The decision-making process and patient selection for ruptured aneurysms treatment has evolved more as an art than as a science, which is a consequence of the collaborative efforts occurring between all subspecialties involved, the availability of both techniques on a 24–48-h window of treatment, the anatomical factors of the aneurysm neck and sac, as well as local expertise and morbidity factors involved with both options of treatment.
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 1).
Although each of these trials was not methodologically flawless, the combined results from all three suggest that endovascular treatment of ruptured aneurysms suitable for this treatment strategy results in quicker recovery and better functional outcomes at one year at the expenses of lower rates of complete aneurysm obliteration frequently requiring retreatment 2).
The treatment of intracranial aneurysms is best performed at high volume centers that utilize a multidisciplinary, team-based approach 3).
In a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes 4).
European Stroke Organization Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage – February 2013
Fennell et al. conducted a retrospective analysis of a large national database, the University HealthSystem Consortium, that was queried in the years 2009-2013. Cases of both unruptured cerebral aneurysms and subarachnoid hemorrhage treated by endovascular obliteration were studied. Outcome measures of morbidity and mortality were evaluated according to the specialty of the treating physician.
Elective embolization of an unruptured aneurysm was the procedure code and primary diagnosis, respectively, for 12,400 cases. Patients with at least 1 complication were reported in 799 cases (6.4%). Deaths were reported in 193 cases (1.6%). Complications and deaths were varied by specialty; the highest incidence of complications (11.1%) and deaths (3.0%) were reported by neurologists. The fewest complications were reported by neurosurgeons (5.4%; 1.4% deaths), with a higher incidence of complications reported in cases performed by neurologists (p < 0.0001 for both complications and deaths) and to a lesser degree interventional radiologists (p = 0.0093 for complications). Subarachnoid hemorrhage was the primary diagnosis and procedure for 8197 cases. At least 1 complication was reported in 2385 cases (29%) and deaths in 983 cases (12%). The number of complications and deaths varied among specialties. The highest incidence of complications (34%) and deaths (13.5%) in subarachnoid hemorrhage was in cases performed by neurologists. The fewest complications were in cases by neurosurgeons (27%), with a higher incidence of complications in cases performed by neurologists (34%, p < 0.0001), and a trend of increased complications with interventional radiologists (30%, p < 0.0676). The lowest incidence of mortality was in cases performed by neurosurgeons (11.5%), with a significantly higher incidence of mortality in cases performed by neurologists (13.5%, p = 0.0372). Mortality rates did not reach statistical significance with respect to interventional radiologists (12.1%, p = 0.4884).
Physicians of varied training types and backgrounds use endovascular treatment of ruptured and unruptured intracerebral aneurysms. In this study there was a statistically significant finding that neurosurgically trained physicians may demonstrate improved outcomes with respect to endovascular treatment of unruptured aneurysms in this cohort. This finding warrants further investigation 5).