The goal of both surgery (clipping) and endovascular (coiling) treatment is to exclude the lumen of the aneurysm from circulation while preserving cerebral perfusion. Although often controversial, certain factors are used in standard practice to decide the type of treatment. These factors may include patient demographic, ability to tolerate a craniotomy (patient's comorbidities), aneurysm characteristics (eg, size, location, morphology), and available expertise. Endovascular approach is preferred in older patients, patients with severe comorbidities, and high grade SAH. It is also preferred in posterior location aneurysms, giant aneurysms, aneurysms with narrow neck or dome ratio >1.5-2, and unilobar aneurysms.
| Favors Endovascular Treatment | Favors Surgical Treatment |
Age | >70 Years | Younger Age |
Severe Comorbidities | X | |
SAH Grade | High | Low |
Presence of ICH | No | Yes |
Location | Posterior circulation, proximal | MCA, pericallosal, distal |
Neck | Narrow | Wide |
Morphology | Unilobar | Unilobar or fusiform (with arterial branches exiting from aneurysm sac) |
Size | >25 mm | 25 mm or less |
Dome ratio (width/neck) | >1.5-2 | <1.5-2 |
Vascular Anatomy | Nontortuous, nonatherosclerotic proximal vessels | Tortuous or atherosclerotic proximal vessels |
Atherosclerotic calcifications of aneurysm or perianeurysmal parent artery | X | |
Vasospasm | X | |
ICH, intracerebral hemorrhage; MCA, middle cerebral artery; SAH, subarachnoid hemorrhage; X, favors.
Pierot L,Wakhloo AK. Endovascular treatment of intracranial aneurysms: current status. Stroke. 2013;44(7):2046-2054.