Endovascular treatment for cerebrovascular disease has undergone major developments over the last 15 years. Its dramatic evolution has secured its primary role in the treatment of many conditions (intracranial aneurysms, a proportion of venous sinus thrombosis, some arteriovenous malformations, and many dural fistulas), as an effective alternative to surgery in those with pre-morbid medical conditions (carotid angioplasty and stenting), and as a valuable adjunct to neurosurgery (arteriovenous malformations, some complex giant aneurysms, and skull base tumours). Its current place in hyperacute stroke or idiopathic intracranial hypertension is yet to be defined.

Spinal intervention is also evolving (but is not discussed here).

Neurovascular disease should be managed collectively by a multidisciplinary team comprising an interventional neuroradiologist in conjunction with a neurosurgeon (preferably one with a vascular interest) or head and neck surgeon and/or neurologist as appropriate. Neuropsychological assessment both before and after therapy is desirable to document fully and accurately the efficacy of treatment.

CEREBRAL ANEURYSMS

Cerebral aneurysms may present with subarachnoid haemorrhage (SAH) (incidence 6–8 per 100 000 in most western populations), mass effect or are discovered incidentally. Diagnosis is achieved using computed tomographic (CT) angiography or magnetic resonance (MR) angiography, but the gold standard in most centres is still digital subtraction angiography. Two methods of treatment are available—neurosurgery and, since the introduction of the platinum Guglielimi (electrolytically) detachable coil (GDC) in 1990, endovascular treatment.

The international subarachnoid aneurysm trial (ISAT),^1,2 the only prospective large scale international randomised controlled trial (RCT) comparing neurosurgery with endovascular treatment of ruptured aneurysms, demonstrated a 24% relative and 7.4% absolute reduction of death or dependency at one year in favour of coiling.

Patients are treated usually under general anaesthesia and are systemically heparinised during the procedure. A 6 or 7 French guide catheter is introduced via the femoral artery into the internal carotid artery …