A Stepping Stone in the Quest for Precision Treatment of Unruptured Intracranial Aneurysms

The potential devastation caused by the rupture of an intracranial aneurysm has reinforced the fact that the status quo is not good enough, and continual advances need to be made to optimize patient care. These guidelines are a valuable contribution, because like the ones that have preceded them, they document our rapid advances regarding management of unruptured intracranial aneurysms and provide meaningful recommendations based on the best available literature ^{1, 2}.

Perhaps one of the most exciting aspects of these guidelines is that they highlight the fact that we are entering an era where increasingly, the care of patients can be tailored to their individual pathology. The era of patient precise treatment for intracranial aneurysms is not here yet, but we are making strides toward it. Microsurgical clip ligation and endovascular treatment are no longer viewed as competing treatment options, but rather consideration is given to what is optimal for a particular patient and the morphology of the aneurysm.

There was a time not too long ago that success in treating unruptured aneurysms was at times simply measured by survival. The shift to functional outcome is a testament to the continued evolution of our specialty. This evolution has seen an increased understanding of the molecular biology of some aneurysms and started to provide some tools that allow for the actual visualization of unique radiographic properties of intracranial aneurysms ^3-9. Whether any of these will allow for improved risk stratification still needs to be determined.

Though improved outcomes are seen with patients treated at high volume centers, the definition of high volume centers remains somewhat abstract. What is the minimum number of cases necessary to confer competency? Certainly, this will vary based on the case type and clinician aptitude. As we strive for improved outcomes, it is essential that all tools are available in the armamentarium of the treating physician/team. This will include both microsurgical and endovascular tools. Otherwise, we will be back in the same situation we were in previously, and we will have to force a particular tool for treatment. To ensure that we do not see a regression, further centralization will likely be necessary to ensure that both microsurgical and endovascular care are readily available. The way we train future cerebrovascular specialists will also have to continue to evolve.

The tremendous work/contribution by the authors of this guideline document serves as a testament that the continued multidisciplinary evolution of cerebrovascular disease treatment will afford treatments to patients tomorrow that we can only imagine today.