Our Philosophy On Aneurysms

The current treatment methods for aSAH include surgical clipping and endovascular coiling. Coiling has been popular in Europe for more than a decade and is now the method of treatment for 60% to 70% of aneurysms; however, it is less popular in the United States. Despite many recent studies that have shown coiling to be more effective than surgical clipping in terms of cost, recovery time, and morbidity and mortality reduction, only approximately 30% of aneurysms are coiled (8,12-16). Currently, only approximately 300 hospitals out of United States' 3000 offer coiling as an option to clipping. We believe that patients should have an informed choice on whether to receive treatment by coiling or clipping. More neurosurgeons, neurologists, and neuroradiologists should be trained in this technique so that the choice is available to greater numbers of people. The insurance reimbursement system might also need to be reevaluated and changed in a way that discourages turf battles over which technique, surgical or endovas-cular, is performed, so that the patients are evaluated in an unbiased manner that determines which treatment is best for them. Additionally, we recognize the need for more studies to evaluate the long-term efficacy and safety of coiling.

It is clear that endovascular coiling is one of the most important developments in the treatment of intracranial aneurysms within the last decade. Although surgical therapy of aneurysms over the past 32 years has reduced the mortality associated with aSAH from 35% to 17.8%, it is also apparent that not all aneurysms can be optimally treated with surgery. Aneurysms are complex lesions that are best approached by complementary, not competing, therapies. We believe that the current challenge is not to prove whether endovascular coiling or surgical clipping is "better," but, instead, to define which types of aneurysm are best approached surgically, endovascularly, or by a combination of the 2 techniques (139).

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