Subarachnoid haemorrhage (spontaneous aneurysmal)
Aneurysmal subarachnoid haemorrhage (aSAH) is a neurosurgical emergency that comes with high morbidity and mortality. Accurate and timely diagnosis is imperative, along with the management of intra-cranial complications such as vasospasm/delayed ischaemic neurological deficit, hydrocephalus, seizure disorder, as well as extra-cranial complications such as cardiac abnormalities or neurogenic pulmonary oedema. The prevalence of unruptured aneurysms is 2% to 4%. Only a proportion of these rupture. Annual worldwide incidence of aSAH has been reported to be approximately 9 per 100,000 person/years; 10% of aSAH patients die before hospital, 25% die in the first 24 hours, and 40% to 50% die within the first 30 days. Of those who survive, up to 20% can be dependent on others for activities of daily living due to neurological deficits or cognitive impairment. Other sequela of aSAH that have major implications for patients is neuropsychological outcomes such as depression. There are two treatment approaches: open transcranial surgery, which primarily involves clipping of the aneurysm via performing a craniotomy and navigating through the cisterns and natural subarachnoid corridors of the brain to reach the aneurysm, at which point a metallic clip is applied to the exterior of the aneurysm to occlude it.; and endovascular treatment, which primarily involves coiling of the aneurysm via an arterial puncture (usually femoral).
Focus of the review
Until recently, surgical clipping of aneurysms has been the gold standard treatment. With advancement in neuro-interventional techniques and technology, this minimally invasive procedure offers an alternative treatment option for most aneurysms. Therefore, we focused this update on a comparison of these surgical treatments.
Comments on evidence
Neuro-interventional techniques and technology is advancing at a rapid pace and any evidence quoted here must be put in context of the date of publication against the timeline of evolution of this field.
Search and appraisal summary
The update literature search for this overview was carried out from the date of the last search, March 2009, to October 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 82 studies. After deduplication and removal of conference abstracts, 47 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 33 studies and the further review of 14 full publications. Of the 14 full articles evaluated, one systematic review, one RCT, and four further reports were added at this update.
Substantive changes at this update
INTRODUCTION: Subarachnoid haemorrhage (SAH) may arise spontaneously or as a result of trauma. Spontaneous SAH accounts for about 5% of all strokes. Ruptured aneurysms are the cause of 85% of spontaneous SAH. The most characteristic clinical feature is sudden-onset severe headache. Other features include vomiting, photophobia, and focal neurological deficit or seizures, or both. As the headache may have insidious onset in some cases, or may even be absent, a high degree of suspicion is required to diagnose SAH with less typical presentations. METHODS AND OUTCOMES: We conducted a systematic review, aiming to answer the following clinical question: What are the effects of surgical treatments for people with confirmed aSAH? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2014 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). RESULTS: At this update, searching of electronic databases retrieved 82 studies. After deduplication and removal of conference abstracts, 47 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 33 studies and the further review of 14 full publications. Of the 14 full articles evaluated, one systematic review, one RCT, and four further reports were added at this update. We performed a GRADE evaluation for six PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for one comparison based on information about the effectiveness and safety of endovascular coiling versus surgical clipping.
Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. ( 10 January 2017 )
Rated by doctors in Relevance Newsworthiness Emergency Medicine ******* ***** Hospital Doctor/Hospitalists ****** ***** Internal Medicine ****** ***** Neurology ****** ****
Rated by doctors in Relevance Newsworthiness Neurology ***** **** Surgery - Neurosurgery ****** *****