Neurosciences
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The International Subarachnoid Aneurysm Trial (ISAT) was designed as the first multi-central international prospective randomized trial aiming to compare the safety and efficacy of the 2 available treatments for ruptured intracranial aneurysms; endovascular coiling and surgical clipping. The initial results were published in the Lancet (2002), and it showed clearly a superiority of coiling over clipping in the treatment of ruptured intracranial aneurysms; 22.7% of coiled patients were dependent or dead compared with 30.6% in the surgical group with absolute risk reduction of 6.9%. ⋯ Despite criticisms, the study has made a significant impact on the treatment of aneurysmal subarachnoid hemorrhage, especially in the United Kingdom and Europe. Since their initial results, the ISAT group has published further papers and updates covering more interesting results regarding the risks of rebleeding, repeat procedures, epilepsy, and the cost effectiveness of both treatments.
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This case report highlights causes of failure of the ventriculo-sagittal sinus (V-S) shunt and precautions to avoid them. We present, a 14-year-old girl, a case of post-hemorrhagic hydrocephalus with multiple revisions of ventriculo-peritoneal (V-P) and ventriculo-atrial (V-A) shunts. ⋯ To avoid malfunction, a cardiac catheter with side slits should be used, magnetic resonance angiography is recommended before shunt placement to check the patency of the sinus, and the pressure in the superior sagittal sinus should be measured at the time of surgery. In patients with problematic distal catheters, direct placement of the catheter into the right atrium using thoracoscope could be an alternative to gall bladder or ureter shunts.