¿Embolización o clipaje?

International subarachnoid aneurysm trial 2009: endovascular coiling of ruptured intracranial aneurysms has no significant advantage over neurosurgical clipping.

Bakker NA, Metzemaekers JD, Groen RJ, Mooij JJ, Van Dijk JM.

Neurosurgery. 2010 May;66(5):961-2.

Department of Neurosurgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands.

In the May 2009 issue of The Lancet Neurology, the 5-year follow-up results of the International Subarachnoid Aneurysm Trial (ISAT) were published. The authors concluded that, although the significant difference between coiling and neurosurgical clipping of ruptured intracranial aneurysms in terms of death and severe disability after 1 year has vanished (primary endpoint), coiling should still be favored over neurosurgical clipping because mortality rates significantly favored coiling. In this commentary, it is this particular conclusion that is challenged by combining data from previous ISAT publications with the current 5-year follow-up results. This modified intent-to-treat analysis clearly demonstrates that the significant advantage in terms of mortality in favor of the endovascularly treated patients is no longer present, with a hazard ratio of 0.80 in favor of endovascular treatment (95% confidence interval: 0.60-1.05; P = .10). Therefore, for everyday clinical practice and decision making, coiling and clipping are to be considered equivalent in the long term. 



¿Qué opinión os merece esta afirmación publicada en Neurosurgery?

Desde mi punto de vista el hecho de que la hemorragia subaracnoidea por rotura aneurismática sea una patología poco prevalente junto con la necesidad de seguimiento a largo plazo dificultan la correcta percepción del médico sobre cuál es mejor tratamiento. La necesidad de retratamiento es mayor en los embolizados y el clipaje es más agresivo. No consigo intuir cuál es mejor aunque parece lógico que dependa de la probabilidad de embolización completa, es decir, de las características del aneurisma.