Introduction: Small intracranial aneurysms pose significant challenges to endovascular therapy. Surgical clipping is considered by many as the preferred treatment for these lesions. We present the results of the first study comparing the two treatment modalities in small ruptured aneurysms (SRA).
Methods: Between 2004 and 2011, 151 patients with SRA (= 3 mm) were treated in our institution, 91 (60.3%) with endovascular therapy and 60 (39.7%) with surgical clipping. Perioperative adverse events and clinical outcomes were analyzed and compared.
Results: The surgical and endovascular groups were generally comparable with respect to baseline demographics with the exception of larger mean aneurysm size in the endovascular compared to surgical group (2.81 vs. 2.55mm, respectively, p<0.001) and a higher proportion of posterior circulation aneurysms in the endovascular group. Endovascular treatment failed in 9.9% of patients. Procedure-related complications occurred in 26.7% of surgical patients versus 9.8% of endovascular patients (p=0.008). Only 3.7% of patients undergoing endovascular therapy experienced an intra-procedural aneurysm rupture. There were no procedural deaths or rehemorrhages in either group. The rates of aneurysm recanalization and retreatment after endovascular therapy were 18.2% and 12.7%, respectively. Favorable outcomes (GOS IV-V) were not statistically different between endovascular (67.1%) and surgical (56.7%, p=0.27) groups.
Conclusions: Lower perioperative complication rates were seen with endovascular therapy compared to open surgery in SRA. However, treatment failure and aneurysm recanalization are serious limitations of endovascular therapy. Surgical clipping remains a valuable treatment modality and both treatment options may be effectively applied in patients harboring SRA.
Patient Care: Our study is the first to provide comparative data between endovascular therapy and surgical clipping in SRA, a category of aneurysms that represents a therapeutic challenge. The data provided will help neurosurgeons make evidence-based clinical decisions for patients with SRA and optimize the management of these patients.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the advantages and limitations of endovascular therapy in SRA. 2) Discuss the advantages and limitations of surgical clipping in SRA. 3) Optimize the management of patients with SRA.