A 65-year-old man presents with a ruptured intracranial saccular aneurysm confirmed by CT and CTA showing a 9 mm posterior communicating artery aneurysm with an irregular bleb. GCS is 14, no focal deficits (Hunt and Hess Grade I-II). Based on the ISAT trial evidence, the preferred intervention modality is:
- A Neurosurgical clipping via craniotomy
- B Endovascular coiling (embolization) as the preferred option when technically feasible ✓
- C Conservative management with nimodipine and repeat CTA in 48 hours
- D Lumbar drain placement and delayed intervention after 2 weeks
Explanation
The International Subarachnoid Aneurysm Trial (ISAT) was the landmark RCT demonstrating that endovascular coiling of ruptured intracranial aneurysms reduced the risk of death or dependency at 1 year compared to surgical clipping (23.7% vs 30.6% for coiling vs clipping; RRR 22.6%). Endovascular coiling is now the preferred treatment for ruptured aneurysms when technically feasible. Surgical clipping is preferred for middle cerebral artery aneurysms (due to anatomy), aneurysms associated with large intracerebral hematomas (requiring surgical evacuation), or when coiling is technically not possible. BRAT (Barrow Ruptured Aneurysm Trial) showed similar results.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.