Aneurysms unsuitable for endovascular intervention: surgical outcome and management challenges over a 5-year period following International Subarachnoid Haemorrhage Trial (ISAT).

OBJECTIVE: To analyse outcome of surgical management of aneurysms unsuitable for endovascular intervention in a tertiary referral neurosurgical unit over a 5-year post-ISAT period. To compare secondary parameters such as operating time, number of clips required, and training over last 5 years with similar number of patients in the pre-ISAT period.
METHODS: Consecutive 54 patients harbouring 62 uncoilable aneurysms admitted from May 2002 to April 2007 in a tertiary neurosurgical unit. Outcome analysed at 3 months using Glasgow Outcome Score and Modified Rankin Scale based on standard questionnaires. Comparison with outcome of surgical arm of ISAT study performed.
RESULTS: At 3 months 28 (90%) of Grades I-II and 9 (39%) of Grades III-V patients harbouring uncoilable aneurysms had good clinical outcome (MRS 0-2) comparing favourably with the surgical arm of the ISAT study at 2 months. (relative risk=0.28, 95% CI 0.08-0.45; P=0.01) Surgical time, number of clips required for aneurysmal obliteration had however increased significantly compared to pre-ISAT period. The training potential was severely restricted with uncoilable aneurysms.
CONCLUSIONS: Ruptured cerebral aneurysms deemed unsuitable for endovascular intervention are also difficult cases to treat surgically. However, with neurovascular sub-specialisation, it is possible to achieve favourable surgical outcome in a higher percentage of cases than reported in the ISAT study and the National Study of Subarachnoid Haemorrhage. These cases, due to their technical complexities, unfortunately offer limited training potential for pre-certification Neurosurgical trainees.