Comparative changes in serum and CSF levels of CRP and Caspase-3 with keyhole clipping and endovascular coiling for ruptured anterior circulation aneurysms.

In addition to traditional clipping and coiling, the keyhole approach provides a third alternative for ruptured aneurysms, promising minimal invasiveness with surgical cure. While biochemical markers of inflammation & apoptosis play a crucial role in the pathophysiology of SAH, the impact of the intervention modality on their levels has not been fully evaluated. This is probably the first study to assess peri-treatment changes in levels of C-Reactive Protein (CRP), an inflammatory biomarker & Caspase-3, an indicator of apoptosis, between patients undergoing keyhole clipping and endovascular coiling, with pterional clipping as the control. Patients with select uncomplicated ruptured anterior circulation aneurysms, admitted within 72 h of ictus, in World Federation of Neurosurgical Societies (WFNS) grades 1–3, were included. Giant aneurysms (> 2.5 cm) and those with midline shift (> 5 mm) were excluded. CRP & Caspase-3 levels were evaluated at admission and after the definitive treatment in serum and CSF. DCI was assessed within 10 days of ictus, while WHOQOL-BREF was evaluated at 3 months. The study included 41 patients who underwent coiling, 38 patients who underwent the supraorbital keyhole approach, and 174 patients who underwent traditional clipping, serving as controls. Important baseline parameters were comparable across the groups. The median peri-treatment percent increase in serum CRP was 248%, 377%, and 416%, while median CSF CRP levels increased by 0.51, 0.53, and 0.65 mg/L among endovascular coiling, keyhole clipping, and traditional clipping groups, respectively. CSF levels of Caspase-3 increased 12% and 55% after keyhole and coiling, respectively. DCI was noted in 32%, 44%, and 43%, while refractory vasospasm was seen in 5.3%, 9.8%, and 14.9% in the keyhole, coiling, and pterional treatment arms, respectively. These were not, however, statistically significant. Subgroup analysis indicated a higher risk of DCI in coiling than keyhole, especially in mFisher 4 (79% vs. 39%, p = 0.03) and WFNS grade 3 (78% vs. 0%, p = 0.05). The median QOL scores were similar in the keyhole (67.17) and coiling (65.89) groups, whereas they were marginally lower in the pterional (64.71) group. The increasing trend of both serum and CSF CRP levels (from before to after-treatment) was the lowest with coiling, moderate with keyhole, and the highest with pterional clipping, apparently suggesting an intermediate inflammatory footprint by keyhole clipping, while CSF Caspase-3 levels, indicative of apoptosis, increased somewhat more with coiling than keyhole.