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Standard of practice: embolization of ruptured and unruptured intracranial aneurysms
  1. Athos Patsalides1,
  2. Ketan R Bulsara2,
  3. Daniel P Hsu3,
  4. Todd Abruzzo4,
  5. Sandra Narayanan5,
  6. Mahesh V Jayaraman6,
  7. Gary Duckwiler7,
  8. Richard Paul Klucznik8,
  9. Michael Kelly9,
  10. Joshua A Hirsch10,
  11. Don Heck11,
  12. Jeffery Sunshine12,
  13. Don Frei13,
  14. Michael J Alexander14,
  15. Huy M Do15,
  16. Philip M Meyers16
  1. 1Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
  2. 2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  3. 3Department of Interventional Neuroradiology, University Hospitals, Case Medical Center, Cleveland, Ohio, USA
  4. 4Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
  5. 5Departments of Neurosurgery & Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
  6. 6Departments of Diagnostic Imaging and Neurosurgery, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
  7. 7Department of Radiological Sciences, UCLA Medical Center, Los Angeles, California, USA
  8. 8Department of Neuroradiology, Methodist Hospital, Houston, Texas, USA
  9. 9Department of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  10. 10NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  11. 11Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
  12. 12Department of Radiology, University Hospitals, Case Medical Center, Cleveland, Ohio, USA
  13. 13Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
  14. 14Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  15. 15Department of Radiology and Neurosurgery, Stanford University Medical Center, Stanford, California, USA
  16. 16Department of Radiology and Neurological Surgery, Columbia University, New York, New York, USA
  1. Correspondence to Dr Athos Patsalides, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 99, New York, NY 10065, USA; atp9002{at}med.cornell.edu

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Introduction

Since its inception, coil embolization of cerebral aneurysms was designed and approved by the US Food and Drug Administration for aneurysms considered to be high risk for microsurgical clip ligation, but it is now increasingly considered as the first line of treatment. The techniques for endovascular aneurysm treatment have evolved: new devices have been developed that allow treatment of aneurysms with anatomy previously unfavorable for endovascular occlusion, and indications for endovascular treatment have expanded. Nevertheless, intrasaccular coil embolization has become the mainstay of endovascular aneurysm treatment at the present time, and the medical literature demonstrates better outcomes with treatment by coiling than with clipping in specific patient groups.1–3 In a recent scientific statement from the American Heart Association (AHA),4 either endovascular or microsurgical treatment of cerebral aneurysms amenable to treatment was indicated with AHA Class I level of recommendation for ruptured aneurysms and Class IIa for unruptured aneurysms. In both groups the evidence suggests that the benefit of treatment outweighs the risks. A multidisciplinary team experienced in vascular microneurosurgery, neurocritical care and neurointerventional surgery most appropriately applies best techniques to the management of intracranial aneurysms. The Neurovascular Coalition Writing Group has previously published recommendations for training and competence in cerebrovascular intervention with a joint statement.5

The progressive adoption of endovascular techniques for the treatment of the majority of cerebral aneurysms and the availability of new endovascular devices do not necessarily correspond to continuously improving outcomes. A recent study comparing patient outcomes in New York State showed that patient outcomes have not improved significantly over the last decade despite the association of endovascular coiling with better patient outcomes compared with clipping for patients with unruptured intracranial aneurysms (UIAs).6 This finding raises the concern that the quality of endovascular treatment is at a plateau, thus justifying the need …

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