Compare and contrast the advantages and disadvantages of coiling versus clipping of cerebral aneurysms after Sub-Arachnoid Haemorrhage.
Recent published experience demonstrates that there are some significant potential benefits associated with coiling of cerebral aneurysms. These include decreased costs, no need for craniotomy and associated neuroanaesthetic, and increased independent survival (“ISAT” Lancet 2002; 360:1267-74). Other potential advantages include no need for temporary clipping. Major disadvantages include the need for a skilled operator, the fact that technique is not suitable for all aneurysms, requirement for anticoagulation, and inability to deal with major complications. A neurosurgical procedure may still be required if complications ensue.
Clipping has a long track record with clearly defined risks, with no evidence of increased mortality. Most aneurysms are amenable to clipping, though in some regions (eg. posterior fossa), because of accessibility, coiling is considered the procedure of choice. Disadvantages of surgical clipping include need for a skilled operator, a craniotomy and neuroanaesthesia, and potentially increased costs.
Both techniques require some degree of sedation/paralysis, and subsequent neuro-Intensive care with close monitoring and re-evaluation for complications. Either technique may be quite prolonged.
The coiling vs clipping debate is aired briefly in the chapter on management of the unsecured aneurysm in subarachnoid haemorrhage. In it, there is this table:
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Advantages of coiling:
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Advantages of clipping:
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Disadvantages of coiling
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Disadvantages of clipping:
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Bakker, Nicolaas A., et al. "International subarachnoid aneurysm trial 2009: endovascular coiling of ruptured intracranial aneurysms has no significant advantage over neurosurgical clipping." Neurosurgery 66.5 (2010): 961-962.
Connolly, E. Sander, et al. "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association." Stroke 43.6 (2012): 1711-1737.