Update on the Management of Subarachnoid Hemorrhage

Katja E Wartenberg


Future Neurology. 2013;8(2):205-224. 

In This Article

Aneurysm Repair

Clipping within 48–72 h of ictus and safer microsurgical techniques result in permanent aneurysm obliteration in over 90% of patients, confirmed by intra- or post-operative angiograms as well as in low morbidity and mortality (5–15%) excluding giant aneurysms.[17,30,101,102] The complication rate of clipping is highest during the repair of large or basilar artery aneurysms.[103–105] Aneurysms on the middle cerebral artery may be more amendable to surgery.[106,107]

With the introduction of Guglielmi Detachable Coils (Target Therapeutics, CA, USA; soft thrombogenic detachable platinum coils) for endovascular therapy of aneurysms in 1991,[108,109] coil embolization became an important alternative to craniotomy and aneurysm clipping. Obliteration of small-necked aneurysms is achieved in 80–90% of cases. The complication rate is up to 9% including perforation and cerebral ischemia.[110] The ISAT trial enrolled 2134 good-grade patients with mostly small aneurysms (<10 mm) in the anterior circulation in a randomized fashion to undergo aneurysm clipping or coiling.[95,111] At 1 year, death and dependency was 23.5% after coiling and 30.9% after clipping (absolute risk reduction of death and dependence at 1 year 7.4% with coiling), which may be attributed to decreased brain retraction injury or intraprocedural rebleeding with coiling compared with clipping. The risk of epilepsy is decreased with coiling after 1 year (14 vs 24%). The main concern about endovascular therapy is an increased rate of rebleeding after several years due to coil compaction and aneurysm regrowth at the residual neck (recurrent hemorrhage 7% after coiling vs 2% with clipping after 1 year).[95,111]

The decision between surgical clipping and endovascular coiling should be made by a team of neurological, surgical and interventional cerebrovascular experts and should be based on clinical and radiological characteristics such as: clinical status of the patient; anticipated surgical ease or difficulty based on anatomical location; anatomy of the access vessels (tortuosity, extent of arteriosclerotic change); width of aneurysm neck in comparison with the dome and the parent artery (wide neck aneurysms are difficult to completely obliterate with coils, coils may migrate and be a source for emboli); and presence of an intracerebral hematoma with mass effect.[29,104]

Recent advances in technique including the balloon remodeling technique that holds the coils in the aneurysm cavity, liquid polymer coils and embolic agents make treatment of broad neck aneurysm feasible. The skills of the treating interventionalist or neurosurgeon, as well as the institution, may have a great impact on outcome. Regardless of the methods, aneurysms should be treated as early as possible to prevent rebleeding. Delayed follow-up imaging to determine the status of the aneurysm over time is reasonable, but deserves further study.[29]