title: Treatment of small ruptured intracranial aneurysms: comparison of surgical and endovascular options.
abstract: BACKGROUND
  Small intracranial aneurysms pose significant challenges to endovascular therapy. Surgical clipping is considered by many to be the preferred treatment for these lesions. We present the results of the first study comparing the 2 treatment modalities in small ruptured aneurysms.
  
  
  RESULTS
  Between 2004 and 2011, 151 patients with small ruptured aneurysms (≤3 mm) were treated in our institution: 91 (60.3%) with endovascular therapy and 60 (39.7%) with surgical clipping. The surgical and endovascular groups were generally comparable with regard to baseline demographics, with the exception of larger mean aneurysm size in the endovascular group versus the surgical group (2.8 versus 2.5 mm, 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 23.3% of surgical patients versus 9.8% of endovascular patients (P=0.01). Only 3.7% of patients undergoing endovascular therapy experienced an intraprocedural 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 (moderate, mild, or no disability) were not statistically different between the endovascular (67.1%) and surgical (56.7%) groups (P=0.3).
  
  
  CONCLUSIONS
  Surgical clipping was associated with a higher rate of periprocedural complications, but overall disability outcomes were similar. Endovascular therapy, if technically feasible, might be a preferred option in this setting. Inclusion of patients with small aneurysms in randomized controlled trials seems feasible and will be needed to provide definitive information on the best therapeutic approach. (J Am Heart Assoc. 2012;1:e002865 doi: 10.1161/JAHA.112.002865.).
authors.affiliation: Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience,  Philadelphia, PA.
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: David L
authors.initials: DL
authors.lastname: Penn
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.forename: L Fernando
authors.initials: LF
authors.lastname: Gonzalez
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Muhammad S
authors.initials: MS
authors.lastname: Ali
authors.forename: Robert
authors.initials: R
authors.lastname: Rosenwasser
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
keywords: aneurysm, ruptured; aneurysm, small; clipping; endovascular procedures