[Neurosurgery or endovascular treatment for subarachnoid hemorrhage due to ruptured aneurysm? In case of doubt choose endovascular treatment].
In the 'International subarachnoid aneurysm trial' (ISAT), patients with ruptured intracranial aneurysms were randomised to endovascular detachable coil treatment or craniotomy with clipping of the aneurysm if either treatment was judged to be suitable. Of all patients assessed for eligibility, endovascular treatment was considered the best treatment for 29% and neurosurgical clipping was considered best for 38%, in 11% the treatment was unknown, which left 22% for whom there was no preference for one of the two treatments and who gave permission for randomisation. In patients allocated endovascular treatment, 24% was dependent or dead at 1 year versus 31% of patients allocated neurosurgical treatment. The relative-risk reduction in dependency or death at 1 year was 23%. The risk of re-bleeding after 1 year was 2 per 1276 patient years in patients allocated endovascular treatment and 0 per 1081 patient years in those allocated neurosurgical treatment. Based on these results it is estimated that in the Netherlands each year at least 500 patients with a ruptured intracranial aneurysm should be treated with endovascular coiling within 3 days of the haemorrhage. This treatment can best be limited to a few centres, since it will otherwise not be possible to gain sufficient experience. The same applies to neurosurgical treatment since the number of patients treated with neurosurgical clipping will decrease.
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Afd. Neurologie, Academisch Medisch Centrum/Universiteit van Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam.
Bosch
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van Rooij
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D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000401:mortality / Q000628:therapy*; D008297:Male; D009426:Netherlands; D018579:Patient Selection; D012008:Recurrence; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D013525:Surgical Instruments; D016896:Treatment Outcome