Compare  and  contrast  the advantages  and  disadvantages  of coiling versus clipping of cerebral aneurysms after Sub-Arachnoid Haemorrhage.

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College Answer

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.

Discussion

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:

Coiling vs clipping in ruptured aneurysms

Advantages of coiling:

  • minimally invasive
  • improved survival at 1 year
  • Better effects in posterior fossa aneurysms
  • Less risk of cognitive decline or epilepsy

Advantages of clipping:

  • More certain: 81% of aneurysms are completely obliterated
  • Less risk of rebleeding (0.9%)
  • MCA aneurysms are more amenable to clipping

Disadvantages of coiling

  • Greater risk of rebleeding (2.9%)
  • Fewer aneurysms get completely obliterated (58%)
  • Small aneurysms (<3mm) are impossible to coil

Disadvantages of clipping:

  • More invasive
  • Greater risk of cognitive decline or epilepsy
  • Survival rates equivalent at 5 years
  • Posterior fossa aneurysms are inaccesible to clipping

 

References