Aneurysm surgery after the International Subarachnoid Aneurysm Trial (ISAT)
- Correspondence to: R S Maurice-Williams Consultant Neurosurgeon, The Royal Free Hospital and Medical School, London, NW3 2QG, UK; Diane.Faraday-Browneroyalfree.nhs.uk
Every so often in the history of medicine a major technical or pharmaceutical innovation leads to a sudden and fundamental shift in practice. Such events as the introduction of general anaesthesia, the use of antisepsis in surgery, and the introduction of streptomycin immediately spring to mind. Similar events have also occurred in the narrow world of neurology and neurosurgery. The appearance of carbamazepine and l-dopa had an immediate and dramatic effect upon the extent to which surgery was used in trigeminal neuralgia and Parkinson’s disease. The computed tomography (CT) scan quickly led to the disappearance of lumbar air encephalography and ventriculography and the redundancy of the radiological expertise that these older forms of investigation required.
It seems likely that the International Subarachnoid Aneurysm Trial (ISAT) will have a comparable effect on aneurysm surgery. Even before the publication of the results of the interrupted trial in The Lancet in October 20021 there had been a progressive shift from surgery to coiling in the treatment of aneurysms whether these had ruptured or not. Since the publication of ISAT it is clear that many units in the UK have almost abandoned direct surgery. This change may have been more marked in the UK than in other countries for, in this country, few patients with aneurysms receive private treatment—meaning that any change in policy has no economic disadvantage for the surgeon.
The gravity of this development for neurosurgery cannot be overestimated. A ruptured aneurysm is the most common neurosurgical condition which requires the highest degree of surgical skill. The condition affects relatively young patients who are otherwise in good health, and treatment can make the difference between a full cure with a normal life expectancy on the one hand and death or hopeless disability on the other. Aneurysm surgery constitutes, or at …
