability to extract conclusions about comparative effectiveness or efficacy of the aneurysm treatment.

Objective: To study the patient/aneurysm characteristics as possible biases in the option for endovascular or neurosurgical treatment of PComA aneurysms.

Methods: A single-center, retrospective cohort study was performed, including all patients with treated PComA aneurysms with neurosurgical clipping or endovascular coiling between January of 2010 and January of 2021. Clinical and morphological data were collected from electronic records and statistical analysis was performed.

Results: A total of 64 patients were eligible for inclusion. 24 (37,5%) patients were proposed for neurosurgical treatment, while 40 (62,5%) for endovascular treatment. 10 patients (25%) crossed-over to the clipping group whereas none crossed-over to the coiling side. Actual treatment analysis showed significantly higher diameters of mother-vessel (T-test, p=0,034) and aneurysm neck (Mann-Whitney, p=0,029) in the clipping group and higher aspect and dome-to-neck ratios in the endovascular group (Mann-Whitney, p=0,008). A significantly higher vasospasm frequency was found in the clipping group but only in the intention-to-treat analysis (Chi-Square, p=0,032).

Conclusion: Significant morphological differences between effective endovascular and surgical groups and differences on intention-to-treat analysis may limit the validity of a direct comparison between treatment options and suggest the presence of a possible selection bias.