Purpose— The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods— A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. Results— Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. Conclusions— aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

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Fifteen patients with high-risk intracranial saccular aneurysms were treated using electrolytically detachable coils introduced via an endovascular approach. The patients ranged in age from 21 to 69 years. The most frequent clinical presentation was subarachnoid hemorrhage (eight cases). Considerable thrombosis of the aneurysm (70% to 100%) was achieved in all 15 patients, and preservation of the parent artery was obtained in 14. Although temporary neurological deterioration due to the technique was recorded in one patient, no permanent neurological deficit was observed in this series and there were no deaths. It is believed that this new technology is a viable alternative in the management of patients with high-risk intracranial saccular aneurysms. It may also play an important role in the occlusion of aneurysms in the acute phase of subarachnoid hemorrhage.

In a multicenter study, 120 patients with intracranial aneurysms presenting a high surgical risk were treated using electrolytically detachable coils and electrothrombosis via an endovascular approach. The results of treatment in patients with posterior fossa aneurysms (42 patients with 43 aneurysms) are presented. The most frequent clinical presentation was subarachnoid hemorrhage (24 cases). The clinical follow-up periods ranged from 1 week to 18 months. Complete aneurysm occlusion was obtained in 13 of 16 aneurysms with a small neck and in four of 26 wide-necked aneurysms. A 70% to 98% thrombosis of the aneurysm was achieved in 22 of 26 aneurysms with a wide neck and in three of 16 small-necked aneurysms. One aneurysm could not be treated due to a technical complication. Two cases required postprocedural surgical clipping of a residual aneurysm. One patient (originally in Hunt and Hess Grade V) experienced procedural rupture of the aneurysm requiring an emergency parent artery occlusion. He eventually died 5 days later. Another patient (originally in Grade IV) had coil migration and posterior cerebral artery territory ischemia. A third patient developed a permanent neurological deficit (hemianopsia) after complete occlusion of a wide-necked basilar bifurcation aneurysm. One patient, harboring an inoperable giant basilar bifurcation aneurysm, died from aneurysm bleeding 18 months after partial occlusion. Overall morbidity and mortality rates related to treatment were 4.8% (two cases) and 2.4% (one case), respectively (2.6% and 0% if considering only patients in Hunt and Hess Grades I, II, and III). It is suggested that this technique is a viable alternative in the management of patients with posterior fossa aneurysms associated with high surgical risk. Longer angiographic and clinical follow-up study is necessary to determine the long-term efficacy of this recently developed endovascular occlusion technique. Close postoperative angiographic and clinical monitoring of patients with wide-necked subtotally occluded aneurysms is mandatory to check for potential aneurysmal recanalization, regrowth, and rupture.

Background and Purpose-A well-defined complication rate of cerebral angiography in patients with subarachnoid hemorrhage (SAH), cerebral aneurysm, and arteriovenous malformation (AVM) would be useful to physicians making decisions regarding the imaging of these patients. We sought to define a statistically significant complication rate through meta-analysis of prospective studies in the literature. Methods-Meta-analysis of 3 published prospective studies of complications in cerebral angiography was performed to specifically define the risk of cerebral angiography in patients presenting with SAH, cerebral aneurysm, and AVM.

Clinical events following cerebral angiography were prospectively evaluated in 1,002 procedures. The ischemic event rate between 0 and 24 hours was 1.3% (0.1% permanent). This incidence was higher (2.5%) in patients investigated for cerebrovascular disease, but the difference was not significant. In addition, 1.8% of the patients suffered ischemia (0.3% permanent) between 24 and 72 hours after angiography. Cerebral ischemic events occurred as a recurrence or worsening of a preexisting condition twice as often as de novo. All permanent ischemia was a worsening of a preexisting phenomenon. There was a significant increase in the incidence of neurologic events between 0 and 24 hours when the procedure lasted longer than 60 minutes and when there was systolic hypertension. Trends toward higher incidence were noted with the use of increased volume of contrast, with increased serum creatinine, when transient ischemic attacks or stroke were the indications, and when 3 or more catheters were used. The incidence of neurologic events between 24 and 72 hours increased significantly with the increase in the amount of contrast used, with age, and with diabetes. The occurrence of nonneurologic events (mostly hematomas) was significantly increased by multiple factors. This study shows that events can and do occur beyond the usual observation period of 24 hours but confirms the low risk of cerebral angiography when performed judiciously. (Stroke 1987;18:997-1004)

Proximal ICA location and large aneurysm size significantly predicted revision of surgery following intraoperative angiography. Unexpected findings, even in less complex locations, are frequently identified on intraoperative angiography. Low complication rates, high accuracy, and the unexpected need for clip readjustments favor a more widespread use of intraoperative angiography.

Tentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.