title: Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey.
abstract: BACKGROUND
  Asymptomatic aneurysms that are increasingly discovered on cranial diagnostic imaging are a growing management dilemma. Large-scale studies have shown that in most instances, conservative management is appropriate for the majority of patients with aneurysms less than 7 mm in maximum diameter. It is unclear whether international practise mirrors practise in these large trials.
  
  
  OBJECTIVE
  To determine how neurosurgeons around the world manage patients with asymptomatic aneurysms.
  
  
  METHODS
  Electronic survey of 283 clinicians managing patients with aneurysms using a 55-item questionnaire detailing characteristics of their experience, their hospitals and their present and future practises and insights regarding the management of patients with intracerebral aneurysms.
  
  
  RESULTS
  The 203 neurosurgeons (72%) who responded had a median of 17 years of practise with aneurysms and managed a median of 25 aneurysms annually. The majority of neurosurgeons endorsed treatment of all asymptomatic aneurysms regardless of size. Only four out of 10 neurosurgeons would manage patients with 4 mm anterior communicating artery or middle cerebral artery aneurysms non-surgically, whereas fewer than 2% would conservatively manage asymptomatic patients with 10 or 16 mm aneurysms. Neurosurgeons were split as to the recommended techniques for asymptomatic aneurysms of 10 or 16 mm with about half of them electing clipping and half coiling for ACoA and nearly three quarters favouring clipping for the MCA aneurysm. Although international differences exist between Europe, North America and the rest of the world, most state that their choice of treatment related to decisions around what option would provide the best neurological outcome and prevention of long-term bleeding.
  
  
  CONCLUSIONS
  Despite large trials supporting the management of small asymptomatic aneurysms, most neurosurgeons internationally chooses to treat them with surgery or endovascular means. Since clinicians use a number of factors beyond the maximum diameter when considering treatment options, future trials should consider these factors in their design.
authors.affiliation: a Division of Neurosurgery , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Ontario , Canada ;
authors.forename: Nabeel
authors.initials: N
authors.lastname: Alshafai
authors.affiliation: b Faculty of Education, Ontario Institute for Studies in Education , University of Toronto , Toronto , Ontario , Canada ;
authors.forename: Olesya
authors.initials: O
authors.lastname: Falenchuk
authors.affiliation: a Division of Neurosurgery , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Ontario , Canada ;|b Faculty of Education, Ontario Institute for Studies in Education , University of Toronto , Toronto , Ontario , Canada ;|c Dalla Lana School of Public Health, University of Toronto , Toronto , Ontario , Canada.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Cusimano
mesh_terms: D000328:Adult; D020771:Anterior Cerebral Artery / Q000473:pathology / Q000601:surgery; D001291:Attitude of Health Personnel; D003362:Cost-Benefit Analysis; D057510:Endovascular Procedures; D005260:Female; D019538:Health Care Surveys; D006761:Hospitals; D006801:Humans; D020407:Internet; D002532:Intracranial Aneurysm / Q000191:economics / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery; D000069471:Neurosurgeons; D019635:Neurosurgical Procedures; D011795:Surveys and Questionnaires
keywords: Asymptomatic aneurysms; clipping; endovascular; international; management