Management of the unsecured aneurysm in subarachnoid haemorrhage

Surgical control

The AHA recommends to coil the aneurysm wherever possible, and to do it as soon as possible, so as to decrease the risk of the second bleed. However, if coiling is impossible, one may be stuck for some unpredictable period of time.  So, you wait, with an unsecured aneurysm.

Coiling versus clipping

Why does the AHA recommend coiling? After all, the ISAT trial of 2009 did not find any difference in terms of death or severe disability. Sure, to begin with the coiled patients survive more often (at one year), but this mortality benefit disappears after 5 years. Interestingly, for a patient to be considered eligible for the trial, neurosurgeons and interventionalists had to agree that the aneurysm was comparably suitable for treatment with either modality. Thus, it is no surprise that the ISAT people recommend " for everyday clinical practice and decision making, coiling and clipping are to be considered equivalent in the long term". Some aneurysms are ineligible for one or the other.

Still, the AHA recommend that "For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered".

Question 16 from the second paper of 2004 asks the candidates to compare and contrast the two techniques. The table below was used to answer this question.

Coiling vs clipping in ruptured aneurysms

Advantages of coiling:

  • minimally invasive
  • improved survival at 1 year
  • Better effects in posterior fossa aneurysms
  • Less risk of cognitive decline or epilepsy

Advantages of clipping:

  • More certain: 81% of aneurysms are completely obliterated
  • Less risk of rebleeding (0.9%)
  • MCA aneurysms are more amenable to clipping

Disadvantages of coiling

  • Greater risk of rebleeding (2.9%)
  • Fewer aneurysms get completely obliterated (58%)
  • Small aneurysms (<3mm) are impossible to coil
  • Heparin or antiplatelets may be required for the procedure, increasing the risk of bleeding

Disadvantages of clipping:

  • More invasive
  • Greater risk of cognitive decline or epilepsy
  • Survival rates equivalent at 5 years
  • Posterior fossa aneurysms are inaccesible to clipping


Blood pressure control for an unsecured aneurysm

While we ave no idea what blood pressure to aim for in a clipped or coiled aneurysm post SAH, at least there is some agreement as to what blood pressure is safe in the context of an unsecured aneurysm. The AHA guidelines recommend you not allow the systolic to exceed 160 mmHg, or the MAP beyond 110 mmHg.

When is it safe to start the subcutaneous heparin?

In spite of the understandable trepidation one may feel, Oh's Manual suggests that unfractionated heparin may be commenced 24 hours after the aneurysm has been coiled or clipped.


Oh's Intensive Care manual

Chapter   51   (pp. 568)  Acute  cerebrovascular  complications by Bernard  Riley  and  Thearina  de  Beer

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LITFL offer this reference as a follow-on to their chapter:

Dabus, Guilherme, and Raul G. Nogueira. "Current Options for the Management of Aneurysmal Subarachnoid Hemorrhage-Induced Cerebral Vasospasm: A Comprehensive Review of the Literature." Interventional Neurology 2.1 (2013): 30-51.

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Brathwaite, Shakira, and R. Loch Macdonald. "Current Management of Delayed Cerebral Ischemia: Update from Results of Recent Clinical Trials." Translational stroke research 5.2 (2014): 207-226.

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Tagami, Takashi, et al. "Effect of Triple-H Prophylaxis on Global End-Diastolic Volume and Clinical Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage." Neurocritical care (2014): 1-8.

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Anand, Saurabh, Gaurav Goel, and Vipul Gupta. "Continuous intra-arterial dilatation with nimodipine and milrinone for refractory cerebral vasospasm." Journal of neurosurgical anesthesiology 26.1 (2014): 92-93.

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Wartenberg, Katja E., et al. "Impact of medical complications on outcome after subarachnoid hemorrhage*." Critical care medicine 34.3 (2006): 617-623.