Management of ruptured intracranial aneurysms in the post-ISAT era: outcome of surgical clipping versus endovascular coiling in a Singapore tertiary institution

Abstract

O r i g i n a l A r tic le 332 I NTRO D U C TIO NSubarachnoid haemorrhage (SAH) secondary to intracranial aneurysm rupture remains one of the most serious neurosurgical emergencies today. Intracranial aneurysms are acquired cerebrovascular anomalies that develop throughout a patient's lifetime.(1) They are arterial lesions defined by thinned and dilated regions of the cerebrovascular wall that exhibit loss of the internal elastic lamina, thinning of the tunica media, and subsequent remodelling and degradation of extracellular matrix proteins throughout the vessel wall. Most aneurysms occur at bifurcation sites along the Circle of Willis, as these areas are prone to haemodynamic patterns that potentiate aneurysm development.( 2) The key to minimising the risk of rebleeding following aneurysmal rupture is to isolate the aneurysm from its cerebral circulation. In this regard, surgical clipping and endovascular coiling are both effective, although there has been much debate on the merits of each intervention. there has been much criticism of the trial, as was eloquently highlighted by the BRAT study. For example, it has been cited that in the ISAT, almost 80% of aneurysms were excluded, the proficiencies between the different interventionists and neurosurgeons were varied, and the types of recruiting centres as well as type and location of aneurysms between groups had wide differences. (3,4) Furthermore, the subsequent five-year follow-up data of the ISAT suggest that the benefit in outcome seen at six months had vanished over the ensuing years.However, the current results of the ongoing BRAT study haveshown that a policy of intent to treat by endovascular coiling results in a reduction of poor clinical outcome at one-year of follow-up.Our study was a retrospective audit of our institution's experience in the management of ruptured intracranial aneurysms. We assessed the overall outcomes of patients admitted for SAH secondary to aneurysmal bleeding, and

CSF S100B in patients treated by endovascular coiling or surgical clipping after aneurysmal subarachnoid hemorrhage and its correlation to cerebral vasospasm

“…Recently, a meta-analysis also draw the same conclusion [22]. In addition, some investigations show that surgical clipping is more prone to hydrocephalus [23], cerebral vasospasm [22,24] and epilepsy [21]. In this study, there was a difference of mean CSF S100B between high grade and low grade, which demonstrated that the brain injury degree of high grade was significantly higher than that of low grade.…”

Evolution of Management of Intracranial Aneurysms in Children

“…This trial has influenced treatment of aneurysms at many centers with a trend from surgical clipping toward endovascular management. 70 –72 However, with regard to treatment of pediatric aneurysms, one aspect of the International Subarachnoid Aneurysm Trial is particularly important: the long-term follow-up published in 2009 showed a small but increased risk of recurrent bleeding from a coiled aneurysm compared to a clipped aneurysm. 73 Long-term durability of treatment is crucial in children given the long remaining lifespan.…”

Case-series analysis of intracranial saccular aneurysms treatment

“…The use of coiling spreads from primarily large, teaching hospitals to smaller, non-teaching hospitals (28). Similar trends are in Korea, Australia and Singapore (17,18,29,30).…”