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Review article: Biomedical intelligence

Vol. 146 No. 4344 (2016)

Interdisciplinary decision-making and treatment of intracranial aneurysms in the era of complementary microsurgical and endovascular techniques

  • Serge Marbacher
  • Michael Diepers
  • Timo Kahles
  • Krassen Nedeltchev
  • Luca Remonda
  • Javier Fandino
Cite this as:
Swiss Med Wkly. 2016;146:w14372


Rupture of an intracranial aneurysm is a life-threatening event. Only one third of intracranial aneurysms rupture during a patient’s lifetime. Accurate markers that predict which intracranial aneurysms rupture and which do not are currently lacking in routine clinical practice. Therefore, the treatment decision is a careful balance between the natural history of the intracranial aneurysm and the risk of intervention based on aneurysm- and patient-specific risk factors. Many of these risk factors are also used to determine the modality of intervention. In this review, the authors discuss the interdisciplinary decision-making process and treatment approach in the era of complementary techniques for intracranial aneurysm obliteration.


  1. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009;8(7):635–42. doi: PubMed
  2. Hoffmann E, Marbacher S, Jakob S, Takala J, Remonda L, Fandino J. Incidence of vasospasm, outcome, and quality of life after endovascular and surgical treatment of ruptured intracranial aneurysms: Results of a single-center prospective study in Switzerland. Int Sch Res Notices. 2011;782568. doi:10.5402/2011/782568
  3. Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol. 2011;10(7):626–36. doi: PubMed
  4. Rincon F, Rossenwasser RH, Dumont A. The epidemiology of admissions of nontraumatic subarachnoid hemorrhage in the United States. Neurosurgery. 2013;73(2):217–22, discussion 212–3. doi: PubMed
  5. Gabriel RA, Kim H, Sidney S, McCulloch CE, Singh V, Johnston SC, et al. Ten-year detection rate of brain arteriovenous malformations in a large, multiethnic, defined population. Stroke. 2010;41(1):21–6. doi: PubMed
  6. Wiebers DO, Whisnant JP, Huston J, 3rd, Meissner I, Brown RD, Jr, Piepgras DG, et al.; International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362(9378):103–10. doi: PubMed
  7. Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al., UCAS Japan Investigators. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366(26):2474–82. doi: PubMed
  8. Sonobe M, Yamazaki T, Yonekura M, Kikuchi H. Small unruptured intracranial aneurysm verification study: SUAVe study, Japan. Stroke. 2010;41(9):1969–77. doi: PubMed
  9. Crompton MR. Mechanism of growth and rupture in cerebral berry aneurysms. BMJ. 1966;1(5496):1138–42. doi: PubMed
  10. Beck J, Rohde S, Berkefeld J, Seifert V, Raabe A. Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography. Surg Neurol. 2006;65(1):18–25, discussion 25–7. doi: PubMed
  11. Kemp WJ, 3rd, Fulkerson DH, Payner TD, Leipzig TJ, Horner TG, Palmer EL, et al. Risk of hemorrhage from de novo cerebral aneurysms. J Neurosurg. 2013;118(1):58–62. doi: PubMed
  12. Villablanca JP, Duckwiler GR, Jahan R, Tateshima S, Martin NA, Frazee J, et al. Natural history of asymptomatic unruptured cerebral aneurysms evaluated at CT angiography: growth and rupture incidence and correlation with epidemiologic risk factors. Radiology. 2013;269(1):258–65. doi: PubMed
  13. Güresir E, Vatter H, Schuss P, Platz J, Konczalla J, de Rochement RM, et al. Natural history of small unruptured anterior circulation aneurysms: a prospective cohort study. Stroke. 2013;44(11):3027–31. doi: PubMed
  14. Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke. 1998;29(1):251–6. doi: PubMed
  15. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al.; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial. J Stroke Cerebrovasc Dis. 2002;11(6):304–14. doi: PubMed
  16. Molyneux AJ, Kerr RSC, Yu L-M, Clarke M, Sneade M, Yarnold JA, et al.; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809–17. doi: PubMed
  17. Forget TR, Jr, Benitez R, Veznedaroglu E, Sharan A, Mitchell W, Silva M, et al. A review of size and location of ruptured intracranial aneurysms. Neurosurgery. 2001;49(6):1322–5, discussion 1325–6. doi: PubMed
  18. Chang HS. Simulation of the natural history of cerebral aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms. J Neurosurg. 2006;104(2):188–94. doi: PubMed
  19. Koffijberg H, Buskens E, Algra A, Wermer MJ, Rinkel GJ. Growth rates of intracranial aneurysms: exploring constancy. J Neurosurg. 2008;109(2):176–85. doi: PubMed
  20. Ferns SP, Sprengers ME, van Rooij WJ, van den Berg R, Velthuis BK, de Kort GA, et al. De novo aneurysm formation and growth of untreated aneurysms: a 5-year MRA follow-up in a large cohort of patients with coiled aneurysms and review of the literature. Stroke. 2011;42(2):313–8. doi: PubMed
  21. Chmayssani M, Rebeiz JG, Rebeiz TJ, Batjer HH, Bendok BR. Relationship of growth to aneurysm rupture in asymptomatic aneurysms 7 mm: a systematic analysis of the literature. Neurosurgery. 2011;68(5):1164–71, discussion 1171. PubMed
  22. Greving JP, Wermer MJ, Brown RD, Jr, Morita A, Juvela S, Yonekura M, et al. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol. 2014;13(1):59–66. doi: PubMed
  23. Backes D, Vergouwen MD, Tiel Groenestege AT, Bor AS, Velthuis BK, Greving JP, et al. Phases score for prediction of intracranial aneurysm growth. Stroke. 2015;46(5):1221–6. doi: PubMed
  24. Etminan N, Brown RD, Jr, Beseoglu K, Juvela S, Raymond J, Morita A, et al. The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus. Neurology. 2015;85(10):881–9. doi: PubMed
  25. Naggara ON, Lecler A, Oppenheim C, Meder JF, Raymond J. Endovascular treatment of intracranial unruptured aneurysms: a systematic review of the literature on safety with emphasis on subgroup analyses. Radiology. 2012;263(3):828–35. doi: PubMed
  26. Kotowski M, Naggara O, Darsaut TE, Nolet S, Gevry G, Kouznetsov E, et al. Safety and occlusion rates of surgical treatment of unruptured intracranial aneurysms: a systematic review and meta-analysis of the literature from 1990 to 2011. J Neurol Neurosurg Psychiatry. 2013;84(1):42–8. doi: PubMed
  27. Mayer TE, Etminan N, Morita A, Juvela S. The unruptured intracranial aneurysm treatment score: A multidisciplinary consensus. Neurology. 2016;86(8):792–3. doi: PubMed
  28. Raymond J. Incidental intracranial aneurysms: rationale for treatment. Curr Opin Neurol. 2009;22(1):96–102. doi: PubMed
  29. Thompson BG, Brown RD, Jr, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Jr, et al.; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention; American Heart Association; American Stroke Association. Guidelines for the management of patients with unruptured intracranial aneurysms: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(8):2368–400. doi: PubMed
  30. David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg. 1999;91(3):396–401. doi: PubMed
  31. Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T. Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke. 2001;32(5):1191–4. doi: PubMed
  32. Koivisto T, Vanninen R, Hurskainen H, Saari T, Hernesniemi J, Vapalahti M. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. Stroke. 2000;31(10):2369–77. doi: PubMed
  33. Owen CM, Montemurro N, Lawton MT. Microsurgical management of residual and recurrent aneurysms after coiling and clipping: An experience with 97 patients. Neurosurgery. 2015;62(Suppl 1):92–102. doi: PubMed
  34. Ferns SP, Sprengers MES, van Rooij WJ, Rinkel GJE, van Rijn JC, Bipat S, et al. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates. Stroke. 2009;40(8):e523–9. doi: PubMed
  35. Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J, et al. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years’ experience. J Neurosurg. 2003;98(5):959–66. doi: PubMed
  36. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003;34(6):1398–403. doi: PubMed
  37. Dorfer C, Gruber A, Standhardt H, Bavinzski G, Knosp E. Management of residual and recurrent aneurysms after initial endovascular treatment. Neurosurgery. 2012;70(3):537–53, discussion 553–4. doi: PubMed
  38. Crobeddu E, Lanzino G, Kallmes DF, Cloft HJ. Review of 2 decades of aneurysm-recurrence literature, part 2: Managing recurrence after endovascular coiling. AJNR Am J Neuroradiol. 2013;34(3):481–5. doi: PubMed
  39. Ogilvy CS, Chua MH, Fusco MR, Griessenauer CJ, Harrigan MR, Sonig A, et al. Validation of a system to predict recanalization after endovascular treatment of intracranial aneurysms. Neurosurgery. 2015;77(2):168–73, discussion 173–4. doi: PubMed
  40. Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke. 2001;32(9):1998–2004. doi: PubMed
  41. Ogilvy CS, Chua MH, Fusco MR, Reddy AS, Thomas AJ. Stratification of recanalization for patients with endovascular treatment of intracranial aneurysms. Neurosurgery. 2015;76(4):390–5, discussion 395. doi: PubMed
  42. Raymond J, Darsaut TE, Molyneux AJ; TEAM collaborative Group. A trial on unruptured intracranial aneurysms (the TEAM trial): results, lessons from a failure and the necessity for clinical care trials. Trials. 2011;12(1):64. doi: PubMed
  43. Gonda DD, Khalessi AA, McCutcheon BA, Marcus LP, Noorbakhsh A, Chen CC, et al. Long-term follow-up of unruptured intracranial aneurysms repaired in California. J Neurosurg. 2014;120(6):1349–57. doi: PubMed
  44. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. The barrow ruptured aneurysm trial. J Neurosurg. 2012;116(1):135–44. doi: PubMed
  45. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al.; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74. doi: PubMed
  46. Li ZQ, Wang QH, Chen G, Quan Z. Outcomes of endovascular coiling versus surgical clipping in the treatment of ruptured intracranial aneurysms. J Int Med Res. 2012;40(6):2145–51. doi: PubMed
  47. Korja M. ISAT: end of the debate on coiling versus clipping? Lancet. 2015;385(9984):2250–1. doi: PubMed
  48. Thomas AJ, Ogilvy CS. ISAT: equipoise in treatment of ruptured cerebral aneurysms? Lancet. 2015;385(9969):666–8. doi: PubMed
  49. Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RS. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet. 2015;385(9969):691–7. doi: PubMed
  50. Hernesniemi J, Dashti R, Niemelä M, Romani R, Rinne J, Jääskeläinen JE. Microsurgical and angiographic anatomy of middle cerebral artery aneurysm. Neurosurgery. 2010;66(5):E1030. doi: PubMed
  51. Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome. Neurosurgery. 1996;38(1):2–11. doi: PubMed
  52. Marbacher S, Fandino J, Lukes A. Acute subdural hematoma from ruptured cerebral aneurysm. Acta Neurochir (Wien). 2010;152(3):501–7. doi: PubMed
  53. Regli L, Dehdashti AR, Uske A, de Tribolet N. Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: an update. Acta Neurochir Suppl (Wien). 2002;82:41–6. PubMed
  54. Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular treatment of intracranial aneurysms in elderly patients: a systematic review and meta-analysis. Stroke. 2013;44(7):1897–902. doi: PubMed
  55. Lubicz B, Leclerc X, Gauvrit JY, Lejeune JP, Pruvo JP. Endovascular treatment of ruptured intracranial aneurysms in elderly people. AJNR Am J Neuroradiol. 2004;25(4):592–5. PubMed
  56. Kremer C, Groden C, Hansen HC, Grzyska U, Zeumer H. Outcome after endovascular treatment of Hunt and Hess grade IV or V aneurysms: comparison of anterior versus posterior circulation. Stroke. 1999;30(12):2617–22. doi: PubMed
  57. Lusseveld E, Brilstra EH, Nijssen PC, van Rooij WJ, Sluzewski M, Tulleken CA, et al. Endovascular coiling versus neurosurgical clipping in patients with a ruptured basilar tip aneurysm. J Neurol Neurosurg Psychiatry. 2002;73(5):591–3. doi: PubMed
  58. Choudhri O, Mukerji N, Steinberg GK. Combined endovascular and microsurgical management of complex cerebral aneurysms. Front Neurol. 2013;4:108. doi: PubMed
  59. Fandino J, Taussky P, Marbacher S, Muroi C, Diepers M, Fathi AR, et al. The concept of a hybrid operating room: applications in cerebrovascular surgery. Acta Neurochir Suppl (Wien). 2013;115:113–7. PubMed
  60. Murayama Y, Arakawa H, Ishibashi T, Kawamura D, Ebara M, Irie K, et al. Combined surgical and endovascular treatment of complex cerebrovascular diseases in the hybrid operating room. J Neurointerv Surg. 2013;5(5):489–93. doi: PubMed
  61. Etminan N, Beseoglu K, Barrow DL, Bederson J, Brown RD, Jr, Connolly ES, Jr, et al. Multidisciplinary consensus on assessment of unruptured intracranial aneurysms: proposal of an international research group. Stroke. 2014;45(5):1523–30. doi: PubMed
  62. Kataoka K, Taneda M, Asai T, Kinoshita A, Ito M, Kuroda R. Structural fragility and inflammatory response of ruptured cerebral aneurysms. A comparative study between ruptured and unruptured cerebral aneurysms. Stroke. 1999;30(7):1396–401. doi: PubMed
  63. Frösen J, Piippo A, Paetau A, Kangasniemi M, Niemelä M, Hernesniemi J, et al. Remodeling of saccular cerebral artery aneurysm wall is associated with rupture: histological analysis of 24 unruptured and 42 ruptured cases. Stroke. 2004;35(10):2287–93. doi: PubMed
  64. Marbacher S, Frösén J, Marjamaa J, Anisimov A, Honkanen P, von Gunten M, et al. Intraluminal cell transplantation prevents growth and rupture in a model of rupture-prone saccular aneurysms. Stroke. 2014;45(12):3684–90. doi: PubMed
  65. Marbacher S, Marjamaa J, Bradacova K, von Gunten M, Honkanen P, Abo-Ramadan U, et al. Loss of mural cells leads to wall degeneration, aneurysm growth, and eventual rupture in a rat aneurysm model. Stroke. 2014;45(1):248–54. doi: PubMed

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