Wide neck bifurcation aneurysms: what is the optimal endovascular treatment?

Wide neck bifurcation aneurysms (WNBAs) are among the most difficult saccular aneurysms (with large and giant aneurysms) to treat by a surgical or endovascular approach.1 Since aneurysm coiling was introduced, endovascular treatment (EVT) of WNBAs has been challenging for several reasons: (1) neck width makes it difficult to stabilize coils in the aneurysm sac and there is an associated risk of coil protrusion and thromboembolic complication; (2) WNBAs frequently have one to several branches arising from the neck, which may lead to branch occlusion during coiling; and (3) wide neck is associated with a higher risk of aneurysm recanalization.2 To overcome these challenges, several options have been successively developed: balloon assisted coiling (BAC, also known as remodeling technique), stent assisted coiling (SAC), flow diversion, and intrasaccular flow disruption.3 Comparative evaluation of these techniques is complicated by the great variety of aneurysm morphology and lack of a homogeneous indication system for selecting one or another in a specific case. Therefore, creating a safety and efficacy hierarchy between these different techniques requires a scientifically sound evaluation of the individual technique results to determine its specific place in the armamentarium of tools available for EVT of WNBA. This evidence based approach is particularly critical during the COVID-19 pandemic, which forces practitioners to rely on digital techniques to share knowledge and experience. As the possibility of debate is limited in this increasingly digital environment, there is a clear risk of clinicians deliberately misrepresenting studies and results while reporting their beliefs to be scientifically proven to the interventional neuroradiology community. More than anything, it is vital that we avoid disseminating 'fake news' in the interventional neuroradiology field. BAC was evaluated in several series and primarily showed a similar safety compared with coiling alone, but no real improvement to anatomical results.4 This …