Editorial. Will Hypocrisis Persist after ISAT

Ten years after aneurysms have started being treated with GDC coils, the debate on coils versus clips still exists and will probably exist for a long time. This is my impression if I trust the recent discussions that we had in various neurosurgical meetings around the world since the primary results of the ISAT are known. Before we knew those results, the major argument was that there was no real scientific data that proved the benefit of coiling. Neither the retrospective nor the prospective studies published were convincing enough for those who refuse to open their eyes and their mind. Now we have data coming from a randomized study which is supposed to be “the proof” scientifically speaking. But some people don't care, they just criticise and here are some examples: “Of the 9559 patients only 2143 were randomised! The results are biased just because the population of patients is too selected-Or-The clinical follow-up data was done through questionnaires sent by mail which is too subjective so a patient can easily move from the (some restriction in life style) group to the (significant restriction in life style) group”. Of course those critics are not scientifically founded. Those who criticize either defend corporatism or misunderstand the primary conclusion of the ISAT study. This study does not pretend to demonstrate that coiling should replace clipping, it just says that in case a patient seems to be a good candidate for both techniques, after one year follow-up, the clinical status of the patient is significantly better after endovascular treatment and that's all. Everybody knows that depending on the personal experience of a given team the appreciation of what's possible to achieve can be completely different. Due to the youth of endovascular approach (routine approach since 1995-1996) the neuroradiological analysis has probably underestimated the feasibility of the technique especially regarding middle cerebral artery aneurysms. On the other hand the neurosurgical analysis has probably overestimated the feasibility of the technique. The dramatic evolution of the quality of the angiographic screening (3D angio) is also too young and for that reason the criteria to make a selection for one or the other treatment was at the time of the study more restrictive than it is currently. If the study was started today, I bet that 70 to 80% of aneurysms would be considered suitable for coiling. But there is one thing that would have never been known without this study. It is the rate of early rebleeding after clipping. Yes the early rebleeding rate is a little bit higher after coiling (especially when you input to coiling the rebleeding due to the delay to get Surgery after failure of embolisation), but it was supposed to be zero after clipping ! Just for this, modesty and humility are probably better on both sides. The conclusion of the ISAT study was already perceived for several years (around 70% of aneurysms are coiled in Europe) by most of the Neurosur- geons in Europe and as an Interventional Neuroradiologist I would like to take this opportunity to thank our European Neurosurgeons colleagues for being so objective and open minded. Having said that, it does not explain why some Neurosurgical teams, around the world, keep on clipping 70 to 80% of the berry aneurysms despite the fact they claim that aneurysms treatment is a symbiotic approach with Interventional Neuroradiologists. The “privilege” to admit Patients, which belongs historically to the clinical services, does not mean having rights on Patients. Man power and culture of ego is for sure not the only explanation for continuing clipping aneurysms. Perhaps the explanation is conflict of interest that is to say money. One of the reasons to raise this question is just common sense: The countries where clipping is still the main option for aneurysms treatment are also the one where money is involved. Still more malicious is the manoeuvre of the same group of Neurosurgeons to try to “grab” Interventional procedures to be done in their own department? Is there another option to explain why on one hand one refuses a gift officially and on the other hand one try to get it officiously? How long times will this situation persist after the ISAT results? This is the main concern. How much energy is going to be screwed up to reject or put the discredit on ISAT data in the coming years? On the other hand, in some European countries whose France is the leader, the health care administration does not recognise coiling of aneurysms as being medically and financially a treatment by itself. This administration keeps on giving much more “weight” to neurosurgical approach compared to endovascular approach in the manner coiling is calculated for evaluation of the neuroradiological activity. This administration does not care about the high level of Doctor's expertise, about the cost of the sophisticated angiographic equipment, about the cost of the disposable material that we need for endovascular treatment. Are the comfort and the safety of the patients still a concern for this administration? This is another way to screw up the technique and probably worse than the way some Neurosurgeons behave just because it is not more ethical but much more cagey. There is no doubt that one cannot move back. Endovascular technique is definitely established and will continue to be more and more efficient and safe. It is now our concern as Interventional Neuroradiologists to teach and train Doctors to become competent in the daily work for the benefit of the Patient. But we also have to make these Doctors remember that they are not technicians specialised in aneurysms treatment, but Doctors in charge of Patients. The Neuroradiologists have to take a much more active part in the Patient's care. For the time being it is still the weak point in a lot of interven- tional centres around the world. The decision to treat (why, when and how) does not belong any more to one single team which has the “privilege of beds” it does belong to a multidisciplinary approach whose goal is to give the Patient a treatment which fits with the current gold standard, and the current gold standard in intracranial aneurysms treatment is coiling or rather en- dovascular treatment.