Intracranial Aneurysm treatment

Volovici et al. reviewed and analyzed studies investigating devices and procedures used in intracranial aneurysm (IA) treatment for methods and completeness of reporting and to compare the results of studies with positive, uncertain, and negative conclusions.

Embase, MEDLINE, Web of Science, and The Cochrane Central Register of Clinical Trials were searched for studies on IA treatment published between January 1, 1995, and October 1, 2022. Grey literature was retrieved from Google Scholar.

All studies making any kind of claims of safety, effectiveness, or durability in the field of IA treatment were included.

Data extraction and synthesis: Using a predefined data dictionary and analysis plan, variables ranging from patient and aneurysm characteristics to the results of treatment were extracted, as were details pertaining to study methods and completeness of reporting. Extraction was performed by 10 independent reviewers. A blinded academic neuro-linguist without involvement in IA research evaluated the conclusion of each study as either positive, uncertain, or negative. The study followed Preferring Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Main outcomes and measures: The incidence of domain-specific outcomes between studies with positive, uncertain, or hostile conclusions regarding safety, effectiveness, or durability were compared. The number of studies that provided a definition of safety, effectiveness, or durability and the incidence of incomplete reporting of domain-specific outcomes were evaluated.

Overall, 12 954 studies were screened, and 1356 studies were included, comprising a total of 410 993 treated patients. There was no difference in the proportion of patients with poor outcomes or in-hospital mortality between studies claiming a technique was safe, uncertain, or not safe. Similarly, there was no difference in the proportion of IAs completely occluded at the last follow-up between studies claiming a technique was effective, uncertain, or ineffective. Less than 2% of studies provided any definition of safety, effectiveness, or durability, and only 1 of the 1356 studies provided a threshold under which the technique would be considered unsafe. Incomplete reporting was found in 546 reports (40%).

Conclusions and Relevance: In this systematic review and meta-analysis of IA treatment literature, studies claiming safety, effectiveness, or durability of IA treatment had methodological flaws and incomplete reporting of relevant outcomes supporting these claims 1).

see Ruptured intracranial aneurysm treatment.

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

The efficacy of intracranial aneurysm treatment (long-term success or effectiveness of the treatment) is measured by evidence of the aneurysm obliteration (failure to be demonstrated by conventional or noninvasive angiography), without evidence of aneurysm recanalization (any blood flow into the aneurysm) or aneurysm recurrence (reappearance).

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 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 2).

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 3).

The treatment of intracranial aneurysms is best performed at high volume centers that utilize a multidisciplinary, team-based approach 4).

In a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes 5).

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 6).

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

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Shivashankar R, Miller TR, Jindal G, Simard JM, Aldrich EF, Gandhi D. Treatment of cerebraPIIneurysms-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.
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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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