Aneurysmal subarachnoid hemorrhage (SAH) poses an immediate threat to life. The accepted paradigm of treatment generally involves surgical intervention requiring craniotomy to allow neck clipping of the ruptured cerebral aneurysm, with the alternative approach of embolization of the aneurysm sac by the deposition of detachable coils delivered through the endovascular route. The selection of the treatment method depends on the establishment of clear guidelines for the attending neurosurgeon, but unfortunately no such definitive guidelines leading to a definitive treatment policy have been developed in Japan. Controlled comparison of the alternative treatment approaches of clipping and coil embolization is rendered difficult by the lack of reported series of interventions in patients using either clipping or coil embolization, and the methodological difficulties inherent in the retrospective comparison of the specific results achieved by unrelated institutes or individual surgeons. We describe our 5 years of experience of clipping and coil embolization to promote a consensus of decision-making for acute SAH.
Our therapeutic protocol emphasizes clipping, with coil embolization mainly considered for patients with poor neurological condition (Hunt & Kosnik Grades IV-V without hematoma), paraclinoid or basilar aneurysm, or serious systemic complications, and for elderly patients over 74 years old or older. We treated 198 patients, 55 males and 143 females aged from 31 to 91 years old (mean 61.3 years) with aneurysmal SAH between 2000 and 2005. Surgical clipping was performed in 164 cases, endovascular treatment in 25 cases, and conservative therapy for ruptured aneurysms in 9 cases. Overall, 95% of patients underwent radical treatment. On admission, 26% of patients were in poor neurological condition (Hunt & Kosnik Grades IV-V). Aneurysms arose from the anterior circle of Willis in 87% of cases. Eighty-seven percent of patients were treated with surgical clipping within 3 days of onset, and 84% were treated with coiling within 3 days.
Favorable outcome was defined as good recovery or moderately disabled classified by Glasgow Outcome Scale at discharge, which was achieved in 71% of all patients, 76% of patients treated by clipping, and 60% of patients treated by coil embolization. Symptomatic vasospasm occurred in 21% of patients after clipping but only in 3% after coil embolization (p<0.05). Computed tomography showed a low density area in 14% of patients after clipping but only in 3% after coil embolization. Administration of eicosapentaenoic acid significantly reduced the low density area in patients after clipping from 13.5% to 3.3% (p=0.035). Shunt surgery was required in 25% of patients after clipping, but only in 8% after coil embolization. Poor outcome occurred in patients with better preoperative neurological condition (Hunt & Kosnik Grades I-III) in 12% after clipping and in 14% after coil embolization, and preventable causes accounted for 75% and 50% of these cases, respectively.
Recently, the Ministry of Health, Labour and Welfare has required the collection and submission of accurate and complete information about treatment options, indications, and expected results for ruptured cerebral aneurysms. The availability of such an extensive database enabling rigorous analytical correlations will provide the required foundation to establish specific indications for the selection of the optimal methodology of clipping or coil embolization treatment for patients with acute SAH.