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.
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.
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Advantages of coiling:
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Advantages of clipping:
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Disadvantages of coiling
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Disadvantages of clipping:
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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.
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.
Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer
Teasdale, G. M., et al. "A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies." Journal of neurology, neurosurgery, and psychiatry 51.11 (1988): 1457.
Connolly, E. Sander, et al. "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association." Stroke 43.6 (2012): 1711-1737.
Myburgh, J. A. "Triple h” therapy for aneurysmal subarachnoid haemorrhage: real therapy or chasing numbers." Crit Care Resusc 7.3 (2005): 206-212.
Bederson, Joshua B., et al. "Guidelines for the management of aneurysmal subarachnoid hemorrhage a statement for healthcare professionals from a special Writing Group of the Stroke Council, American Heart Association."Stroke 40.3 (2009): 994-1025.
Muizelaar, J. Paul, and Donald P. Becker. "Induced hypertension for the treatment of cerebral ischemia after subarachnoid hemorrhage. Direct effect on cerebral blood flow." Surgical neurology 25.4 (1986): 317-325.
Dhar, Rajat, et al. "Comparison of induced hypertension, fluid bolus, and blood transfusion to augment cerebral oxygen delivery after subarachnoid hemorrhage: Clinical article." Journal of neurosurgery 116.3 (2012): 648-656.
Pickard, J. D., et al. "Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial."BMJ: British Medical Journal 298.6674 (1989): 636.
Origitano, Thomas C., et al. "Sustained increased cerebral blood flow with prophylactic hypertensive hypervolemic hemodilution (" triple-H" therapy) after subarachnoid hemorrhage." Neurosurgery 27.5 (1990): 729-740.
Marshall, Scott A., Paul Nyquist, and Wendy C. Ziai. "The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage." Neurosurgery Clinics of North America21.2 (2010): 291-303.
Greenberg, E. D., et al. "Diagnostic accuracy of CT angiography and CT perfusion for cerebral vasospasm: a meta-analysis." American Journal of Neuroradiology 31.10 (2010): 1853-1860.
Sloan, M. A., et al. "Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage." Neurology 39.11 (1989): 1514-1514.
Rivierez, M., et al. "Value of electroencephalogram in prediction and diagnosis of vasospasm after intracranial aneurysm rupture." Acta neurochirurgica 110.1-2 (1991): 17-23.
Kawamoto, Shunsuke, et al. "Effectiveness of the head-shaking method combined with cisternal irrigation with urokinase in preventing cerebral vasospasm after subarachnoid hemorrhage." Journal of neurosurgery 100.2 (2004): 236-243.
Vergouwen, Mervyn DI, et al. "Biologic effects of simvastatin in patients with aneurysmal subarachnoid hemorrhage: a double-blind, placebo-controlled randomized trial." Journal of Cerebral Blood Flow & Metabolism 29.8 (2009): 1444-1453.
Macdonald, R. Loch, et al. "Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) Randomized, Double-Blind, Placebo-Controlled Phase 2 Dose-Finding Trial."Stroke 39.11 (2008): 3015-3021.
Bakker, Nicolaas A., et al. "International subarachnoid aneurysm trial 2009: endovascular coiling of ruptured intracranial aneurysms has no significant advantage over neurosurgical clipping." Neurosurgery 66.5 (2010): 961-962.
Fisher, C. M., J. P. Kistler, and J. M. Davis. "Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning." Neurosurgery 6.1 (1980): 1-9.
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.
Frontera, Jennifer A., et al. "Defining Vasospasm After Subarachnoid Hemorrhage What Is the Most Clinically Relevant Definition?." Stroke 40.6 (2009): 1963-1968.
Vergouwen, Mervyn DI, et al. "Definition of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage as an Outcome Event in Clinical Trials and Observational Studies Proposal of a Multidisciplinary Research Group."Stroke 41.10 (2010): 2391-2395.
Etminan, Nima, et al. "Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis." Journal of Cerebral Blood Flow & Metabolism 31.6 (2011): 1443-1451.
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.
Mir, D. I. A., et al. "CT Perfusion for detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis." American Journal of Neuroradiology 35.5 (2014): 866-871.
Lasner, Todd M., et al. "Cigarette smoking-induced increase in the risk of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage." Journal of neurosurgery 87.3 (1997): 381-384.
Conway, James E., and Rafael J. Tamargo. "Cocaine use is an independent risk factor for cerebral vasospasm after aneurysmal subarachnoid hemorrhage."Stroke 32.10 (2001): 2338-2343.
Charpentier, Claire, et al. "Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage." Stroke30.7 (1999): 1402-1408.
Singhal, A. B., et al. "SSRI and statin use increases the risk for vasospasm after subarachnoid hemorrhage." Neurology 64.6 (2005): 1008-1013.
Yin, L., et al. "Predictors analysis of symptomatic cerebral vasospasm after subarachnoid hemorrhage." Early Brain Injury or Cerebral Vasospasm. Springer Vienna, 2011. 175-178.
Hussein, Haitham M., et al. "Intracranial Vascular Calcification is Protective from Vasospasm after Aneurysmal Subarachnoid Hemorrhage." Journal of Stroke and Cerebrovascular Diseases (2014).
Inagawa, T., K. Yahara, and N. Ohbayashi. "Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage."Neurologia medico-chirurgica (2014).
Inagawa, T., K. Yahara, and N. Ohbayashi. "Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage."Neurologia medico-chirurgica (2014).
Kolias, Angelos G., Jon Sen, and Antonio Belli. "Pathogenesis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage: putative mechanisms and novel approaches." Journal of neuroscience research 87.1 (2009): 1-11.
Haley Jr, E. Clarke, Neal F. Kassell, and James C. Torner. "A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage: a report of the Cooperative Aneurysm Study." Journal of neurosurgery 78.4 (1993): 537-547.
Rosenquist, Ashley, et al. "921: Safety of intrathecal nicardipine for vasospasm due to aneurysmal subarachnoid hemorrhage." Critical Care Medicine 41.12 (2013): A231.
Huang, Ren-qiang, et al. "Nicardipine in the treatment of aneurysmal subarachnoid haemorrhage: a meta-analysis of published data." Acta Neurologica Belgica 113.1 (2013): 3-6.
Kasuya, H. "Clinical trial of nicardipine prolonged-release implants for preventing cerebral vasospasm: multicenter cooperative study in Tokyo." Early Brain Injury or Cerebral Vasospasm. Springer Vienna, 2011. 165-167.
Pandey, Paritosh, et al. "A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion." Neurosurgery 71 (2012): ons77-ons85.
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.
Dankbaar, Jan W., et al. "Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review." Crit Care 14.1 (2010): R23.
Lennihan, Laura, et al. "Effect of Hypervolemic Therapy on Cerebral Blood Flow After Subarachnoid Hemorrhage A Randomized Controlled Trial." Stroke 31.2 (2000): 383-391.
Diringer, Michael N., et al. "Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference." Neurocritical care 15.2 (2011): 211-240.
Velly, Lionel J., et al. "Anaesthetic and ICU management of aneurysmal subarachnoid haemorrhage: A survey of European practice." European journal of anaesthesiology (2014).
Kimball, Matthew M., Gregory J. Velat, and Brian L. Hoh. "Critical care guidelines on the endovascular management of cerebral vasospasm." Neurocritical care 15.2 (2011): 336-341.
Kirkpatrick, Peter J., et al. "Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial." The Lancet Neurology (2014), Volume 13, Issue 7, Pages 666 - 675
Mees, Sanne M. Dorhout, et al. "Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial." The Lancet 380.9836 (2012): 44-49.
Nishiguchi, Mitsuhisa, et al. "Effect of vasodilation by milrinone, a phosphodiesterase III inhibitor, on vasospastic arteries after a subarachnoid hemorrhage in vitro and in vivo: effectiveness of cisternal injection of milrinone." Neurosurgery 66.1 (2010): 158-164.
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.
Wartenberg, Katja Eliriede, and Stephan A. Mayer. "Intracerebral hemorrhage."The Stroke Book (2013): 204.
Wartenberg, Katja E., et al. "Impact of medical complications on outcome after subarachnoid hemorrhage*." Critical care medicine 34.3 (2006): 617-623.