Controversies in the investigation and management of subarachnoid haemorrhage and its complications : is a more pragmatic approach and comprehensive endovascular treatment justified?

• Main Author: Mortimer, Alexander M.
• Published: University of Warwick 2017
• Subjects: 610; RC Internal medicine
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.731410

There are multiple factors that may impact on the outcome of a patient with subarachnoid haemorrhage (SAH). As well as the acute injury, these include the mode of treatment: surgical clipping (SC) or endovascular coiling (EVC); the complications and durability of investigations and treatment and the delayed ischaemic processes/cerebral vasospasm. The International Subarachnoid Aneurysm Trial (ISAT) demonstrated a significant reduction in the rate of death or dependency for patients treated with EVC rather than SC but ISAT did not address certain issues that remain controversial. This research focuses on some of the reasons for the ISAT findings and investigates areas that were not specifically investigated in the trial including the role of EVC of middle cerebral artery (MCA) aneurysms; cognition and the brain injury incurred through SC and EVC of anterior communicating artery (ACOM) aneurysms; the interaction between SC and EVC and the physiological derangement of the patient; the potential use of non-invasive imaging only in the investigation of more benign perimesencephalic subarachnoid haemorrhage (PMSAH); endovascular treatment of severe vasospasm and finally, the follow-up necessary for adequately coiled aneurysms. The findings of this thesis suggest that EVC is a suitable first line treatment for MCA aneurysms; that the injury sustained by brain regions heavily involved with cognition is significantly greater in patients with ACOM aneurysms treated with SC; that clinical outcomes in patients with more severe physiological derangement are superior for coiled patients; that invasive imaging may be unnecessary in patients with PMSAH; that endovascular treatment of vasospasm results in low rates of cerebral infarction and may negate its clinical impact; and finally that long term follow-up of adequately occluded coiled aneurysms is probably not necessary.