• Mario Zanaty, Nohra Chalouhi, Robert M Starke, Badih Daou, Michael Todd, Emine Bayman, James Torner, and David Hasan.
• Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA.
• World Neurosurg. 2016 Nov 1; 95: 262-269.

ObjectiveStudies that showed endovascular coiling of ruptured intracranial aneurysms (RAs) to be superior to microsurgical clipping have compared dedicated endovascular interventionists versus open cerebrovascular surgeons. This is the first study to evaluate outcomes of coiling versus clipping of RAs treated by a dual-trained cerebrovascular surgeon using a specific intervention protocol.MethodsThe prospectively maintained database was reviewed for all patients with RAs undergoing endovascular coiling (± stenting) or clipping by the senior author (dual-trained vascular neurosurgeon) between July 2010 and April 2015.ResultsOf the 252 patients identified, 70 underwent clipping and 182 underwent endovascular treatment. The mean and median time to last follow-up were 179.6 and 176.5 days in the endovascular cohort and 203.9 and 154.0 days in the surgical cohort. There was no difference in age, gender, World Federation of Neurosurgical Societies grade and Fisher grade, mean aneurysm size, and length of stay in the hospital/intensive care unit. Clipping had a higher proportion of middle cerebral artery aneurysms (37.1% vs. 8.8%; P < 0.001) and a lower proportion of aneurysms in the remaining locations (P < 0.001). 34.5% of the endovascular cohort and 32.9% of the clipping cohort were discharged home. There was no difference in modified Rankin Scale score at first or latest follow-up. Most had no significant disability. Mortality of endovascular treatment was 13.2% compared with 10.0% in clipping, and 16.5% versus 18.6% at the latest follow-up (both nonsignificant). The rate of conversion from coiling to clipping was 25.0%.ConclusionsRA treatment should be individualized, with clipping and coiling being 2 complementary arms. Assessment of patient and aneurysm characteristics along with the advantages of both techniques provides an optimal therapeutic modality.Copyright © 2016 Elsevier Inc. All rights reserved.

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