Interventional Neuroradiology

neuroradiologist. In general, however, GDC is favored in the following circumstances:

Posterior Circulation Aneurysms Surgical morbidity/mortality for posterior circulation aneurysms is higher than that for anterior circulation aneurysms and may require invasive approaches through the skull base. Morbidity for GDC treatment is similar for both anterior and posterior circulation aneurysms.

Frail or Very Elderly Patients In frail or very elderly patients at high risk from craniotomy or patients of poor grade: endovas-cular packing can prevent re-bleeding and allow more aggressive treatment of vasospasm; treatment options at other sites are more controversial. The GDC was initially used to treat aneurysms not suitable for surgery (those thought to be of high surgical risk). It was soon found, however, that coiling small aneurysms that were suitable for surgery had the lowest morbidity and best results.

Anterior Communicating Artery Aneurysms

Opinions amongst neuroradiologists and neurosurgeons vary widely, even in individual centers. There is controversy as to whether neurosurgical treatment of anterior communicating artery aneurysms causes more neuropsy-chological damage than coiling, or whether damage is due to the hematoma from rupture of the aneurysm itself. Wiebers, in his recent publication on the natural history and treatment of unruptured aneurysms [12], showed significant neuropsychological deficit in patients undergoing elective clipping. There is also controversy as to whether patients undergoing coiling experience less vasospasm than those undergoing surgery [13]. Many centers thus choose coiling for suitable anterior communicating artery aneurysms.

Middle Cerebral Artery Aneurysms Middle cerebral artery aneurysms have complex anatomy and it is often difficult, because of this anatomy, to adequately image and preserve normal branches during coiling. The consequences of a large MCA stroke are also dire, with 40-50% mortality. Many centers, including ours, do not coil MCA aneurysms unless the patient is elderly or of poor grade.

Posterior Communicating Artery Aneurysms

Posterior communicating artery aneurysms are technically straightforward to clip and usually to coil. Despite the fact that the GDC was first used in 1990 and over 20,000 patients worldwide have been treated, only case series have been presented and published. Case series are unreliable and can be biased, particularly if the operator (surgeon and neuroradiologist) reports the case series [14].

The best way to determine the difference between two treatment modalities is to conduct a prospective randomised control trial. The International Subarachnoid Aneurysm Trial was the first multi-centre prospective randomised clinical trial comparing neurosurgical clipping and endovascular coil treatment for patients with a ruptured cerebral aneurysm causing acute subarachnoid haemorrhage. This was funded primarily by the Medical Research Council, UK. The pilot phase commenced in 1994 and ISAT actively commenced centre recruitment in January 1997, with the aim of enrolling up to 3,000 patients. The ISAT steering committee halted recruitment in May 2002 at 2,143 patients after an interim analysis by the independent data monitoring committee showed a clear advantage to the coiling technique. Follow-up data was available on 1,594 patients overall. 27.2% were dead or dependent, with 30.6% in the neurosurgery arm and 23.7% in the endovascular arm, representing a 22.6% relative risk reduction and a 6.9% absolute risk reduction in the endovascular arm. The overall mortality rate was similar between the two groups, with a 10.1% of the neurosurgical group having died and 8.1% of the endovascular group. What this means for patients in the future is that potentially out of 100 patients treated, around 7 could expect to be better off one year on if they receive endovascular treatment rather than surgery. For many patients, this could be the difference between a return to normal life or substantial disability. Although there has been substantial debate about this trial, particularly about the durability of coiling and the small re-bleed rate, this trial has already impacted on clinical practice in the UK, Europe and the United States. Many centres now choose coiling as the preferred method of treatment of ruptured aneurysms but the debate continues [14a].

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