patients with impaired renal function, an allergic reaction to the dye, and radiation exposure.
The gold-standard test for cerebral aneurysm detection and characterization is catheter-based DSA (Table 6.1, Section 3). The test has the highest sensitivity and specifi city provided that the angio- graphic equipment is capable of performing three- dimensional rotational angiography, a form of catheter-based angiography in which images are sequentially acquired as the fl uoroscopic gantry rotates 360 degrees around the patient’s head, enabling reformatted images to be manipulated in three dimensions (Figure 6.3d). This is the most expensive of the radiographic tests for aneurysms and also requires physicians trained in techniques of angiography. The procedure requires skilled opera- tors to introduce catheters into the arterial system (generally from the transfemoral route) using radio- graphic guidance. Catheters are selectively advanced into the carotid and vertebral arteries, contrast is injected, and images are obtained (Figure 6.3c and 6.3d). Increased experience has led to lower compli- cation rates; yet this remains an invasive technique.
Minor risks include groin hematoma (6.9–10.7%), arterial puncture site injury (0.05–0.55), allergic dye reaction, contrast-induced renal toxicity (1–2%), and radiation exposure. Major risks include throm- boembolic stroke or vascular dissection (less than 1% with experienced operators) [16–18].
Management of ruptured aneurysms
Fig. 6.4 CT scan after aneurysmal rupture almost always shows varying amounts of subarachnoid hemorrhage (a–d), although additional intraventricular (c) or intraparenchymal (d) blood is not infrequently seen and often suggests the location of the aneurysm.
is generally no signifi cant difference in the number of red blood cells between the fi rst and fourth tubes.
Xanthochromia of the CSF supernatant is the most reliable way to differentiate an aneurysmal SAH from a traumatic lumbar puncture. This yellowish discoloration of the CSF represents bilirubin from hemoglobin breakdown and would not be expected to be present if the blood were fresh (less than 6 hours) as is the case in a traumatic spinal tap. Guide- lines for interpreting CSF results in this setting have been published [20]. If the CT scan shows no blood and the CSF is normal, the likelihood of SAH is very low.
Acute management
The initial assessment of the patient with SAH should focus on maintaining airway, breathing, and circulation. Rapid sequence intubation is recom- mended for those requiring ventilator support.
Aneurysmal SAH is an emergency, and any patient with this diagnosis, once cardiovascular and respira-
tory stability is achieved, should be referred to a facility with familiarity in treating this disease, as patients cared for in high-volume centers have better outcomes (Table 6.1, Section 7) [21]. Dedicated neurological intensive care units and neurointensiv- ists have also been associated with improved outcome in SAH patients. The accepting institution should have surgeons capable of performing aneu- rysm clipping and coiling (described later). Upon admission to an intensive care unit, blood pressure should be kept in the normal range, and this is often achieved with the assistance of an arterial line and an IV agent such as labetalol or nicardipine (Table 6.1, Section 5). Anticonvulsants are given, particu- larly if there is an intracerebral hematoma in addi- tion to SAH or if craniotomy is planned (Table 6.1, Section 11). The duration of anticonvulsant usage, the choice of anticonvulsant agent, and whether to administer such medication at all for patients with SAH without intracerebral hematoma are currently being re-evaluated [22].
The most important issue on admission is the identifi cation of the ruptured aneurysm and treat- ment of the lesion to prevent a potentially disastrous rehemorrhage. Based on the prospective Coopera- tive Aneurysm Study, rebleeding from an unrepaired aneurysm is estimated at 4% within 24 hours of the initial bleed followed by approximately 1–2% per day for the fi rst 4 weeks (Table 6.1, Section 2) [23].
Bed rest and antifi brinolytic therapy are no longer considered adequate therapy to prevent rebleeding (Table 6.1, Section 5). Securing the aneurysm is achieved by either endovascular coiling or microsur- gical clipping (described later), which should be attempted within 72 hours of the hemorrhage in almost all patients (Table 6.1, Section 6). Hunt and Hess Grade 5 patients or those at the extremes of age (>85) are a complex subset of patients for whom no specifi c guidelines are available, and treatment must therefore be individualized.
Many physicians obtain an emergent CTA on admission, which has a very high degree of sensitiv- ity in disclosing the site and morphology of the aneurysm. The example patient had a CTA per- formed the evening of admission that clearly showed an anterior communicating artery aneurysm (Figure 6.2b). Regardless of the results of this test, catheter- based cerebral angiography is usually indicated to determine the source of the SAH, which will be a ruptured cerebral aneurysm in most (80–85%) cases. Angiography in this patient confi rmed the fi ndings of CTA and showed a small anterior com- municating artery aneurysm that was presumed to have ruptured (Figure 6.2c and 6.2d). Four-vessel angiography (both vertebral arteries and both carotid arteries) is recommended as multiple aneu- rysms are present in up to 15% of patients [24], and this provides a baseline of the intracranial blood vessels that can aid in diagnosing vasospasm (dis- cussed later) should it develop. Some centers use CTA alone if clipping is the chosen treatment modal- ity, but there is insuffi cient data to support this strat- egy [16]. If four-vessel angiography does not reveal a lesion, angiography of the external carotid arteries bilaterally should be performed to rule out a dural arteriovenous fi stula, a rare but important cause of SAH (Figure 6.5a–6.5d). If properly performed angiography is negative (10–20% of SAH), the study is repeated in 1 week, and MRI with and without gadolinium of the brain and cervical spine is obtained
to rule out small tumor, thrombosed aneurysm, which may not appear with angiography, or other more rare entities.
“Benign perimesencephalic nonaneurysmal SAH”
is a recognized condition in which the same clinical signs and symptoms of aneurysmal SAH are present and the CT scan shows a very small amount of blood strictly localized anterior to the brain stem, usually in the region of the midbrain [25]. Angiography is negative, and this is almost always a benign condi- tion. Because of the increasing resolution of CTA, some have recommended this as the sole test when the CT appearance is classic for perimesencephalic SAH [26]. Adequate data are not available to support CTA as the sole imaging modality, and DSA is indi- cated. A second DSA, however, is not necessary.
Repair of cerebral aneurysms: microsurgical clipping and endovascular coiling
There are two main treatment options to secure a ruptured aneurysm: endovascular coiling and microsurgical clipping. In the former, a neurosur- geon, neurologist, or neuroradiologist with special training performs a cerebral angiogram followed by the placement of very small microcatheters into the aneurysm through which metallic coils of varying sizes and shapes are deployed (Figure 6.6). The coils are thrombogenic and cause an acute occlusion of the aneurysm while preserving fl ow in the surround- ing normal vessels. The procedure is generally per- formed under general anesthesia, although some physicians prefer to keep the patients awake to monitor their neurological status. The use of IV heparinization during the procedure is variably used and continued for 12–36 hours. Microsurgical clip- ping is performed by neurosurgeons under general anesthesia. After a craniotomy is performed, perma- nent clips made from MRI-compatible alloys with a spring-loaded mechanism are ideally placed across the neck of the aneurysm, excluding it from the cir- culation (Figure 6.7). Although some aneurysm morphologies and locations are better suited to one technique or the other, many aneurysms can be suc- cessfully secured with either method, and the deci- sion to use one or the other is made based on other patient-, institutional-, and operator-specifi c factors.
In general, the decision should be made by a team with expertise in both treatment modalities (Table 6.1, Section 6).
Comparing outcomes for clipping and coiling Although clipping techniques have been used and improved upon for over 50 years, the fi rst descrip- tion of coil placement within aneurysms was in 1991, followed by the Food and Drug Administra- tion approval in 1995. Whereas coiling was initially used as a last resort for aneurysms that could not be clipped in the mid-1990s, the techniques and coils have improved dramatically such that it is now con- sidered a safe and less invasive alternative to clip- ping. Coiling is now fi rst-line therapy in many centers.
The exact risks of coiling are somewhat diffi cult to quantify due to technical advances in recent years leading to increased safety, and the inability to divorce the consequences of a coiling procedure from the consequences of the SAH. Minor risks associated with coiling are similar to that of diagnos- tic angiography. More serious risks include arterial dissection, a thromboembolic event with stroke, and aneurysm rupture (1.0–2.7%) [27]. With increased
experience, operators are now learning how to manage these complications to keep adverse out- comes acceptably low [28,29]. Approximately 5–
14.5% of aneurysms at one large volume center could not be coiled because of unusual vascular tortuosity or failure of coils to properly sit within the aneurysm, usually due to a broad base of the aneurysm in relation to the dome [30]. Advanced techniques in which balloons are infl ated or stents are deployed across the neck of the aneurysm, as well as newer complex-shaped coils, permit the treat- ment of many wide-neck lesions previously felt not to be candidates for this technique (Figure 6.8a–6.8c). Risks of surgery include those associated with any craniotomy, such as bleeding and infec- tion, as well as the risks associated with the direct attack of an aneurysm requiring brain retraction, vessel manipulation, aneurysm dissection, and clipping.
One disadvantage of coiling is that complete occlusion is not always guaranteed. Complete or
(a) (b)
(c) (d)
Fig. 6.5 Four-vessel angiography was negative in this 50-year-old man who presented with a diffuse subarachnoid hemorrhage (a) and a CT angiography suggestive of a ruptured aneurysm (b, arrow). Angiography of the external carotid arteries in the anteroposterior (c) and lateral projection (d) clearly shows a dural-based arteriovenous fi stula with an associated venous aneurysm (double arrows).
(a)
(b)
Fig. 6.6 Endovascular occlusion of an aneurysm of the posterior communicating artery with Guglielmi detachable coils. (a) The
microcatheter is inserted into the femoral artery and navigated through the aorta, the left carotid artery, and then into the aneurysm where coils are deployed. (b) At the end of the coiling, the aneurysm no longer fi lls with blood. Reprinted with permission, Massachusetts Medical Society. From Brisman JL, et al. N Engl J Med. 2006;355:928–939.
near complete occlusions in 85–90% can be expected, with lower rates of success with larger aneurysms [27]. Another disadvantage to coiling is that over time, the coil mass can compact in response to blood fl ow and result in aneurysm recanalization, which places such patients at risk for recurrent hemor- rhage. Recurrence secondary to aneurysm recanali-
zation, estimated at 20.9–33.6%, is more common in larger aneurysms [31]. Rehemorrhage after coiling was noted in 0.8% with a mean follow-up of 31.32
± 24.96 months [31]. Vigilant angiographic follow- up is required after coiling as repeat coiling can be safely performed. Newer coils embedded with bio- logical agents to promote neointima formation and
prevent recurrence are under clinical investigation.
Residual aneurysm and aneurysm recurrence is also possible with clipping but signifi cantly less so, making this a more defi nitive and durable treatment [32].
The International Subarachnoid Aneurysm Trial (ISAT) was a prospective multicenter study con- ducted primarily in Europe, which compared out- comes at 1 year for 2143 SAH patients randomized to microsurgical clipping versus endovascular
coiling. The trial was stopped after a planned interim analysis at 1 year found a 23.7% risk of dependency or death in the endovascular cohort compared with a 30.6% risk (relative risk of 22.6% and absolute risk of 6.9% difference) in the surgical arm [33]. It should be noted that to be randomized in the study, an aneurysm had to be deemed equally treatable by either technique, a condition met by only 2143 out of 9559 patients screened, or 22.4% of all SAH evaluated at participating centers. Second, the great (a)
(b)
Fig. 6.7 Microsurgical clipping of an aneurysm of the posterior communicating artery. (a) The skin incision (unbroken curved line) and craniotomy (dashed lines) needed to approach the aneurysm are depicted. (b) The application of the clip blades to the neck of the aneurysm to achieve occlusion. Reprinted with permission, Massachusetts Medical Society. From Brisman JL, et al. N Engl J Med. 2006;355:928–939.
majority of the lesions treated were in patients in good clinical grade (>90%), who harbored anterior circulation aneurysms (97.3%) and whose aneu- rysms were less than 10 mm (almost 95%). The gen- eralization of this study to all aneurysms, or even to all ruptured aneurysms, would not be valid.
A separate publication confi rmed these fi ndings at the 1 year follow-up for all randomized patients [34]. A third publication from the ISAT study inves- tigators reanalyzed the data substratifi ed for age and found that the fi ndings were not as robust for patients less than 50 years and may not be valid for patients less than 40 years old, again due to poorer durability and slightly increased rehemorrhage risk of coiling [35]. A proposed algorithm for the treat- ment of ruptured aneurysms is presented (Figure 6.9).
The example patient’s aneurysm was evaluated by an endovascular neurosurgeon who performs both clipping and coiling. It was deemed to be equally treatable using either modality. Based on the ISAT data, the patient was offered coiling as the recom- mended treatment. If the aneurysm could not be safely coiled, clipping would be recommended. The patient agreed to undergo coiling, which was per- formed uneventfully with complete occlusion (Figure 6.2e and 6.2f). She was discharged home 10 days later, neurologically intact. Her fi rst follow-up angiogram was performed 6 months later and showed no aneurysm recanalization.