Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies

Abstract

Object. The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery.Methods. One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome-indicated by mRS scores of 0 to 2 after at least 6 months-was achieved in 71% of patients.Conclusions. Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination. KEY WORDS • intracranial aneurysm• subarachnoid hemorrhage • surgery • endovascular embolization • outcome J. Neurosurg. / Volume 104 / March, 2006 See the Editorial and the Response in this issue, pp 341-343.ESULTS of the ISAT 15 have sparked heated debate over the best treatment modality for ruptured intracranial aneurysms: endovascular coil occlusion or surgical clip application. The ISAT was halted prematurely after data from an interim analysis showed better functional outcome at 1 year posttreatment in patients who had undergone endovascular embolization compared with those who had undergone surgical clip ligation. In Europe, particularly the United Kingdom, the study has had a profound effect on the management of ruptured intracranial aneurysms. 13 On the other hand, the ISAT has not had such a significant impact on neurosurgical vascular practices in the US. A major criticism of the ISAT is that only a minority of the patients evaluated at the participating centers were indeed enrolled in the trial. For inclusion in the study, the patient in question had to have an aneurysm judged by both a neurosurgeon and a neurointerventionalist to be equally amenable to surgery or endovascular embolization...

Endovascular Treatment of Very Small (3 mm or Smaller) Intracranial Aneurysms

“…Moreover, as we have stressed in other publications, it is also important that the risk assessment is carried forward well into the procedure. 17 If, during coiling of a very small aneurysm, the procedure is judged to be technically more challenging than expected, we have a very low threshold to take the patient to surgery. Based on the morbidity and mortality rates observed in this meta-analysis among patients with very small unruptured aneurysms, endovascular treatment of these cases should be pursued very selectively.…”

Embolización versus clipaje microquirúrgico en aneurismas cerebrales de circulación anterior.

“…La literatura indica que los aneurismas gigantes, con mala relación saco/cuello, fusiformes y de arteria cerebral media, no son buenos candidatos para tratamiento endovascular; sin embargo, el diseño de nuevos coils y técnicas como embolización asistida por balón o por stent y sole stenting; permiten obtener buenos resultados en los aneurismas mencionados. 5,[10][11][12][13][14][15] En este estudio se observó que todos los aneurismas gigantes, fusiformes, de arteria cerebral media, y 93 % (n=25) de los aneurismas de cuello ancho se embolizaron sin complicación, realizando embolización asistida con stent en dos casos y sole stenting en uno.…”

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies

“…However, long-term follow up showed that endovascular occlusion of aneurysms is associated with a higher rate of regrowth and consecutive necessity of re-intervention [Molyneux et al 2009]. Nevertheless, numerous studies have been published with the aim of comparing surgical and endovascular aneurysm treatment in order to investigate the superiority of one over the other Therapeutic Advances in Neurological Disorders 4 (5) [Klompenhouwer et al 2011;de Oliveira et al 2007;Fraser et al 2006;Lanzino et al 2006;Taha et al 2006;Sandalcioglu et al 2005;van der Schaaf et al 2005;Hoh et al 2004;Wanke et al 2002].…”