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Juergen Konczalla, Volker Seifert, Juergen Beck, Erdem Güresir, Hartmut Vatter, Andreas Raabe, and Gerhard Marquardt

(earlier period) and post-ISAT era (current period) Characteristic Earlier Period (1980–1995) Current Period (2005–2014) p Value * OR (95% CI) H & H Grade V SAH 54 of 654 (8%) 203 of 1174 (17%) <0.0001 2.3 (1.7–3.2) Aneurysm location   ACA & distal 10 (19%) 61 (30%) NS   MCA & distal 13 (24%) 49 (24%) NS   ICA 10 (19%) 32 (16%) NS   Posterior circulation 4 (7%) 41 (20%) <0.05 3.2 (1.1–9.3)   No aneurysm 1 (2%) 7 (3%) NS   Unknown 16 (30%) 13 (6%) <0.0001 6.2 (2.7–13.8) EVD 18 (33%) 161 (79%) <0.0001 7.7 (4.0–14.8) Early treatment w/in 72 hrs 12 (22%) 137 (67%) <0.0001 7

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Robert F. Spetzler, Cameron G. McDougall, Felipe C. Albuquerque, Joseph M. Zabramski, Nancy K. Hills, Shahram Partovi, Peter Nakaji, and Robert C. Wallace

E ndovascular coil embolization of intracranial aneurysms has become a widely accepted treatment alternative to surgical clip occlusion, especially after the results of the ISAT were published in 2002. 17 In that trial, the coil-treated cohort had fewer poor clinical outcomes after 1 year of follow-up compared with patients who had undergone surgical clipping. However, concerns have persisted regarding the applicability of ISAT, which excluded almost 80% of eligible aneurysms from the study population, thereby calling into question whether the study

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Robert F. Spetzler, Cameron G. McDougall, Joseph M. Zabramski, Felipe C. Albuquerque, Nancy K. Hills, Jonathan J. Russin, Shahram Partovi, Peter Nakaji, and Robert C. Wallace

E ndovascular coil embolization and surgical clip occlusion are the currently accepted treatment options for patients with ruptured intracranial aneurysms. Since the publication of results from the International Subarachnoid Aneurysm Trial (ISAT) in 2002, endovascular treatment has become the mainstay in many centers, especially in Europe. 6 The 1-year results of ISAT showed that for the treatment of ruptured aneurysms, coil embolization was superior to clip occlusion, but most of the trial patients had small aneurysms in the anterior circulation and were

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Robert F. Spetzler, Joseph M. Zabramski, Cameron G. McDougall, Felipe C. Albuquerque, Nancy K. Hills, Robert C. Wallace, and Peter Nakaji

restricted to saccular aneurysms. However, in light of the fact that all other randomized trials comparing clipping and coiling are limited to saccular aneurysms, it is appropriate to analyze this subgroup in the BRAT. Of the 4 randomized trials 4 , 5 , 9 , 11 in the literature that compare coiling and clipping, only the International Sub-arachnoid Aneurysm Trial (ISAT) has demonstrated the superiority of endovascular coiling over surgical clipping beyond the 1st year. 7 Although the remaining 3 studies 4 , 5 , 11 were statistically underpowered, it is noteworthy that

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Robert F. Spetzler, Cameron G. McDougall, Joseph M. Zabramski, Felipe C. Albuquerque, Nancy K. Hills, Peter Nakaji, John P. Karis, and Robert C. Wallace

those with fusiform, blister, dissecting, and saccular aneurysms, and those with aneurysms associated with an arteriovenous malformation or fistula. Although the BRAT was specifically initiated to be compared with the International Subarachnoid Aneurysm Trial (ISAT), we did not predetermine in our protocol that we were limiting the analysis to saccular aneurysms. However, given that every other randomized trial comparing clipping and coiling has been limited to saccular aneurysms, an analysis of this cohort in BRAT is appropriate. Methods The study protocol for the

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Adnan I. Qureshi, Gabriela Vazquez, Nauman Tariq, M. Fareed K. Suri, Kamakshi Lakshminarayan, and Giuseppe Lanzino

2002, the results of the multicenter Phase III International Subarachnoid Aneurysm Trial (ISAT) 22 were reported. The study compared the efficacy of endovascular treatment with surgical treatment in 2143 patients with ruptured aneurysms suitable for either treatment. Recruitment was prematurely stopped after a planned interim analysis showed reduced disability in the endovascular treatment group. A higher proportion of patients allocated to surgery (31% of 793) were dependent or dead at 1 year compared with patients allocated to endovascular treatment (24% of 801

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Tim E. Darsaut, Robert Fahed, R. Loch Macdonald, Adam S. Arthur, M. Yashar S. Kalani, Fuat Arikan, Daniel Roy, Alain Weill, Alain Bilocq, Jeremy L. Rempel, Michael M. Chow, Robert A. Ashforth, J. Max Findlay, Luis H. Castro-Afonso, Miguel Chagnon, Guylaine Gevry, and Jean Raymond

T he International Subarachnoid Aneurysm Trial (ISAT) was a turning point in modern neurosurgical history. 9 The ISAT compared surgical clipping and endovascular coiling of ruptured intracranial aneurysms (RIAs) and showed an absolute 7.4% increase in good clinical outcomes (modified Rankin Scale score < 3) at 1 year for patients treated with endovascular coiling. Because the ISAT was a pragmatic trial, a proper interpretation of results was that coiling should be first-line treatment for patients with the sort of aneurysms included in the study (i.e., those

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Cian J. O'Kelly, Abhaya V. Kulkarni, Peter C. Austin, M. Christopher Wallace, and David Urbach

A neurysmal SAH remains a devastating and often fatal form of stroke. In patients who survive the initial ictus, the aneurysm is targeted for obliteration to prevent the occurrence and sequelae of rehemorrhage events. In recent years, endovascular coiling has emerged as a less invasive alternative to conventional surgical clipping of the aneurysm. The ISAT compared surgical clipping and endovascular coiling of ruptured intracranial aneurysms in a large randomized controlled trial. At 1 year, the results favored coiling and demonstrated a 7.4% absolute risk

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Patrick Mitchell, Richard Kerr, A. David Mendelow, and Andy Molyneux

T he purpose of this paper was to define the sensitivity of the superiority of coil embolization observed in the ISAT cohort according to the rate of late rebleeding over a reasonable range, and to find the range of rebleeding rates for which the superiority of coil embolization may be overturned. Treatment of aneurysmal SAH involves protecting the aneurysm responsible from further hemorrhage. Currently there are 2 methods available to do this: intravascular coil embolization and surgical clip ligation. The relative merits of these treatments depend on 2

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Giuseppe Lanzino, Kenneth Fraser, Yassine Kanaan, and Anne Wagenbach

R esults of the ISAT 15 have sparked heated debate over the best treatment modality for ruptured intracranial aneurysms: endovascular coil occlusion or surgical clip application. The ISAT was halted prematurely after data from an interim analysis showed better functional outcome at 1 year posttreatment in patients who had undergone endovascular embolization compared with those who had undergone surgical clip ligation. In Europe, particularly the United Kingdom, the study has had a profound effect on the management of ruptured intracranial aneurysms. 13