Intracranial Aneurysm treatment

Intracranial Aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT has taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned.

The treatment of intracranial aneurysm aims the complete elimination of the aneurysm from the circulation with neuroendovascular treatment or surgery.

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).

Given the similar clinical results of both modalities, the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventually repeated procedure which is more likely if an endovascular procedure is chosen 5).

European Stroke Organization Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage – February 2013

Liu A, Huang J. Treatment of Intracranial Aneurysms: Clipping Versus Coiling. Curr Cardiol Rep. 2015 Sep;17(9):628. doi: 10.1007/s11886-015-0628-2. PubMed PMID: 26238743.
Sorenson T, Lanzino G. Trials and tribulations: an evidence-based approach to aneurysm treatment. J Neurosurg Sci. 2015 Oct 16. [Epub ahead of print] PubMed PMID: 26474147.
Shivashankar R, Miller TR, Jindal G, Simard JM, Aldrich EF, Gandhi D. Treatment of cerebral aneurysms-surgical clipping or endovascular coiling: the guiding principles. Semin Neurol. 2013 Nov;33(5):476-87. doi: 10.1055/s-0033-1364217. Epub 2014 Feb 6. PubMed PMID: 24504611.
Aboukais R, Zairi F, Thines L, Aguettaz P, Leclerc X, Lejeune JP. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie. 2014 Sep 19. pii: S0028-3770(14)00121-0. doi: 10.1016/j.neuchi.2014.06.010. [Epub ahead of print] PubMed PMID: 25245925.
Beneš V, Štekláčová A, Bradáč O. Repeated Aneurysm Intervention. Adv Tech Stand Neurosurg. 2022;44:277-296. doi: 10.1007/978-3-030-87649-4_16. PMID: 35107686.
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