Treatment selection for ruptured aneurysm and outcomes: clipping or coil embolization

The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.