29/08/2025
The concept of a "gold standard" treatment for cerebral aneurysms has evolved significantly over time, and there is currently no single universally accepted gold standard. The treatment landscape has shifted from one dominant approach to multiple effective options. # # Historical Gold Standard: Microsurgical Clipping**For decades, microsurgical clipping remained the gold standard and foremost modality for treatment of cerebral aneurysms**[1]. This surgical approach was established as the primary treatment method and was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937[2]. Surgical clipping involves placing a specially designed clip at the base of the aneurysm, typically performed through craniotomy[2]. # # Current Treatment Paradigm: Dual StandardsThe treatment of cerebral aneurysms now involves two primary approaches that are considered equally effective: # # # 1. Surgical Clipping- Involves direct surgical access to place a clip at the aneurysm base- Provides definitive occlusion of the aneurysm- Generally associated with lower rebleeding rates compared to coiling[2] # # # 2. Endovascular Coiling- **Neurointerventional surgery has become the primary management strategy for both ruptured and unruptured cerebral aneurysms in most institutions**[3]- Involves threading a catheter through arteries to place coils inside the aneurysm- Less invasive than surgical clipping and may be safer[4]- Uses soft, flexible wire coils that seal off the aneurysm from the artery[4] # # Treatment Selection Considerations**While a large meta-analysis found the outcomes and risks of surgical clipping and endovascular coiling to be statistically similar, no consensus has been reached**[2]. The choice between treatments depends on several factors:- **Aneurysm characteristics**: Size, location, neck width, and morphology- **Patient factors**: Age, medical comorbidities, and neurological status- **Timing**: Whether the aneurysm is ruptured or unruptured- **Institutional expertise**: Availability of specialized teams # # Advanced Endovascular OptionsFor complex cases, additional endovascular techniques have emerged: # # # Flow Diverters- **Pipeline embolization device (PED) is currently used most often in the U.S.**[5] for large or giant wide-necked aneurysms- FDA approved for specific types of aneurysms on the internal carotid artery[5]- Particularly useful for aneurysms challenging for traditional coiling[5] # # # Assisted Coiling Techniques- **Stent-assisted coil embolisation** and **balloon-assisted coil embolisation** for wide-necked and complex aneurysms[1]- These techniques improve occlusion rates and reduce recurrence[1] # # Current Clinical Practice**There is little doubt on the treatment for ruptured cerebral aneurysms, which are typically secured with clips or coils to prevent re-rupture**[5]. Both surgical clipping and endovascular coiling are performed within the first 24 hours after bleeding when possible[2].The treatment decision is individualized based on the specific characteristics of each case, with both approaches representing current standards of care rather than a single gold standard. The field continues to evolve with technological advances in both surgical and endovascular techniques.
