Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature

An Excellent Functional Recovery Following Grade IV Subarachnoid Hemorrhage From a Cerebral Aneurysm Rebleed With Ultra-Early Surgical Intervention: A Case Report

Aneurysms are focal abnormal dilations of the arterial wall occurring frequently at branching points along the arteries of the base of the brain. Aneurysmal rupture is one of the possible aneurysm complications and can cause aneurysmal subarachnoid hemorrhages (aSAH). Treatment of aSAH consists of pharmacologic, surgical, or endovascular approaches. The ultra-early intervention of ruptured aSAH occurs within the first 24 hours after ruptured aSAH. This case is about a 49-year-old obese male with multiple comorbidities who suffered from a grade IV subarachnoid hemorrhage and underwent an ultra-early surgical clipping approximately four hours after admission to the emergency center. The patient had excellent functional recovery at a six-month follow-up. Ultra-early surgical intervention for high-grade aSAH with rebleeding could improve outcomes.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

BACKGROUND/OBJECTIVE

Patients with poor-grade subarachnoid bleed (World Federation of Neurosurgical Societies grades 4-5) often improve their neurocognitive function months after their ictus. However, it is essential to explore the timing of intervention and its impact on long-term outcome. We compared the long-term outcomes between immediate management within 24 h and delayed management after 24 h in patients following poor-grade subarachnoid bleed.

METHODS

This was a retrospective population-based study, including patients with poor-grade subarachnoid bleed who received definitive management between 1 January 2011 and 31 December 2016 in a large tertiary neurocritical care unit. The primary outcome was adjusted odds ratio of favourable outcome (Glasgow Outcome Scale 4-5) for survivors at 12 months following discharge, as measured by the Glasgow Outcome Scale. The secondary outcomes included adjusted odds ratio of a favourable outcome at discharge, 3 months and 6 months following discharge and survival rate at 28 days, 3 months, 6 months and 12 months following haemorrhage.

RESULTS

A total of 111 patients were included in this study: 53 (48%) received immediate management and 58 (52%) received delayed management. The mean time delay from referral to intervention was 14.9 ± 5.8 h in immediate management patients, compared to 79.6 ± 106.1 h in delayed management patients. At 12 months following discharge, the adjusted odds ratio for favourable outcome in immediate management versus delayed management patients was 0.96 (confidence interval (CI) = 0.17, 5.39; p = 0.961). At hospital discharge, 3 months and 6 months, the adjusted odds ratio for favourable outcome was 3.85 (CI = 1.38, 10.73; p = 0.010), 1.04 (CI = 0.22, 5.00; p = 0.956) and 0.98 (CI = 0.21, 4.58; p = 0.982), respectively. There were no differences in survival rate between the groups at 28 days, 3 months, 6 months and 12 months (71.7% in immediate management group vs. 82.8% in delayed management group at 12 months, p = 0.163).

CONCLUSIONS

Immediate management and delayed management after poor-grade subarachnoid bleed are associated with similar morbidity and mortality at 12 months. Therefore, delaying intervention in poor-grade patients may be a reasonable approach, especially if time is needed to plan the procedure or stabilise the patient adequately.

Timing of treatment of aneurysmal subarachnoid haemorrhage: are the goals set in international guidelines achievable?

BACKGROUND AND AIMS

International guidelines emphasise the importance of securing ruptured cerebral aneurysms within 48-72 h of ictus. We assessed the timing of treatment of patients with aneurysmal subarachnoid haemorrhage (aSAH) referred to a national neurosurgical centre.

MATERIALS AND METHODS

Analysis of a prospective database of patients with aSAH admitted between 1st of February 2016 and 29th of February 2020 was performed. The timing to treatment was expressed in days and analysed in three ways: ictus to treatment, ictus to referral and referral to treatment. ORs with 95% CI were calculated for aneurysm treatment within 24, 48 and 72 h for good grade (WFSN 1-3) and poor grade (WFNS 4-5) cohorts separately.

RESULTS

Of a total of 538 patients with aSAH, the aneurysm was secured in 312 (58%) within 24 h and in 398 (74%) within 48 h of ictus. Securing the aneurysm within 48 h of ictus was achieved in 89% (395/444) of patients who were referred within 24 h of ictus, but in only 3.2% (3/94) who were referred > 24 h after ictus. Poor grade patients (WFNS 4-5) were more likely than good grade patients (WFNS 1-3) to be referred to neurosurgery within 48 h of ictus (OR 22.87, 95% CI 3.14-166.49, p = 0.0020) and for their aneurysm to be secured within 48 h (OR 1.78, 95% CI 1.06-2.98, p = 0.0297) of ictus. Ictus to referral delay was highest in WFNS grade 1 patients.

CONCLUSIONS

In centres with 7 day per week provision of interventional neuroradiology and vascular neurosurgery, the majority of patients with aSAH can be treated within the timeframes recommended by international guidelines and this applies to all grades of aSAH. However, delays still occur in a significant proportion of patients and this particularly applies to delays in presentation and diagnosis in good grade patients.

Complete relief of vasospasm - Effect of nicardipine coating during direct clipping for the patient with symptomatic vasospasm of subarachnoid hemorrhage

Background:

Some patients come to the hospital presenting with ischemic neurological deficits due to postsubarachnoid hemorrhage (SAH) cerebral vasospasm. In such a situation, neurosurgeons tend to avoid direct clipping, since mechanical irritation to the vessels could worsen the vasospasm and exacerbate ischemic symptoms. The optimal timing of direct clipping in patients with evidence of vasospasm is undetermined. Herein, we present the case of a patient who underwent direct clipping in the presence of severe symptomatic and post-SAH angiographic vasospasm. During surgery, we coated the severely spastic artery with nicardipine.

Case Description:

A 49-year-old woman was admitted to our hospital with the diagnosis of ruptured intracranial aneurysm and severe vasospasm. On the admission day, we performed direct clipping together with direct application of nicardipine to the spastic artery. Postoperative immediate cerebral angiography showed complete disappearance of the vasospasm.

Conclusion:

Direct clipping should not be contraindicated during the vasospasm period in patients with a ruptured aneurysm, and direct application of nicardipine on the spastic artery would completely relieve vasospasm.

Results of a Preventive Rebleeding Protocol in Patients with Ruptured Cerebral Aneurysm: A Retrospective Cohort Study

Objective:

In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol.

Methodology:

Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months).

Results:

Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28).

Conclusion:

Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.

Treatment at Safety-Net Hospitals Is Associated with Delays in Coil Embolization in Patients with Subarachnoid Hemorrhage

BACKGROUND

Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment.

METHODS

Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days).

RESULTS

Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals.

CONCLUSIONS

After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

State of Practice: Endovascular Treatment of Acute Aneurysmal SAH in Germany

BACKGROUND AND PURPOSE

Acute aneurysmal SAH is a severe disease that requires prompt treatment. Endovascular coiling and neurosurgical clipping are established treatment options. Our intention was to determine the state of current practice in acute aneurysmal SAH treatment in Germany, with emphasis on logistic and temporal aspects.

MATERIALS AND METHODS

We interviewed 74 German university and nonuniversity hospitals with an anonymous questionnaire comprising 15 questions concerning the practice of treatment and diagnostics of acute aneurysmal SAH at their respective institutions. The response rate was 74% among all institutions (55/74); among university hospitals, 77%; and among nonuniversity hospitals, 72%.

RESULTS

The majority of all aneurysms were treated endovascularly (66% of acute aneurysmal SAH, 66% of unruptured aneurysms). Treatment on weekends was provided by 100% of endovascular and 96% of neurosurgical facilities. Average patients with acute aneurysmal SAH were not treated during the night (98%). Seventy percent of endovascular and 78% of neurosurgical treatments were not started later than 8:00 pm. Fifty-three percent of hospitals would not start a same-day diagnostic angiography in acute aneurysmal SAH if treatment was scheduled for the following day. Eighty-two percent of all centers performed DSA after clipping to evaluate the treatment results.

CONCLUSIONS

Our survey gives a detailed summary of the current practice of endovascular treatment and related topics in acute aneurysmal SAH in Germany and also reveals considerable changes in practice in comparison with older data.

Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature

Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

Treatment of aneurysms arising from the proximal (A1) segment of the anterior cerebral artery

The aim of our study was to report a series of 15 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery. In 15 patients with diagnosed A1 aneurysms, representing 2.1% of 720 aneurysm patients treated at a University Clinical Center between October 1999 and August 2012, clinical presentation, neuroradiological findings, surgical treatment methods and outcome were retrospectively analyzed. Mean patient age was 53.06 (range 32 to 75) years. Ten saccular aneurysms were treated with micro neurosurgical approach via standard pterional craniotomy, four fusiform aneurysms with coiling, and one fusiform aneurysm with stent. No patients died during the operation. The mean follow-up period was 32 months (range 5 months to 7 years). Clinical outcomes revealed good recovery in all patients. Despite the general opinion that A1 aneurysms are benign lesions, an increasing number of reports have demonstrated their potential complications. To date, due to the rarity of A1 aneurysms, only a few consecutive series have been reported. Conduct of multicenter studies are required in order to understand clinical features of A1 aneurysms and devise a proper treatment plan.

Principles of neuroanesthesia in aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage is associated with high mortality. Understanding of the underlying pathophysiology is important as early intervention can improve outcome. Increasing age, altered sensorium and poor Hunt and Hess grade are independent predictors of adverse outcome. Early operative interventions imposes an onus on anesthesiologists to provide brain relaxation. Coiling and clipping are the two treatment options with increasing trends toward coiling. Intraoperatively, tight control of blood pressure and adequate brain relaxation is desirable, so that accidental aneurysm rupture can be averted. Patients with poor grades tolerate higher blood pressures, but are prone to ischemia whereas patients with lower grades tolerate lower blood pressure, but are prone to aneurysm rupture if blood pressure increases. Patients with Hunt and Hess Grade I or II with uneventful intraoperative course are extubated in operation theater, whereas, higher grades are kept electively ventilated. Postoperative management includes attention toward fluid status and early management of vasospasm.

Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

BACKGROUND

Subarachnoid hemorrhage is a common and dangerous disease with an unfavorable prognosis. Patients with poor-grade subarachnoid hemorrhage (Hunt & Hess Grades 4-5) are unconscious on admission. Because of the high mortality and disability rate associated with poor-grade subarachnoid hemorrhage, it is often treated conservatively. Timing of surgery for poor-grade aneurysmal subarachnoid hemorrhage is still controversial, therefore this study aims to identify the optimal time to operate on patients admitted in poor clinical condition.

METHODS/DESIGN

Ninety-nine patients meeting the inclusion criteria were randomly assigned into three treatment groups. The early surgery group received operation within 3 days after onset of subarachnoid hemorrhage (day of SAH = day 1); the intermediate surgery group received operation from days 4 to 7, and surgery was performed on the late surgery group after day 7. Follow-up was performed 1, 3, and 6 months after aneurysm clipping. Primary indicators of outcome included the Extended Glasgow Outcome Scale and the Modified Rankin Scale, while secondary indicators of outcome were assessed using the Barthel Index and mortality.

DISCUSSION

This is the first prospective, single-center, observer-blinded, randomized controlled trial to elucidate optimal timing for surgery in poor-grade subarachnoid hemorrhage patients. The results of this study will be used to direct decisions of surgical intervention in poor-grade subarachnoid hemorrhage, thus improving clinical outcomes for patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-12002917.

Cost-effectiveness of CTA, MRA and DSA in patients with non-traumatic subarachnoid haemorrhage

Objectives

Intra-arterial digital subtraction angiography (DSA), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are imaging modalities used for diagnostic work-up of non-traumatic subarachnoid haemorrhage. The aim of our study was to compare the cost-effectiveness of MRA, DSA and CTA in the first year after the bleed.

Methods

A decision model was used to calculate costs and benefits (in quality-adjusted life-years [QALYs]) that accrued to cohorts of 1,000 patients. Costs and characteristics of diagnostic tests, therapy, patients’ quality of life and associated costs were respected. The diagnostic strategy with highest QALYs and lowest costs was considered most cost-effective.

Results

DSA was the most effective diagnostic option, yielding on average 0.6039 QALYs (95 % CI, 0.5761–0.6327) per patient, followed by CTA 0.5983 QALYs (95 % CI, 0.5704–0.6278) and MRA 0.5947 QALYs (95 % CI, 0.5674–0.6237). Cost was lowest for DSA (39,808 €; 95 % CI, 37,182–42,663), followed by CTA (40,748 €; 95 % CI, 37,937–43,831) and MRA (41,814 €; 95 % CI, 38,730–45,146). A strategy of CTA followed by DSA if CTA was negative or coiling deemed not feasible, was as effective as DSA alone at average costs of 39,767€ (95 % CI, 36,903–42,402).

Conclusion

A combined strategy of CTA and DSA was found to be the most cost-effective diagnostic approach.

Main Messages

• We defined a standard model for cost-effectiveness analysis in diagnostic imaging.

• Comparing total 1-year health costs and benefits, CTA is superior to MRA.

• A strategy of combining CTA and DSA was found to be the most cost-effective diagnostic approach.

Early endovascular treatment of subarachnoid hemorrhage

Subarachnoid hemorrhage is an important cause of morbidity and mortality. Rebleeding is one of its major complications, which occurs mainly within the first 24 h and worsens the clinical outcome in a very dramatic way. It may be prevented by aneurysm treatment: surgical clipping or endovascular coiling. We review the evidence of and recent advances in endovascular treatment and timing of the intervention. Data supporting the benefit of early (<72 h) and ultra-early (<24 h) treatment is based on observational studies. An earlier approach may be relevant for the prevention of rebleeding and improvement of clinical outcome, but several disadvantages should be considered, such as an increased rate of periprocedural complications. Hence, a well-designed randomized controlled trial deems necessary to be able to define the optimal time of treatment. The possibility of treatment concomitant with the initial angiography should also be taken into account in this trial. This fact might represent a benefit favoring coiling over clipping in the prevention of rebleeding, and thus avoiding the inevitable delay necessary for the preparation for surgery.

European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage

BACKGROUND

Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm.

METHODS

We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines.

RESULTS

These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms.

CONCLUSION

Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.

Management of ruptured aneurysms combined with coexisting aneurysms

In patients suffering from subarachnoid haemorrhage (SAH) and presenting with multiple intracranial aneurysms (MIA) two questions have to be decided on: 1st when is the ideal moment to eliminate the ruptured aneurysm and 2nd when to treat the coexisting aneurysms. In our series we retrospectively analysed 124 SAH-patients presenting with a total of 323 aneurysms. In 57 patients the ruptured aneurysm and all coexisting aneurysms were clipped during the first operation, whereas in 9 patients only some of the coexisting aneurysms (group-A; age in median 55 years) were clipped besides the ruptured one. In 55 patients (group-B; age in median 55 years) the first operation was restricted to clipping the ruptured aneurysm, dealing with the coexisting aneurysm subsequently. Immediately after admission 3 patients passed away. One of the 64 patients waiting (average 60 days, median 14 days) for the subsequent clipping of the not yet secured aneurysms suffered a SAH. Six to 12 months after the initial SAH, 78% of the cases in both groups reached a Glasgow Outcome Score of 4 or 5. Even if in patients with coexisting unruptured intracranial aneurysms the elimination of each and every aneurysm is recommended, the advantages of an unstaged procedure versus the additional strain caused by the prolongation of the procedure, e.g. approach over the midline, 2 or more craniotomies, and the risk of additional ischemic damage to the brain, caused by increased manipulation of cerebral arteries and brain tissue, have to be carefully considered. This is of special importance in dealing with patients in higher Hunt and Hess grades.