Endovascular treatment of ruptured aneurysms and vasospasm.

Despite various criticisms, the International Subarachnoid Aneurysm Trial (ISAT) has provided Class I evidence that endovascular therapy (EVT) results in superior 1-year outcomes, compared with surgical repair of ruptured aneurysms equally amenable to both types of treatment. Although the lower occlusion rates and higher rates of recanalization in aneurysms treated with EVT necessitate serial imaging follow-up, these findings do not seem to translate into unacceptably high rates of rebleeding or retreatment morbidity that outweigh the upfront advantage over surgical clipping. EVT also compares favorably to surgery in the treatment of unruptured aneurysms. A randomized, controlled study similar to ISAT is needed for comparing EVT to surgery. EVT appears to have more limitations of durability in large and giant aneurysms, which warrants further research into stent or liquid embolic-assisted treatment because surgical treatment morbidity is also high. Vasospasm is a frequent and potentially devastating complication of aneurysmal subarachnoid hemorrhage. Angioplasty and intra-arterial drug therapy are effective treatments, with an acceptable morbidity and mortality. Angioplasty is more effective and durable and should be considered early in patients with signs of ischemia refractory to maximal medical therapy.