Development of the SAFETEA Scores for Predicting Risks of Complications of Preventive Endovascular or Microneurosurgical Intracranial Aneurysm Occlusion

Annemijn M Algra; Jacoba P Greving; Jordi de Winkel; Arttu Kurtelius; Kamil Laban; Dagmar Verbaan; René van den Berg; William Vandertop; Antti Lindgren; Timo Krings; Peter Y M Woo; George K C Wong; Bob Roozenbeek; Adriaan C G M van Es; Ruben Dammers; Nima Etminan; Hieronymus Boogaarts; Tristan van Doormaal; Albert van der Zwan; Irene C van der Schaaf; Gabriël J E Rinkel; Mervyn D I Vergouwen

doi:10.1212/WNL.0000000000200978

Development of the SAFETEA Scores for Predicting Risks of Complications of Preventive Endovascular or Microneurosurgical Intracranial Aneurysm Occlusion

Neurology. 2022 Oct 17;99(16):e1725-e1737. doi: 10.1212/WNL.0000000000200978.

Authors

Annemijn M Algra¹, Jacoba P Greving², Jordi de Winkel², Arttu Kurtelius², Kamil Laban², Dagmar Verbaan², René van den Berg², William Vandertop², Antti Lindgren², Timo Krings², Peter Y M Woo², George K C Wong², Bob Roozenbeek², Adriaan C G M van Es², Ruben Dammers², Nima Etminan², Hieronymus Boogaarts², Tristan van Doormaal², Albert van der Zwan², Irene C van der Schaaf², Gabriël J E Rinkel², Mervyn D I Vergouwen²

Affiliations

¹ From the Departments of Neurology and Neurosurgery (A.M.A., K.L., T.v.D., A.v.d.Z., G.J.E.R., M.D.I.V.) and Radiology (I.C.v.d.S.), UMC Utrecht Brain Center, and Julius Center for Health Sciences and Primary Care (J.P.G.), University Medical Center Utrecht, Utrecht University; Departments of Neurology (J.d.W., B.R.), Radiology and Nuclear Medicine (A.C.G.M.v.E.), and Neurosurgery (R.D.), Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands; Departments of Neurosurgery (A.K., A.L.) and Clinical Radiology (A.L.), Kuopio University Hospital, Finland; Departments of Neurosurgery (D.V., W.V.) and Radiology and Nuclear Medicine (R.v.d.B.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, the Netherlands; Division of Neuroradiology (T.K.), Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Ontario, Canada; Department of Neurosurgery (P.Y.M.W.), Kwong Wah Hospital, Hong Kong, China; Division of Neurosurgery (G.K.C.W.), Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, China; Department of Neurosurgery (N.E.), University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Neurosurgery (H.B.), Radboud University Medical Center, Nijmegen, the Netherlands. a.m.algra-3@umcutrecht.nl.
² From the Departments of Neurology and Neurosurgery (A.M.A., K.L., T.v.D., A.v.d.Z., G.J.E.R., M.D.I.V.) and Radiology (I.C.v.d.S.), UMC Utrecht Brain Center, and Julius Center for Health Sciences and Primary Care (J.P.G.), University Medical Center Utrecht, Utrecht University; Departments of Neurology (J.d.W., B.R.), Radiology and Nuclear Medicine (A.C.G.M.v.E.), and Neurosurgery (R.D.), Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands; Departments of Neurosurgery (A.K., A.L.) and Clinical Radiology (A.L.), Kuopio University Hospital, Finland; Departments of Neurosurgery (D.V., W.V.) and Radiology and Nuclear Medicine (R.v.d.B.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, the Netherlands; Division of Neuroradiology (T.K.), Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Ontario, Canada; Department of Neurosurgery (P.Y.M.W.), Kwong Wah Hospital, Hong Kong, China; Division of Neurosurgery (G.K.C.W.), Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, China; Department of Neurosurgery (N.E.), University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Neurosurgery (H.B.), Radboud University Medical Center, Nijmegen, the Netherlands.

PMID: 36240099
DOI: 10.1212/WNL.0000000000200978

Abstract

Background and objectives: Preventive unruptured intracranial aneurysm (UIA) occlusion can reduce the risk of subarachnoid hemorrhage, but both endovascular and microneurosurgical treatment carry a risk of serious complications. To improve individualized management decisions, we developed risk scores for complications of endovascular and microneurosurgical treatment based on easily retrievable patient, aneurysm, and treatment characteristics.

Methods: For this multicenter cohort study, we combined individual patient data from patients with UIA aged 18 years or older undergoing preventive endovascular treatment (standard, balloon-assisted or stent-assisted coiling, Woven EndoBridge-device, or flow-diverting stent) or microneurosurgical clipping at one of the 10 participating centers from 3 continents between 2000 and 2018. The primary outcome was death from any cause or clinical deterioration from neurologic complications ≤30 days. We selected predictors based on previous knowledge about relevant risk factors and predictor performance and studied the association between predictors and complications with logistic regression. We assessed model performance with calibration plots and concordance (c) statistics.

Results: Of the 1,282 included patients, 94 (7.3%) had neurologic symptoms that resolved <30 days, 140 (10.9%) had persisting neurologic symptoms, and 6 died (0.5%). At 30 days, 52 patients (4.1%) were dead or dependent. Predictors of procedural complications were size of aneurysm, aneurysm location, familial subarachnoid hemorrhage, earlier atherosclerotic disease, treatment volume, endovascular modality (for endovascular treatment) or extra aneurysm configuration factors (for microneurosurgical treatment, branching artery from aneurysm neck or unfavorable dome-to-neck ratio), and age (acronym: SAFETEA). For endovascular treatment (n = 752), the c-statistic was 0.72 (95% CI 0.67-0.77) and the absolute complication risk ranged from 3.2% (95% CI 1.6%-14.9%; ≤1 point) to 33.1% (95% CI 25.4%-41.5%; ≥6 points). For microneurosurgical treatment (n = 530), the c-statistic was 0.72 (95% CI 0.67-0.77) and the complication risk ranged from 4.9% (95% CI 1.5%-14.9%; ≤1 point) to 49.9% (95% CI 39.4%-60.6%; ≥6 points).

Discussion: The SAFETEA risk scores for endovascular and microneurosurgical treatment are based on 7 easily retrievable risk factors to predict the absolute risk of procedural complications in patients with UIAs. The scores need external validation before the predicted risks can be properly used to support decision-making in clinical practice.

Classification of evidence: This study provides Class III evidence that SAFETEA scores predict the risk of procedural complications after endovascular and microneurosurgical treatment of unruptured intracranial aneurysms.

Publication types

Multicenter Study

MeSH terms

Aneurysm, Ruptured* / complications
Aneurysm, Ruptured* / surgery
Cohort Studies
Embolization, Therapeutic* / adverse effects
Endovascular Procedures* / adverse effects
Humans
Intracranial Aneurysm* / complications
Retrospective Studies
Subarachnoid Hemorrhage* / complications
Subarachnoid Hemorrhage* / surgery
Treatment Outcome