Clipping Versus Coiling for Ruptured Intracranial Aneurysms

Abstract

Patients with intracranial aneurysms, both ruptured and unruptured, are frequently eligible for both open surgery ("clipping") and endovascular repair ("coiling"). Although results of randomized trials have informed this decision, the actual choice of clipping or coiling for individual patients remains complex. At the 2007 Congress of Neurological Surgeons (CNS) Annual Meeting, a novel active learning process called Integrated Medical Learning (IML) was applied to education about this critical treatment choice. CNS members received an electronically distributed premeeting survey and educational materials about the clipping versus coiling decision and related topics. At the Annual Meeting, participants used handheld devices to choose clipping or coiling for treatment of individual aneurysms, both before and after expert opinion presentations. After the meeting, members who had answered premeeting surveys received a follow-up questionnaire. In the premeeting poll, respondents with self-described specialties of "vascular," Cerebrovascular Section members, surgeons with active cerebrovascular practices, and surgeons in practice for less than 20 years had higher levels of baseline knowledge of cerebrovascular literature (P < .03). Surgeons' clinical volumes of clipping and coiling strongly influenced their vote for clipping or coiling for a hypothetical patient (P < .01). At the meeting, in 6 of 8 cases of ruptured aneurysms the audience was split 75%:25% or closer to "clinical equipoise" (50:50 split). Surgeons with vascular specialty, academic surgeons, and residents were more likely to recommend clipping for individual cases (P < .05). After experts' presentations, in 6 of 8 cases the audience opinion changed significantly. Vascular specialists and younger surgeons were less likely to change their opinion (P < .03). The 2 cases with no shift in opinion were the most-clippable and most-coilable cases. Postmeeting surveys showed evidence of retained knowledge from the meeting, and respondents thought IML had been helpful. Using IML, we were able to study baseline knowledge and practice patterns for an important cerebrovascular treatment decision. Evidence suggested that expert presentations were effective in changing audience opinion, at least in cases where preexisting opinion was close to clinical equipoise.