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Published on: August 11, 2015
Microsurgical Clipping of Intracranial Aneurysms in the Endovascular Era
Pablo Harker1, Justin Vranic2, Aman B Patel1
1From the Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Insights
Treatment for intracranial aneurysms has evolved significantly. While endovascular methods are now preferred, microsurgical clipping remains essential for complex cases, posing challenges for surgical training and expertise maintenance.
Area of Science:
- Neurosurgery
- Vascular Neurology
- Medical History
Background:
- Intracranial aneurysms (IA) treatment has a long history marked by evolving techniques and ongoing debates regarding optimal management strategies.
- Historically, cervical carotid ligation was an option, followed by microsurgical clipping, and now endovascular interventions dominate the field.
- The shift towards endovascular treatments presents challenges in maintaining microsurgical expertise for complex IA cases.
Purpose of the Study:
- To provide a historical overview of intracranial aneurysm treatment modalities.
- To critically evaluate the current state-of-the-art in IA treatment.
- To emphasize the continued importance of microsurgical clipping in managing complex intracranial aneurysms.
Main Methods:
- Literature review of historical and contemporary treatment approaches for intracranial aneurysms.
- Analysis of the evolution of surgical and endovascular techniques.
- Discussion of the challenges in maintaining microsurgical expertise.
Main Results:
- Intracranial aneurysm treatment has transitioned from open surgery to a preference for endovascular interventions.
- Endovascular techniques and devices have dramatically shifted treatment paradigms.
- Complex or unsuitable aneurysms still necessitate microsurgical intervention, highlighting a gap in surgical training and volume.
Conclusions:
- Microsurgical clipping remains a critical component of intracranial aneurysm treatment, particularly for complex cases.
- The increasing reliance on endovascular methods poses a challenge to the preservation of essential microsurgical skills.
- A balance between endovascular and microsurgical approaches is necessary for comprehensive IA management.
Abstract:
The treatment of intracranial aneurysms (IA) began in the late 19th century. Some degree of controversy has always surrounded the best treatment modality for IA. Cushing and Dandy debated about cervical carotid ligation as the only surgical alternative before the introduction of microsurgical clipping. In the early 21st century, the debate has centered on surgical versus^ endovascular techniques. With the advent of newer endovascular techniques and devices, there has been a dramatic shift in treatment paradigms toward endovascular intervention that is preferred by both physicians and patients. However, there will always be a need for microsurgical cerebrovascular expertise since some aneurysms cannot or should not be embolized. This creates a difficult conundrum as only the most complex of aneurysms will require open surgery, but the lack of volume and training will be a challenge in teaching and maintaining the surgical expertise required to safely treat them. The purpose of this review is to discuss the history of IA treatment and critically evaluate the current state of the art of IA treatment, with a specific focus on the necessary role microsurgical clipping continues to play in the current treatment landscape.
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