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EDITORIAL
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 59-60

Practicality of aneurysm clipping over coiling in semi-urban and rural India


Department of Neurosurgery, National Neurosciences Mission, Adarsha Super-Specialty Hospital, Manipal-Udupi, Karnataka, India

Date of Submission23-Jan-2022
Date of Decision23-Jan-2022
Date of Acceptance01-Feb-2022
Date of Web Publication5-Apr-2022

Correspondence Address:
Dr. Jaspreet Singh Dil
Department of Neurosurgery, National Neurosciences Mission, Adarsha Super-Specialty Hospital, Manipal-Udupi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_12_22

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How to cite this article:
Dil JS. Practicality of aneurysm clipping over coiling in semi-urban and rural India. J Cerebrovasc Sci 2021;9:59-60

How to cite this URL:
Dil JS. Practicality of aneurysm clipping over coiling in semi-urban and rural India. J Cerebrovasc Sci [serial online] 2021 [cited 2022 Aug 14];9:59-60. Available from: http://www.jcvs.com/text.asp?2021/9/2/59/342556



The tug-of-war between clipping and coiling in the management of aneurysmal bleeds is undeniably constant, as the facts from several perspectives are endless. The ultimate indicator is the patient outcome, but one must also consider the human practicality besides the statistics.

When it comes to clipping or coiling, the first major point is that one may find an exhaustive number of references to back one's argument in support of either mode. That positive outcomes[1],[2],[3] have been achieved through both means, should indicate that the dilemma for the treatment to be chosen is more the victims' than the doctors'.

In a populous country like India with its existing healthcare system, the incidence of disease is higher than the resources available to tackle them. A recent survey[4] on neurovascular intervention had 82% of their participants from urban hospitals while only 18% were in the semi-urban or rural hospitals and showed that endovascular management is performed more frequently in private or nonteaching hospitals, than in government or teaching institutes, where clipping is preferred.

Microsurgical clipping is overall more economical. Neurovascular specialists are more concentrated in larger cities at the disposal of that layer of society that can afford the advancements. However, there are more people in the country who belong to the semi-urban and rural demography and have easier access to centres that can manage them by microsurgical clipping rather than higher centres that facilitate coiling.

As we stress on the importance of time in the salvation of the brain, the above fact makes it clear that patients, who sometimes travel unbelievable distances for treatment, as we have all seen, are able to save and so perhaps gain a lot more time, if they are to opt for a centre where clipping is offered, as compared to coiling. Sometimes, receiving a patient in the 'golden hour' in itself is a long shot; achieving the ideal 'door-to-needle' time is slightly more arduous.

Beyond doubt, the cost of the clip is more affordable than the cost of the stent or coil. Due to this, the theoretical advantages of coiling may not be practically realised.[5] While one may argue that endovascular management is associated with a shorter duration of hospital stay,[6],[7] the time spent outside the hospital in the follow-up period must also be taken into account. Both arms of treatment are associated with the risk of ischaemic stroke, but the coiled patient requires lifelong anti-coagulation and rigorous monitoring of haematological parameters alongside regular consultations, the financial and social burden of which has to be borne for a longer period. It has been recorded that overall cost burden at 2-year and 5-year follow-up is significantly higher in patients treated by coiling as compared to clipping, which may be considered natural, considering the cost of anti-platelets alone.

It has been observed that complication rates from microsurgical clipping, be it intra-operative or post-operative, are higher than from coiling; however, it has also been observed that the risks for need for reoperation and recurrence are higher in coiling.[6] The durability, that is provided by clipping, over coiling, is another major point that favours the practicality of its use in semi-urban and rural India.[1]

The debate between clipping and coiling in the neurovascular world may be perpetual, but so must the desire to improve upon the existing. Provision of acute neurovascular to all parts of the country remains the goal.



 
  References Top

1.
Sharma M, Brown B, Madhugiri V, Cuellar-Saenz H, Sonig A, Ambekar S, et al. Unruptured intracranial aneurysms: Comparison of perioperative complications, discharge disposition, outcome, and effect of calcification, between clipping and coiling: A single institution experience. Neurol India 2013;61:270-6.  Back to cited text no. 1
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2.
Raja PV, Huang J, Germanwala AV, Gailloud P, Murphy KP, Tamargo RJ. Microsurgical clipping and endovascular coiling of intracranial aneurysms: A critical review of the literature. Neurosurgery 2008;62:1187-202.  Back to cited text no. 2
    
3.
Kaku Y, Yamashita K, Kokuzawa J, Hatsuda N, Andoh T. Treatment of ruptured cerebral aneurysms – Clip and coil, not clip versus coil. Acta Neurochir Suppl 2010;107:9-13.  Back to cited text no. 3
    
4.
Ambekar S, Madhugiri V, Pandey P, Yavagal DR. Cerebral aneurysm treatment in India: Results of a national survey regarding practice patterns in India. Neurol India 2016;64 Suppl:S62-9.  Back to cited text no. 4
    
5.
Frontera JA, Moatti J, de los Reyes KM, McCullough S, Moyle H, Bederson JB, et al. Safety and cost of stent-assisted coiling of unruptured intracranial aneurysms compared with coiling or clipping. J Neurointerv Surg 2014;6:65-71.  Back to cited text no. 5
    
6.
Lad SP, Babu R, Rhee MS, Franklin RL, Ugiliweneza B, Hodes J, et al. Long-term economic impact of coiling vs. clipping for unruptured intracranial aneurysms. Neurosurgery 2013;72:1000-11.  Back to cited text no. 6
    
7.
Brunken M, Kehler U, Fiehler J, Leppien A, Eckert B. Coiling vs. clipping: Hospital stay and procedure time in intracranial aneurysm treatment. Rofo 2009;181:989-95.  Back to cited text no. 7
    




 

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