Subarachnoid hemorrhage surgery: Difference between revisions
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{{Subarachnoid hemorrhage}} | {{Subarachnoid hemorrhage}} | ||
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{SaraM}} | ||
==Overview== | |||
==Surgery== | ==Surgery== | ||
===Surgical clipping=== | |||
Following a [[craniotomy]], the small clip is placed across the base, or neck, of the aneurysm in order to block the normal blood flow. The main purpose of surgical clipping is to isolate an aneurysm from the normal circulation without blocking off nearby arteries. | |||
===Endovascular coiling=== | |||
Endovascular coiling is a minimally invasive technique, which is not required craniotomy to treat the brain aneurysm. The catheter is used to reach the aneurysm in the brain and is passed through the groin up into the aneurysm. The coils, which made of platinum, induce clotting of the aneurysm and as a result it prevent blooding. The coil is left in place in the aneurysm and sometimes more than one coil may be needed to completely seal off the [[aneurysm]]. | |||
===Prevention of Rebleeding=== | ===Prevention of Rebleeding=== | ||
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[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
Revision as of 17:14, 15 December 2016
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Subarachnoid Hemorrhage Microchapters |
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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)
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Subarachnoid hemorrhage surgery On the Web |
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American Roentgen Ray Society Images of Subarachnoid hemorrhage surgery |
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Risk calculators and risk factors for Subarachnoid hemorrhage surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sara Mehrsefat, M.D. [3]
Overview
Surgery
Surgical clipping
Following a craniotomy, the small clip is placed across the base, or neck, of the aneurysm in order to block the normal blood flow. The main purpose of surgical clipping is to isolate an aneurysm from the normal circulation without blocking off nearby arteries.
Endovascular coiling
Endovascular coiling is a minimally invasive technique, which is not required craniotomy to treat the brain aneurysm. The catheter is used to reach the aneurysm in the brain and is passed through the groin up into the aneurysm. The coils, which made of platinum, induce clotting of the aneurysm and as a result it prevent blooding. The coil is left in place in the aneurysm and sometimes more than one coil may be needed to completely seal off the aneurysm.
Prevention of Rebleeding
Those patients with a large hematoma, depressed level of consciousness or focal neurology may be candidates for urgent surgical removal of the blood or occlusion of the bleeding site. The remainder are admitted and stabilized more extensively, and undergo an transfemoral angiogram or CT angiogram at a later stage. In those where the bleeding is from an aneurysm (as opposed to non-aneurysmal perimesencephalic hemorrhage), most neurosurgical centers use either coiling or clipping of the aneurysm to prevent rebleeding. After the first 24 hours, rebleeding risk is about 40% over four weeks, suggesting that interventions should be aimed at reducing this risk.
Currently there are two treatment options for brain aneurysms: surgical clipping or endovascular coiling. Surgical clipping was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. It consists of performing a craniotomy, exposing the aneurysm, and closing the base of the aneurysm with a clip.[1] The surgical technique has been modified and improved over the years. Surgical clipping remains the best method to permanently eliminate aneurysms. Endovascular coiling was introduced by Guido Guglielmi at UCLA in 1991.[2] It consists of passing a catheter into the femoral artery in the groin, through the aorta, into the brain arteries, and finally into the aneurysm itself. Once the catheter is in the aneurysm, platinum coils are pushed into the aneurysm and released. These coils initiate a clotting or thrombotic reaction within the aneurysm that, if successful, will eliminate the aneurysm. In the case of broad-based aneurysms, a stent is passed first into the parent artery to serve as a scaffold for the coils ("stent-assisted coiling").
Presently it appears that the risks associated with surgical clipping and endovascular coiling, in terms of stroke or death from the procedure, are the same. The major problem associated with endovascular coiling, however, is the high recurrence rate and subsequent bleeding of the aneurysms. For instance, a major French study reported in 2007 indicates that 28.6% of aneurysms recurred within one year of coiling, and that the recurrence rate increased with time.[3] These results are similar to those previously reported by other endovascular groups; a series from Canada reported in 2003 found that 33.6% of aneurysms recurred within one year of coiling.[4] The long-term coiling results of one of the two prospective randomized studies comparing surgical clipping versus endovascular coiling (the International Subarachnoid Aneurysm Trial or ISAT), too, suggest that the need for late retreatment of aneurysms is 6.9 times more likely for endovascular coiling as compared to surgical clipping.[5]
Therefore it appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher recurrence and bleeding rate after treatment. Patients who undergo endovascular coiling need to have annual studies (such as MRI/MRA, CTA, or angiography) indefinitely to detect early recurrences. If a recurrence is identified, the aneurysm needs to be retreated with either surgery or further coiling. The risks associated with surgical clipping of previously-coiled aneurysms are very high. Ultimately, the decision to treat with surgical clipping versus endovascular coiling should be made by a cerebrovascular team with extensive experience in both modalities. At present it appears that only older patients with aneurysms that are difficult to reach surgically are more likely to benefit from endovascular coiling. These generalizations, however, are difficult to apply to every case, which is reflected in the wide variabilty internationally in the use of surgical clipping versus endovascular coiling.
Medical treatment is available to both reduce the risk of repeat bleeding, and to treat a serious complication of SAH called vasospasm. In the case of spontaneous SAH from an aneurysm, there is a significant risk of repeat bleeding until definitive surgical intervention can be performed. During this waiting period medical treatments to control blood pressure, bed rest, and a quiet environment reduce the risk of rebleed.
References
- ↑ Dandy WE (1938). "Intracranial aneurysm of the internal carotid artery: cured by operation". Ann. Surg. 107 (5): 654–9. PMID 17857170. PMC 1386933
- ↑ Guglielmi G, Viñuela F, Dion J, Duckwiler G (1991). "Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience". J. Neurosurg. 75 (1): 8–14. PMID 2045924.
- ↑ Piotin M, Spelle L, Mounayer C; et al. (2007). "Intracranial aneurysms: treatment with bare platinum coils--aneurysm packing, complex coils, and angiographic recurrence". Radiology. 243 (2): 500–8. doi:10.1148/radiol.2431060006. PMID 17293572.
- ↑ Raymond J, Guilbert F, Weill A; et al. (2003). "Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils". Stroke. 34 (6): 1398–403. doi:10.1161/01.STR.0000073841.88563.E9. PMID 12775880.
- ↑ Campi A, Ramzi N, Molyneux AJ; et al. (2007). "Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT)". Stroke. 38 (5): 1538–44. doi:10.1161/STROKEAHA.106.466987. PMID 17395870.