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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 …
Contributors All authors contributed to the intellectual content of this manuscript.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.