**3.2 Surgical management**

Successful surgery is achieved in most of the cases by excluding aneurysms from circulation but currently, there is a lack of prospective, multicenter and randomized

**187**

**3.4 Coiling**

**3.5 Stent assisted coiling**

*Endovascular Treatment of Brain Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88964*

**3.3 Endovascular treatment (EVT)**

trials that report outcomes in a uniform way. Moreover, most of the studies were done in patients with previous aSAH like the ISAT trial [58], which makes difficult to extrapolate those results to patients with UIA and no history of aSAH. The ISUIA-2 study did evaluate the surgical outcomes of nearly 1500 patients. They reported a mortality rate of 2.7% at 1 year and poor outcome (mRS 3–5) of 1.4% at 1 year. In this study, age > 70, posterior circulation and giant aneurysms were all associated with higher surgical morbidity and mortality. A meta-analysis done in the US with patients without previous history of aSAH that underwent to elective surgical clipping (SC) 14,411 and to endovascular treatment (EVT) 16,659 reported that iatrogenic stroke, intracranial hemorrhage, pulmonary complications, sepsis and status epilepticus were significantly higher after SC [59]. Moreover, the reduced recovery time and shorter stays in hospital [60] play a major role in the final decision of patient to avoid surgery. Nowadays, SC is usually reserved to younger patients that will benefit more from an immediate occlusion of the aneurysm, less need to have follow-up imaging, less probability of retreatment

and the ones with large and giant aneurysms or locations in the MCA.

ments and technological innovation improving safety and efficacy.

with specific characteristics, otherwise new devices must be considered.

EVT emerged in the 1990's with coiling [62]. Since then, technological advances in coil properties made neuro-interventional procedures safer with improved outcomes. Recently, a single center study reported 0% of poor outcomes when coiling was used [25], however >20% of poor outcomes have been reported after coiling in aneurysms >10 mm size, with wide necks, unfavorable dome-to-neck ratio < 2 and fusiform configuration [63]. So, using coiling alone must be used just in aneurysms

This method represents a solution for aneurysms in which coiling alone will not be the best option (mentioned in **Figure 1**), as coiling this endovascular technique has the same concerns about patient selection, recovery and risks. However, when leaving a stent placed in the artery it is important to manage the tolerance and adherence of the patient to dual anti-platelet therapy (DAPT) (**Figure 2**)[64].

Since its conception, endovascular treatment has rapidly taken over as the major treatment for most intracranial aneurysms. While there is supporting data for ruptured intracranial aneurysms from the ISAT trial, there is no randomized controlled trial comparing surgery and endovascular treatment to surgical clipping for unruptured aneurysms. Relative indications for endovascular treatment are poor surgical candidate, favorable aneurysm and vascular anatomy, high risk for anesthesia complications and posterior circulation aneurysms. In 2012, a systematic review and meta-analysis reported different outcomes between endovascular treatments; >52 years, >10 mm and posterior circulation location were main risk factors to poor outcomes [61]. Coiling alone was safer compared to the percent of complications reported with balloon-assisted coiling 7.1% (99% CI 3.9–12.7), 9.3% (99% CI 4.9– 16.9) with stent-assisted coiling and 11.5% (99% CI 4.9–24.6) with flow-diverting stents. However, the increase of the complications reported with additional devices can be due to the more-complex aneurysm cases or due to the number and type of devices placed. Furthermore, in the last decade the neuro-interventional procedures have improved their outcomes with increased understanding of the various treat*Endovascular Treatment of Brain Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88964*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

growth, although it is unclear whether this frequency of time-interval is truly

whether their aneurysm is going to burst and when.

*Giant right vertebral aneurysm before and after coiling.*

**3.2 Surgical management**

necessary. However, is not uncommon to have mixed factors in UIA patients, to make it clear, a systematic review showed that if hypertension and history of SAH are present (considering this both as major risk factors) in a patient under 70 years, with an <10 mm UIA in the anterior circulation, we will still be talking about a probability of risk of ~1% per year [24]. So, a standardized timing for imaging follow-ups according to each patients and aneurysm related factors does not exist, in part because aneurysm growing is discontinuous but the ELAPSS score (mentioned in **Figure 1**) can be helpful to determine the need of follow-up at 3 or 5 years based on the risk of aneurysm growth [55]. These patients who choose conservative management live with a small very definite risk of rupture. Recently, a study showed that patients with untreated UIA, may decrease their quality of life (QoL) and moreover, trigger mental disorder as anxiety and depression [56, 57] possibly due to the uncertainty of

Successful surgery is achieved in most of the cases by excluding aneurysms from circulation but currently, there is a lack of prospective, multicenter and randomized

**186**

**Figure 1.**

trials that report outcomes in a uniform way. Moreover, most of the studies were done in patients with previous aSAH like the ISAT trial [58], which makes difficult to extrapolate those results to patients with UIA and no history of aSAH. The ISUIA-2 study did evaluate the surgical outcomes of nearly 1500 patients. They reported a mortality rate of 2.7% at 1 year and poor outcome (mRS 3–5) of 1.4% at 1 year. In this study, age > 70, posterior circulation and giant aneurysms were all associated with higher surgical morbidity and mortality. A meta-analysis done in the US with patients without previous history of aSAH that underwent to elective surgical clipping (SC) 14,411 and to endovascular treatment (EVT) 16,659 reported that iatrogenic stroke, intracranial hemorrhage, pulmonary complications, sepsis and status epilepticus were significantly higher after SC [59]. Moreover, the reduced recovery time and shorter stays in hospital [60] play a major role in the final decision of patient to avoid surgery. Nowadays, SC is usually reserved to younger patients that will benefit more from an immediate occlusion of the aneurysm, less need to have follow-up imaging, less probability of retreatment and the ones with large and giant aneurysms or locations in the MCA.
