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