Shifting Treatment Paradigms for Ruptured Aneurysms from Open Surgery to Endovascular Therapy Over 25 Years

Background Since the introduction of Gugliemi detachable coils in the early 1990s, major clinical studies have supported an increasing role for coil embolization of ruptured aneurysms. We assessed aneurysm location and treatment modality in aneurysmal subarachnoid hemorrhage (aSAH) over the past 25 years. Methods A prospective, institutional review board–approved aneurysm database was screened for patients presenting with aSAH from 1991 to 2016. Microsurgical and endovascular capabilities were present throughout. All patients underwent cerebral angiography prior to treatment. Results Data were available for 1306/1562 patients (83.6%) presenting with aSAH from 1991–2016. 72% were female, with average age 52.8 years, and average aneurysm size 8.0 mm. The most common vessel of origin was the anterior cerebral artery (37.3%), internal carotid artery (33.3%), and middle cerebral artery (14.6%). Posterior circulation accounted for 14.8% of the aneurysms. Open surgery was performed for 72.4% of aneurysms, endovascular treatment for 22.0%, and 5.7% were not treated. There was an increase in aneurysms treated by endovascular methods over 5-year intervals: 3.0% (1991–1996), 13.4% (1997–2001), 17.2% (2002–2006), 24.3% (2007–2011), and 41.9% (2012–2016). Posterior circulation aneurysms led this trend, increasing from 9.1% endovascular to 71.4%. Endovascular treatment increased from 2.9% and 1.4% of anterior cerebral artery and internal carotid artery aneurysms to 39.6% and 40.7%, respectively, in the most recent 5-year interval. By comparison, endovascular methods remained less commonly used for middle cerebral artery aneurysms (0% initially, now 22.0%). Conclusions Endovascular treatment of ruptured intracranial aneurysms has steadily increased over the past 25 years at our major academic institution. This is consistent with positive data from clinical trials, advances in endovascular technology, and increasing experience of endovascular specialists.