Treatment of Ruptured Intracranial Aneurysm: Our Approach

Abstract

There have been revolutionary developments in surgical clipping and endovascular coiling for the treatment of ruptured aneurysms. Surgical clipping as a treatment modality has been developed since the past 100 years. Endovascular coiling of intracranial aneurysms is a technique that has been available for the past 10 years and widely accepted throughout the world. Guglielmi detachable coil treatment is becoming an accepted alternative to microsurgical clipping for select intracranial aneurysms. Since its development a number of publications have demonstrated that endovascular treatment may be effective in reducing rebleeding after subarachnoid hemorrhage due to aneurysmal rupture [ 1-3]. Although it is more comfortable for the patients and is often associated with lower complications rate, coiling is not thought to be resolve all the mass effect caused by aneurysms. Typically the only questions asked about aneurysm therapy are the ability to close and maintain closure of the aneurysm and the patients does not die or sustain a major complication of treatment. The question as to whether to clip or coil a specific aneurysm has been the topic of many debates and symposia. Conflicting reports have been presented to us over the past few years [2,4–6]. Many factors must be considered when determining whether to coil or clip. Dr. Jeffrey Stone, an interventional neuroradiologist at the MCG Neuroscience Center, warns that coiling is not necessarily less risky than clippingmjust less invasive. MCG Neuroscience Center physicians do not view the two procedures as competitors [7]. Patients with aneurysms, whether ruptured or not, are assessed by a multidisciplinary team that recommends the procedure deemed most effective for each individual case. Patients of ruptured aneurysms would benefit maximally from this healthy competition between clipping and coiling. ISAT (International Subarachonoid Aneurysm Treatment Trail) has shown that, in those patients with aneurysms 10ram or less in size that have a favorable configuration to be coiled, coiling is associated with less morbidity than clipping, Dr. Britz wrote. "However, this finding cannot be translated into believing that coiling is safer than clipping in all cerebral aneurysms." He noted that under current practice most middle cerebral artery aneurysms are treated better with clipping than with coiling. In addition, some aneurysms, such as those with a small dome-to-neck ratio or those that have branches coming out of the aneurysm itself have a worse outcome with coiling [7]. We decided to review our data and formulate clear indications for surgical clipping and coiling. In addition to this we studied the benefits of surgical clipping for ruptured aneurysms over endovascular coiling.