Treatment of Intracranial Aneurysms: Clipping Versus Coiling

Abstract

Intracranial aneurysms (IAs) have an estimated incidence of up to 10 % and can lead to serious morbidity and mortality. Because of this, the natural history of IAs has been studied extensively, with rupture rates ranging from 0.5 to 7 %, depending on aneurysm characteristics. The spectrum of presentation of IAs ranges from incidental detection to devastating subarachnoid hemorrhage. Although the gold standard imaging technique is intra-arterial digital subtraction angiography, other modalities such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are being increasingly used for screening and treatment planning. Management of these patients depends upon a number of factors including aneurysmal, patient, institutional, and operator factors. The ultimate goal of treating patients with IAs is complete and permanent occlusion of the aneurysm sac in order to eliminate future hemorrhagic risk, while preserving or restoring the patient's neurological function. The most common treatment approaches include microsurgical clipping and endovascular coiling, and multiple studies have compared these two techniques. To date, three large prospective, randomized studies have been done: a study from Finland, International Subarachnoid Aneurysm Trial (ISAT), and the Barrow Ruptured Aneurysm Trial (BRAT). Despite differences in methodology, the results were similar: in patients undergoing coiling, although rates of rebleeding and retreatment are higher, the overall rate of poor outcomes at 12 months was significantly lower. As minimally invasive procedures and devices continue to be refined, endovascular strategies are likely to increase in popularity. However, as long-term outcome studies become available, it is increasingly apparent that they are complementary treatment strategies, with patient selection of critical importance.

Off-label uses of the Pipeline embolization device: a review of the literature

“…47 Two well-conducted, randomized, controlled trials have evaluated these 2 methods in the treatment of intracranial aneurysms and looked at recurrence and retreatment rates. 7,66 In the International Subarachnoid Hemorrhage Trial (ISAT), 9.0% of patients treated with coiling and 0.85% of patients treated with microsurgical clipping had to be retreated due to recurrence.…”

Predisposing factors for recanalization of cerebral aneurysms after endovascular embolization: a multivariate study

“…Endovascular therapy is now the first-line treatment for the majority of cerebral aneurysms 1. However, aneurysm treatment after endovascular embolization has a higher frequency of recanalization than surgical clipping, ranging from 6.1% to 33.6% 2.…”

A new combined parameter predicts re-treatment for coil-embolized aneurysms: a computational fluid dynamics multivariable analysis study

“…Although coil embolization is superior compared with surgical clipping when considering the physical burden on patients, aneurysmal recanalization and re-treatment remain major problems for this method. 1–6 In previous studies, recanalization was observed during follow-up in approximately 10% to 25% of coil-embolized aneurysms. 7 8 Many attempts have been made to overcome the drawbacks of coil embolization, including the development of parameters that can help predict recanalization or re-treatment.…”