Infarct Prevention and Management After Stenting and Coiling in Post-Aneurysmal Ruptured SAH

Technical Considerations

The American Heart Association recommends that complete obliteration of the aneurysm whenever possible is done to reduce complications (Class I, Level of Evidence B) 1, 4
The American Heart Association suggests multidisciplinary decision-making involving both experienced cerebrovascular surgeons and endovascular specialists to determine the optimal treatment approach (Class I, Level of Evidence C) 1, 5
Higher incidence of technical complications with clipping (19%) versus coiling (8%) 1
Incomplete aneurysm obliteration, which occurs more frequently with coiling (42% of cases) compared to clipping (19%) 1

Maintenance of euvolemia and normal circulating blood volume is recommended to prevent delayed cerebral ischemia (DCI) (Class I, Level B) 2, 6
Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (Class I, Level B) 2, 6
Close monitoring for vasospasm using transcranial Doppler is reasonable (Class IIa, Level B) 2, 3
Perfusion imaging with CT or MRI can be useful to identify regions of potential brain ischemia (Class IIa, Level B) 2, 3

Stenting of ruptured aneurysms is associated with increased morbidity and mortality (Class III, Level C) 2, 3
For patients with ruptured aneurysms of the posterior circulation that are amenable to coiling, coiling is indicated in preference to clipping to improve outcome (Class 1, Level B-R) 5
Careful consideration of patient-specific factors, such as endovascular coiling being preferable in elderly patients (>70 years), those with poor-grade SAH (WFNS IV/V), and basilar apex aneurysms 3
Microsurgical clipping may be preferable for patients with large intraparenchymal hematomas (>50 mL) and middle cerebral artery aneurysms 3