New Trends in Cerebral Aneurysm Management

Yasuhiro Yonekawa, Yoshiharu Sakurai, Emanuela Keller, Emanuela Tsukahara, eds. New York: Springer-Verlag; 2002. 118 pages, 63 illustrations.

This book is a compendium of papers that were presented at the Swiss-Japanese Joint Conference on Cerebral Aneurysms from May 5–7, 2001. This was a two-day conference: the first day was titled “Management of Unruptured Aneurysms,” and the second day was titled “Treatment of Subarachnoid Hemorrhage and General Considerations.” As opposed to a textbook that is organized sequentially according to the topics chosen by the author/editor and follows some preconceived organizational structure, the 118 pages of text in this book are a collection of 20 papers that, apart from the two-day organization of that conference, bear no real relationship to each other.

This is essentially a neurosurgical, not endovascular, rendition. Of the 20 papers, three are primarily related to endovascular treatment. One of the three is a case report of endovascular coiling of a radiation-induced cerebral aneurysm. Another is titled “Endovascular Coiling Compared with Surgical Clipping for the Treatment of Unruptured Middle Cerebral Artery Aneurysms: An Update.” In this paper, the authors report their experience with 40 unruptured middle cerebral artery (MCA) aneurysms in which they treated one by endovascular embolization, 37 by clipping, and two by surgical trapping. They concluded, therefore, that surgical clipping is still the most efficient treatment for unruptured MCA aneurysms. Therefore, two of the three papers containing some reference to endovascular coiling in their title present a total of two cases in which this mode of therapy was used.

The third paper dealing with endovascular coiling in some fashion is titled “Endovascular Aneurysm Treatment from the Neurosurgeon’s Point of View.” In this paper, a neurosurgeon presents his opinion that surgical clipping is still better than coiling. He cites the incidence of recanalization on long-term follow-up as evidence that the long-term durability of endovascular aneurysm treatment is still less satisfactory than clipping, and, therefore, “patients need to be very carefully chosen for GDC embolization” (000).

A small handful of other presentations throughout the papers of cases involving endovascular treatment are largely endovascular treatment failures that were rescued by neurosurgical clipping.

In fairness, this conference predated the availability of results from the ISAT trial, which demonstrated superiority of coiling in clinical outcomes in a randomized population. It is obvious from the subject matter of the papers and their treatment of that subject matter, however, that this was conference for neurosurgeons without much representation from the endovascular community. Although the papers individually treat their separate subject matters reasonably with illustrations that, overall, are adequate and appropriate, a neuroradiologist should not examine this book with any anticipation that there is much of value in it for him or her. There are multiple discussions of surgical approaches to clipping aneurysms in different locations. There are discussions of studies of adjunctive therapy such as hypothermia. There are some outcome series in different populations.

Relative to endovascular treatment, there is no discussion of stent-assisted or balloon-assisted coiling, newer types of detachment mechanisms, or products from any vendors other than the Guglielmi detachable coils from Target Therapeutics and no discussion of biologically active coils. Again, it should be remembered that this conference took place in 2001, before availability of some of these products, but there was certainly discussion in the endovascular community about stent-assisted and balloon-assisted coiling at the time of this conference. In addition, there is wide variability among the authors in their use of newer technologies to assist them from a diagnostic standpoint. Some authors include images from three-dimensional CT or three-dimensional angiography in some of their case presentations. Most do not.

Overall, this book accomplishes its stated purpose, which is the publication of the proceedings of a joint conference on cerebral aneurysms that took place in 2001. The book should not be seen as a textbook or as a real presentation of “new trends in cerebral aneurysm management.” Its intended audience is primarily neurosurgeons who clip aneurysms. It has little applicability to the neuroradiologic community.