Treatment of Intracranial Aneurysms: Clipping Versus Coiling
- 800 Downloads
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.
KeywordsIntracranial aneurysm Clipping Coiling Coiling versus clipping Endovascular Microsurgical Subarachnoid hemorrhage
Compliance with Ethics Guidelines
Conflict of Interest
Ann Liu and Judy Huang declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 21.Bederson JB, Connolly Jr ES, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025.CrossRefPubMedGoogle Scholar
- 31.Connors 3rd JJ, Sacks D, Furlan AJ, Selman WR, Russell EJ, Stieg PE, et al. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention: a joint statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology. J Vasc Interv Radiol. 2009;20:S292–301.CrossRefPubMedGoogle Scholar
- 34.Hoh BL, Cheung AC, Rabinov JD, Pryor JC, Carter BS, Ogilvy CS. Results of a prospective protocol of computed tomographic angiography in place of catheter angiography as the only diagnostic and pretreatment planning study for cerebral aneurysms by a combined neurovascular team. Neurosurgery. 2004;54:1329–40. discussion 1340–1322.CrossRefPubMedGoogle Scholar
- 45.Deutschmann HA, Augustin M, Simbrunner J, Unger B, Schoellnast H, Fritz GA, et al. Diagnostic accuracy of 3D time-of-flight MR angiography compared with digital subtraction angiography for follow-up of coiled intracranial aneurysms: influence of aneurysm size. AJNR Am J Neuroradiol. 2007;28:628–34.PubMedGoogle Scholar
- 57.Nayar VV F, K. Day, A.L.: Management of Unruptured Intracranial Aneurysms., in A Q-H (ed): Schmidek & Sweet Operative Neurosurgical Techniques; Indications, Methods, and Results. . Philadelphia, PA: Elsevier, 2012, Vol 1, pp 812–822.Google Scholar
- 58.Molyneux A, Kerr R. International Subarachnoid Aneurysm Trial Collaborative G, Stratton I, Sandercock P, Clarke M, et al.: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial. J Stroke Cerebrovasc Dis. 2002;11:304–14.CrossRefPubMedGoogle Scholar
- 60.Mcdougall CG. Endovascular coiling of intracranial aneurysms. In: Winn HR, editor. Youmans neurological surgery. 6th ed. Philadelphia: Elsevier Saunders; 2011.Google Scholar
- 64.Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809–17.CrossRefPubMedGoogle Scholar
- 65.••Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RS. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet. 2015;385:691–7. This study describes the long-term follow-up results of the International Subarachnoid Aneurysm Trial.CrossRefPubMedCentralPubMedGoogle Scholar
- 66.••McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg. 2012;116:135–44. They found that the outcomes at 1 year were improved in patients who underwent coiling as compared to patients who underwent clipping. These results were similar to those in the ISAT study.CrossRefPubMedGoogle Scholar
- 67.••Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, et al. The Barrow ruptured aneurysm trial: 3-year results. J Neurosurg. 2013;119:146–57. This study is a follow-up report on the results of BRAT. The authors found that outcomes of coiled patients remained better than that of clipped patients, although patients who underwent clipping had a higher degree of obliteration with a lower rate of recurrence and retreatment.CrossRefPubMedGoogle Scholar
- 73.Molyneux AJ, Kerr RSC, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009;8:427–33.Google Scholar
- 74.••Lanzino G, Murad MH, d’Urso PI, Rabinstein AA. Coil embolization versus clipping for ruptured intracranial aneurysms: a meta-analysis of prospective controlled published studies. AJNR Am J Neuroradiol. 2013;34:1764–8. This study is a meta-analysis of the three prospective, randomized studies comparing clipping and coiling (ISAT, BRAT, and Vanninen et al.) Overall, the rate of poor outcomes at 1 year was significantly lower in patients undergoing coiling.CrossRefPubMedGoogle Scholar
- 76.•Raymond J, Kotowski M, Darsaut TE, Molyneux AJ, Kerr RS. Ruptured aneurysms and the International Subarachnoid Aneurysm Trial (ISAT): what is known and what remains to be questioned. Neurochirurgie. 2012;58:103–14. This paper reviews the criticisms of ISAT and attempts to identify aspects of ISAT that could have been improved.CrossRefPubMedGoogle Scholar