Neurosurgical clipping versus endovascular coiling of patients with ruptured intracranial aneurysms.

Abstract

Endovascular coiling of intracranial aneurysms is a technique that has been available for more than 10 years in certain centers. The technique has been FDA approved in the United States since the mid-1990s. A number of publications have demonstrated that endovascular treatment may be effective in reducing rebleeding after subarachnoid hemorrhage due to aneurysmal rupture.1–3 Coils have also been used in unruptured aneurysms. This has typically occurred where direct surgical clipping is thought to be of higher risk. As coil technology has evolved, a steadily increasing number of patients have had aneurysms treated with coils. The question as to whether to clip or coil a specific aneurysm has been the topic of many debates and symposia. In order to shed some light on the use of endovascular coils specifically in patients with subarachnoid hemorrhage, a randomized multicenter trial was designed and the results of this trial, the International Subarachnoid Aneurysm Trial (ISAT), were published in The Lancet .4 While this study was highly referenced in the lay press, there are many features of the study that merit careful consideration as conclusions are drawn. The Lancet study provides us with a comparison of neurosurgical clipping versus endovascular coiling in 2143 patients. The study was designed as a prospective randomized trial, and treating centers were required to have between 60 and 200 cases of patients with subarachnoid hemorrhage annually. A total of 43 centers entered patients. Sixteen centers returned complete ascertainment logs (37% of all centers), 16 centers returned incomplete logs (649 patients randomized), and 11 centers did not return logs (64 patients randomized). To be a participating center, endovascular operators had to have done a minimum of 30 aneurysm treatment procedures before they were permitted to treat patients in the trial. There was no minimum number of criteria for …