In most patients with aneurysmal subarachnoid hemorrhage, transcranial microsurgical clamping of a ruptured aneurysm will not prevent any more disability than endovascular spring-ring interventional embolization. However, aneurysm clamping provides better elimination of the aneurysm and requires less re-treatment. Robert Spetzler, MD, PhD, director of the Belo Neurological Center in Phoenix, AZ, presented the results of six years of the Belo Ruptured Aneurysm Study (BRAT), “We can make a strong claim that anterior circulation aneurysms should be surgically clamped. Head-to-Head Study Based on the similar results of the 2 treatment options reported in previous studies, Dr. Spetzler and his colleagues set out to compare the 2 treatment options, following the principles of a head-to-head study. They randomly assigned 238 patients with ruptured aneurysms to the clamping group and 232 to the spring-ring embolization group. Six years later, 336 patients who had been treated were available for further analysis and evaluation. Thirty-eight percent of patients assigned to the spring-ring embolization group crossed over into the clamping group, while 2% of patients in the clamping group crossed over into the spring-ring embolization group. At the end of the first year, 24% of patients assigned to the spring-ring embolization group had a modified Rankin Scale (mRS) score greater than 2, indicating mild to severe disability. In contrast, 35% of patients assigned to the clamping group had a modified Rankin Scale score that high. The difference between the two groups was statistically significant (P=.03). But by the third year, the difference between the two groups had disappeared, according to the 2013 study published in the Journal of Neurosurgery. Also, although there was an absolute difference of 5.8% between the spring-ring embolization group as opposed to the clamping group, the difference between the two groups was not significant. In the sixth year, which is the most recent study, the results are reported here. Modified Rankin Scale scores greater than 2 resulted in 35% of patients assigned to the clamped group and 41% of patients assigned to the spring-ring embolization group, with no statistically significant difference between the two groups (P = .24). At each time period, spring-ring embolization still resulted in better modified Rankin Scale scores for posterior circulation aneurysms, but modified Rankin Scale scores were equal for anterior circulation aneurysms at each time period. Dr. noted just three posterior inferior cerebellar aneurysms ended up in the spring-ring embolization group, while 13 were in the clamping group. Because these aneurysms had a worse overall prognosis, superior modified Rankin Scale scores were obtained at 1 year with spring-ring embolization. Also at year 6, 96% of patients in the clamped group had complete aneurysm resolution, compared with only 48% of patients in the spring-ring embolization group, a finding that was also statistically significant (P = .0001). Also, only 4% of patients in the clamping group required retreatment, compared with 13% of patients in the spring-ring embolization group, a statistically significant difference between the two groups (P =.001). Most aneurysms “are a really great study,” said Robert Rosenwasser, chairman of neurosurgery at Thomas Jefferson University in Philadelphia, Pennsylvania, USA, in an official commentary done in response to the study. And the official comments in response to the study were part of the AANS meeting. “Most of the aneurysms, particularly anterior circulation aneurysms, the data support transcranial surgery,” he said. But he pointed out to surgeons at his institution that slightly better results have been obtained in certain categories of patients in the spring-ring embolization group than in the clamping group, particularly those with posterior circulation aneurysms, those with poorly graded aneurysms and those with comorbid major medical disease. Lesson: We have to remember that the treatment of intracranial aneurysms in patients must last a lifetime, not just a few years. Anterior circulation aneurysms have good surgical exposure and it is entirely possible to cure most anterior circulation aneurysms in a single visit without sequelae, provided the surgeon is experienced enough.