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Chapter 20

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Introduction

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A 45-year-old man with a history of hypertension and tobacco abuse presents to the emergency department following the onset of a severe holocranial headache. He denies nausea, vomiting, head trauma, and previous headaches. His temperature is 38°C, heart rate 110 bpm, blood pressure 150/87 mm Hg. His left pupil is dilated and nonreactive to light. A computed tomographic (CT) brain scan shows diffuse subarachnoid hemorrhage. Catheter cerebral arteriography demonstrates a posterior communicating artery aneurysm (Figure 20-1).

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Figure 20-1.

A 48-year-old man with headache and vomiting. A. Nonenhanced computed tomographic (CT) brain scan reveals subarachnoid hemorrhage into the basilar cisterns (arrow). B. CT angiography with coronal reconstructions demonstrates an aneurysm of the anterior communicating artery (AComA) (arrow). C and D. Catheter angiography of left internal carotid artery in a frontal oblique projection during the arterial phase with 3-dimensional reconstructions confirms the presence of a 6.4 mm × 4.8 mm AcomA aneurysm (arrow). E and F. Angiography post–coil embolization demonstrates no flow into the AComA aneurysm (arrow).

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What are the morbidity and mortality rates accompanying aneurysmal subarachnoid hemorrhage (SAH)?

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Spontaneous rupture of a cerebral aneurysm causing SAH is a life-threatening condition and carries an immediate mortality rate of 10% to 20%.1 Survival through the initial incident provides no guarantee, however; 12% to 30% of patients fail to recover neurologically, and by 6 months mortality may increase to 50%. Furthermore, as many as one-third of survivors remain dependent following aneurysmal hemorrhage.2

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How effective is endovascular therapy in the treatment of ruptured aneurysms?

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Following initial stabilization and diagnosis, attention necessarily turns toward the prevention of recurrent hemorrhage and vasospasm, both causes of significant morbidity and mortality after the initial hemorrhage.1 Endovascular therapy is able to address both concerns, and now has an established role in treatment of ruptured cerebral aneurysms. Generally, this is accomplished by endovascular occlusion of the aneurysm with microcoils.

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Since the 1960s, it has been known that surgically clipping ruptured aneurysms to prevent recurrent hemorrhage produced results superior to those associated with nonsurgical management. Endovascular coil occlusion of a cerebral aneurysm has been shown to accomplish the same goal: prevention of recurrent hemorrhage. Since its approval in 1991, endovascular coil occlusion of ruptured aneurysms has steadfastly garnered acceptance and has become the treatment modality of choice in patients with SAH due to ruptured aneurysms. Advantages of endovascular treatment include femoral access without a craniotomy and access to midline aneurysms without brain retraction.

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The effectiveness of endovascular intervention was directly compared to that of surgical clipping in the International Subarachnoid Aneurysm Trial (ISAT). This trial randomized 2143 patients presenting with SAH attributable to aneurysm rupture and deemed suitable for endovascular treatment or surgical clipping. Patients ...

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