Clipping versus coiling for subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

Journal of Neurosurgery

Posted online on May 26, 2017.

Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka; 2Department of Clinical Trials and Research, National Hospital Organization Nagoya Medical Centre, Nagoya; 3Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita; 4Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo; 5Integrative Stroke Imaging Centre; 6Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita; 7Department of Neurosurgery, Iwate Medical University, Morioka; 8Department of Neurosurgery, Chiba Cerebral and Cardiovascular Centre, Chiba; 9Department of Neurosurgery, Kyorin University, Mitaka; 10Department of Emergency and Critical Care Medicine, Showa University Hospital, Shinagawa; 11Department of Neurosurgery, Osaka Medical College, Takatsuki; 12Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu; 13Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu; 14Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya; 15Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara; 16Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-Akita; and 17Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
ABBREVIATIONS BRAT = Barrow Ruptured Aneurysm Trial; CCI = Charlson Comorbidity Index; CSC = comprehensive stroke center; DPC = Diagnosis Procedure Combination; HAC = hospital-acquired condition; ISAT = International Subarachnoid Aneurysm Trial; JCS = Japan Coma Scale; mRS = modified Rankin Scale; PPV = positive predictive value; PSI = patient safety indicator; RCT = randomized controlled trial; SAH = subarachnoid hemorrhage.
Correspondence Koji Iihara, Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. email: .

INCLUDE WHEN CITING Published online May 26, 2017; DOI: 10.3171/2016.12.JNS161039.

*Dr. Kurogi and Ms. Kada contributed equally to this work.

Disclosures Dr. Yoshimura has participated in the speaker’s bureau and/or has received honoraria from Bayer, Sanofi, Boehringer-Ingelheim, and Otsuka Pharmaceutical Co. and has received grants from Terumo and Takeda Pharmaceutical Co.



Although heterogeneity in patient outcomes following subarachnoid hemorrhage (SAH) has been observed across different centers, the relative merits of clipping and coiling for SAH remain unknown. The authors sought to compare the patient outcomes between these therapeutic modalities using a large nationwide discharge database encompassing hospitals with different comprehensive stroke center (CSC) capabilities.


They analyzed data from 5214 patients with SAH (clipping 3624, coiling 1590) who had been urgently hospitalized at 393 institutions in Japan in the period from April 2012 to March 2013. In-hospital mortality, modified Rankin Scale (mRS) score, cerebral infarction, complications, hospital length of stay, and medical costs were compared between the clipping and coiling groups after adjustment for patient-level and hospital-level characteristics by using mixed-model analysis.


Patients who had undergone coiling had significantly higher in-hospital mortality (12.4% vs 8.7%, OR 1.3) and a shorter median hospital stay (32.0 vs 37.0 days, p < 0.001) than those who had undergone clipping. The respective proportions of patients discharged with mRS scores of 3–6 (46.4% and 42.9%) and median medical costs (thousands US$, 35.7 and 36.7) were not significantly different between the groups. These results remained robust after further adjustment for CSC capabilities as a hospital-related covariate.


Despite the increasing use of coiling, clipping remains the mainstay treatment for SAH. Regardless of CSC capabilities, clipping was associated with reduced in-hospital mortality, similar unfavorable functional outcomes and medical costs, and a longer hospital stay as compared with coiling in 2012 in Japan. Further study is required to determine the influence of unmeasured confounders.


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