Guidelines for the management of aSAH (surgical and endovascular methods of treatment of ruptured cerebral aneurysms)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Sara Mehrsefat, M.D. [2]

2012 AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

Surgical and Endovascular Methods of Treatment of Ruptured Cerebral Aneurysms: Recommendations

Class I

"1. Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Level of Evidence: B)"

"2. Complete obliteration of the aneurysm is recom- mended whenever possible (Level of Evidence: B)"

"3. Determination of aneurysm treatment, as judged by both experienced cerebrovascular surgeons and endovascular specialists, should be a multidisciplinary decision based on characteristics of the patient and the aneurysm (Level of Evidence: C)"

"4. For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Level of Evidence: B)"

"5. In the absence of a compelling contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and strong consideration should be given to retreatment, either by repeat coiling or microsurgical clipping, if there is a clinically significant (eg, growing) remnant (Level of Evidence: B)"

Class III (Harm)

"1. Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and should only be considered when less risky options have been excluded (Level of Evidence: C)"

Class IIb

"1. Microsurgical clipping may receive increased con- sideration in patients presenting with large (>50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling may receive increased consideration in the elderly (􏰃70 years of age), in those presenting with poor-grade (World Federation of Neurological Surgeons classi- fication IV/V) aSAH, and in those with aneurysms of the basilar apex (Level of Evidence: C)"