Management of Aneurysmal Subarachnoid Hemorrhage After Coiling

Current Management Priorities

Complete obliteration of the aneurysm should be the primary goal whenever feasible to reduce the risk of rebleeding, according to the American Heart Association/American Stroke Association guidelines 1
For posterior circulation aneurysms, coiling is preferred over clipping to improve outcomes, as recommended by the American Heart Association/American Stroke Association 1, 2
For patients with incomplete obliteration, partial treatment aimed at securing the rupture site during the acute phase is reasonable, with retreatment in 1-3 months, based on evidence from the American Heart Association/American Stroke Association 1, 3

Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage), as suggested by the American Heart Association/American Stroke Association guidelines 4
Chronic symptomatic hydrocephalus requires permanent cerebrospinal fluid diversion, according to the American Heart Association/American Stroke Association guidelines 4

The incidence of seizures after aSAH ranges from 6% to 18%, with risk factors including middle cerebral artery aneurysms, thick SAH clot, intracerebral hematoma, rebleeding, infarction, poor neurological grade, and history of hypertension, as reported by the American Heart Association/American Stroke Association 5
Patients treated with endovascular coiling have a lower incidence of seizures compared to surgical clipping, based on evidence from the American Heart Association/American Stroke Association 4

Current American Heart Association/American Stroke Association guidelines for aSAH management do not mention montelukast or other leukotriene receptor antagonists as treatment options, due to a lack of evidence 1, 3, 6, 7
No clinical studies have evaluated the efficacy of montelukast specifically in the context of post-aSAH brain protection after coiling, as noted by the American Heart Association/American Stroke Association 4