3. SAH is rare
However, mortality in one month after rupture is 50 %
In the past delayed surgery
Nowadays shifting to early timing surgery
Haley EC Jr, Kassell NF, Torner JC: The international cooperative study on the timing of aneurysm surgery. The North American experience. Stroke 23: 205-214, 1992
Ingall T, Asplund K, Mahonen M, Bonita R: A multinational comparison of subarachnoid hemorrhage epidemiology in the WHO MONICA stroke study. Stroke. 31(5):1054-1061,2000
Javadpour M, Silver N: Subarachnoid haemorrhage (spontaneous aneurysmal). Clin Evid (Online) 2008, 2008
Wong GKC, Poon WS, Chan MTV, Zee BCY: Intravenous magnesium sulphate for aneurysmal subarachnoid hemorrhage (IMASH) A randomized, double-blinded, placebocontrolled, multicenter phase III trial. Stroke 41(5):921-926, 2010
5. Ultra-Early Intervention
first 24 hours of the onset
lower re-bleeding incidence
re-bleeding incidence within the first 24 hours is the highest which ranges from 4.1% to 17.3%
Coiling > clipping
Disadvantages: Greater possibility of perioperative complications and increasing risk of cerebral
vascular dysfunction
May impact some pathophysiological process thus change prognosis
Matias-Guiu JA, Serna-Candel C: Early endovascular treatment of subarachnoid hemorrhage. Interv Neurol 1: 56- 64, 2012
Phillips TJ, Dowling RJ, Yan B, Laidlaw JD, Mitchell PJ: Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke 42: 1936-1945, 2011
Qian Z, Peng T, Liu A, Li Y, Jiang C, Yang H, Wu J, Kang H, Wu Z: Early timing of endovascular treatment for aneurysmal subarachnoid hemorrhage achieves improved outcomes. Curr Neurovasc Res 11: 16-22, 2014
Wong GKC, Boet R, Ng SCP, Chan M, Gin T, Zee B, Poon WS: Ultra-Early (within 24 hours) aneurysm treatment after subarachnoid hemorrhage. World Neurosurg 77: 311-315, 2012
6. Poor Clinical Condition at Admission
Conflicting data
1. no different of outcome between early vs late intervention
2. early intervention has slightly better outcome
Zhang, Q., Ma, L., Liu, Y., He, M., Sun, H., Wang, X., ... & You, C. (2013). Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial. BMC neurology, 13(1), 108.
Zhao, C., & Wei, Y. (2017). Surgical Timing for Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis and Systematic Review. Turk Neurosurg, 27(4), 489-499.
7. Nowadays trend :
early intervention is preferred than late one in treating SAH despite its initial severity
9. Hydrocephalus and delayed cerebral ischemia (DCI) are potential causes of neurological
deterioration that are associated with worse prognosis
Associated with the quantity of blood in the subarachnoid and intraventricular spaces, as well as
the rate of clot clearance
intracisternal thrombolytics may prevent chronic hydrocephalus, attenuate angiographic
vasospasm, reduce DCI, and improve neurological recovery
Via EVD
Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38:2315–21.
Germanwala AV, Huang J, Tamargo RJ. Hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 2010;21:263–70.
Kramer AH, Mikolaenko I, Deis N, Dumont AS, Kassell NF, Bleck TP, Nathan B. Intraventricular hemorrhage volume predicts poor outcomes but not delayed ischemic neurological Neurocrit Care (2014) 21:275–284 283 123 deficits among patients with ruptured cerebral
aneurysms. Neurosurgery. 2010;67:1044–52.
Ko SB, Choi HA, Carpenter AM, et al. Quantitative analysis of hemorrhage volume for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Stroke. 2011;42:559–72.
Reilly C, Amidei C, Tolentino J, Jahromi BS, Macondald RL. Clot volume and clearance rate as independent predictors of vasospasm after aneurysmal subarachnoid hemorrhage. J Neurosurg. 2007;101:255–61.
Kanamura K, Waga S, Sakakura M, et al. Comparative study of cisternal lavage methods for the treatment of cerebral vasospasm. In: Max Findlay J, editor. Cerebral vasospasm. Amsterdam: Elsevier Science Publishers; 1993. p. 471–473.
Findlay JM, Kassell NF, Weir BK, et al. A randomized trial of intraoperative, intracisternal tissue plasminogen activator for the prevention of vasospasm. Neurosurgery. 1995;37:168–76.
Hamada J, Kai Y, Morioka M, et al. Effect on cerebral vasospasm of coil embolization followed by microcatheter intrathecal urokinase infusion into the cisterna magna: a prospective randomized study. Stroke. 2003;34:2549–54.
Hanggi D, Eicker S, Beseoglu K, et al. A multimodal concept in patients after severe aneurysmal subarachnoid hemorrhage: results of a controlled single center prospective randomized multimodal phase I/II trial on cerebral vasospasm. Cen Eur Neurosurg. 2009;70:61–7.
Kramer AH, Fletcher JJ. Locally-administered intrathecal thrombolytics following aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurocrit Care. 2011;14:489–99
10. Dose: 2 mg each 12 hours with maximum 10 mg
Contraindication:
Endovascular surgeon concerned that the aneurysm was incompletely secured;
Uncorrected coagulation disturbance (INR >1.5, PTT >45, platelets < 50.000)
Active extracranial hemorrhage
Pregnancy
Allergic to TPA
