B

Fig. 1. Stent coiling of intracranial aneurysm. (A) Right internal carotid angiogram after endovascular coiling of large aneurysm involving the entire lateral wall of the carotid. Note the irregular interface between the coil mass and the lumen of the parent artery (arrow). (B) Anteroposterior film demonstrates endovascular stent (arrow) within the lumen of the carotid bolstering the coil mass within the wide-necked aneurysm.

Fig. 1. Stent coiling of intracranial aneurysm. (A) Right internal carotid angiogram after endovascular coiling of large aneurysm involving the entire lateral wall of the carotid. Note the irregular interface between the coil mass and the lumen of the parent artery (arrow). (B) Anteroposterior film demonstrates endovascular stent (arrow) within the lumen of the carotid bolstering the coil mass within the wide-necked aneurysm.

1-yr follow-up is insufficient to establish the durability of coiling compared with clipping. There has also been a tendency to apply the ISAT data to all patients harboring intracranial aneurysms. This is dangerous since endovascu-lar coiling of all aneurysms irrespective of the width of the neck, dome-to-neck ratio, and complexity of the vascular anatomy could result in higher complications. Another striking aspect of the ISAT trial is the poor surgical outcome. This highly selective patient population had a higher rate (almost 10%) of poor outcome compared with similar patient populations in large prospective surgical series. Despite these criticisms, it should be acknowledged that endovascu-lar therapy is a viable alternative treatment for intracranial aneurysms in carefully selected patients. The angiographic and long-term follow-up data from the ISAT trial may shed some light on the rebleeding rates and patient outcomes. Until there is clear evidence of improved outcomes with endovascu-lar therapy, surgical clip ligation should be considered the first line of therapy, especially in good-grade patients harboring aneurysms.

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