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Clipping versus Coiling for Intracranial Aneurysms: Recent Trends

Carolina Tintim and Humberto S Machado

Background: Cerebral aneurysms are relevant conditions, and the best therapeutic approach in a patient with Ruptured and Unruptured Intracranial Aneurysm has been debated in the last decades. Coil Embolization therapy has increasingly gained popularity over Surgical Clipping.

Objectives: The aim of this analysis was to review the surgical and endovascular strategies for intracranial aneurysms, and to find out if one intervention is more suitable than other.

Methods: A literature review was carried out identifying studies published from 2002-2017 through Pubmed using the keywords listed below. 75 articles were selected to write this review.

Results: The International Subarachnoid Aneurysm Trial contributed to a change in practice of Intracranial Aneurysms. Endovascular Coiling reduced in 7,4% the proportion of patients who died or became dependent, even if the incidence of late rebleeding was higher at 1 year compared to Neurosurgery (2,9% vs. 0,9%). At 18 years the excess risk of rebleeding has not resulted in a significant worse outcome. Endovascular treatment is usually suitable for anterior and posterior circulating aneurysms. Middle cerebral aneurysms are generally treated through clipping. Asymptomatic Unruptured Intracranial Aneurysms smaller than 7 mm usually benefit from simple observation. Despite its benign natural history the number of Unruptured Intracranial Aneurysms treated has increased overtime. Higher mortality is associated with Neurosurgery compared to Endovascular strategy. Anaesthesia applied in surgical clipping is similar to the one applied in endovascular. The most common approaches are general anaesthesia and conscious sedation.

Conclusions: There is strong evidence to indicate that Endovascular Coil embolization is associated with better outcomes compared to Neurosurgical Clipping in patients amenable to either strategy. Despite the major technical advances in imaging and endovascular treatment of intracranial aneurysms, surgical clipping is still the most efficient treatment for medial cerebral artery aneurysms.