150 Chapter 9 even more detector-row scanners, has led to a clear improvement in image quality.43 It is therefore unlikely that MRA, at the present state of the art, will produce better results than CTA. Proposal 5. CEMRA has no benefit over CTA for assessing coilability of intracranial aneurysms in patients with SAH, and CTA should be used as the primary imaging modality in these patients. It must be noted that our single-center study, with a relatively small patient cohort, is one of many similar studies. While several meta-analyses have been carried out in order to assess the value of CTA in the detection of intracranial aneurysms,43-47 the only meta-analysis assessing the value of MRA in this patient population dates from the year 2000.47 Treatment The suitability of an aneurysm for endovascular coiling depends on the morphology of the aneurysm and its relation to the parent vessel and side branches. A wide neck, or the presence of branches originating from the aneurysm, makes the prospect of successful endovascular treatment less likely. With the use of remodeling balloons, neck-bridging stents and flow diverters, nearly all intracranial aneurysms can be treated nowadays, but with increased –and sometimes unacceptable– risks.48,49 Furthermore, there is little scientific evidence that the increased use of these tools results in better patient outcome after endovascular treatment.50 For some aneurysms, though, these tools were very welcome. For example, aneurysms located at the basilar tip are difficult to approach surgically and, at present, only very skilled and experienced neurosurgeons will treat these.51-53 In the majority of centers, such aneurysms are preferentially treated using endovascular coiling, with the support of balloons and/or stents where necessary.53 Most aneurysm locations require both a neuro-interventionist and a neurosurgeon to make a decision on whether to coil or clip, depending on their experience. Other factors such as age and comorbidity of the patient will also play a role in this decision. In Chapter 5 we showed that this joint decision making in the management of patients presenting with aneurysmal SAH in our hospital leads to satisfactory results. Proposal 6. The preferred treatment of intracranial aneurysms is endovascular coiling, but if additional balloon remodeling or stents are required a multidisciplinary discussion should determine the optimal treatment, being either endovascular or surgical. Aneurysms of the basilar tip are primarily treated by endovascular means with balloon remodeling or stent placement where needed. Treatment in high volume centers High volume centers for treating intracranial aneurysms generally have lower mortality and lower poor outcome rates as compared to low volume centers.54-56 Although this is clearly described in the literature and summarized in Chapter 1, no cut off point between “low” and “high” volume in this perspective is defined. In the survey by Bradac et al. a low volume center was defined as one treating less than 31 ruptured aneurysms per year.53 In the United States 82% of hospitals treat fewer than 18 cases per year and these are considered low-volume centers in the study of Vespa.56 In the guidelines of the American Heart Association (AHA) a low volume center is defined as a center treating less than 10 aneurysmal SAH cases per year.3 Our hospital, which admits around 70-80 patients with ruptured aneurysms per year, would be considered a high volume center in the US and a medium volume center by Bradac et al., in which high volume centers are defined as those treating more than 100 ruptured
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