In 1982, Romodanov and Shcheglov14
reported the first large series in which they treated intracranial aneurysms by intra-aneurysmal obliteration using a detachable balloon. The technique proved unsatisfactory, but pushable platinum coils were then introduced for the endovascular treatment of selected intracranial cerebral aneurysms. The platinum coil was supplanted in 1991 by the detachable coil,15
which established the promise of endovascular approaches. Endovascular treatment, however, was used almost exclusively for aneurysms that could not be treated surgically and for patients treated before their aneurysm had ruptured.
Although endovascular techniques were less invasive, their adoption met two barriers: firstly, patients with aneurysms historically were referred to neurosurgeons, who referred to endovascular specialists only those patients for whom a surgical approach posed unacceptable risks; and, secondly, unfavourable outcomes of endovascular obliteration during the early phases of adoption were widely publicised and exploited to maintain direct surgical clipping as the established procedure for treating intracranial aneurysms. More than a decade later, endovascular management began to spread into medical practice for the following reasons:
- The number of neurovascular surgeons (interventionalists) trained reached a critical mass to establish the new technology
- Stroke units evolved to treat a range of cerebrovascular conditions
- Technological advances in image guidance and the versatility of coils reduced the risks of rupture during endovascular procedures
- A large multi-institutional randomised controlled trial comparing endovascular obliteration with microsurgical clipping established the equivalence of outcomes and the marginal advantages of the endovascular approach on outcomes such as morbidity and cost.16
Experts forecast the continued expansion of endovascular treatment and a sharply limited use of direct microsurgical approaches for repairing intracranial aneurysms by the end of the decade. A venerable surgical technology is about to disappear into the annals of history.