Cerebral aneurysms: Clip or coil?

Endovascular techniques are evolving rapidly and will continue to improve. It has been demonstrated that endovascular access to aneurysms can be achieved safely and reliably. This decade has seen a dramatic improvement in endovascular techniques. The first generation endovascular technique of detachable balloons has given way to the current generation of detachable coils. Having successfully demonstrated safe, reliable access and in selected cases dramatic clinical success, it is expected that future generations of endovascular therapy will equally successfully address the problems of efficacy and durability. Patients with intracranial aneurysms that are not amenable to surgical clipping are indeed fortunate to have an alternative therapy available. For those patients who are surgical candidates, any improvement in the treatment of their aneurysms should be embraced wholeheartedly, but great caution should be exercised in accepting any new technique without rigorous comparison and demonstrable superiority to existing therapies. Only through carefully controlled studies should the use of GDC be expanded beyond the 'non-surgical' aneurysm. At the same time, the definition of 'non-surgical' remains key, and one must guard against the slippery slope of substituting in one's thinking 'non-surgical' for 'difficult.' It must also be remembered that the endovascular treatment of aneurysms is a surgical procedure with attendant risks comparable to other major neurosurgical procedures. Serious consideration of the risks and benefits must be taken before recommending to a patient the replacement of a proven therapy with an unproven therapy of questioned safety, efficacy, and long-term durability. Ultimately, until these questions are answered, patients benefit most from having access to a collaborative team where individuals experienced in all treatment modalities are available and the decisions regarding a particular patient's treatment are made in an open, constructive fashion.