Surgery in subarachnoid haemorrhage
Absolutely all cases of SAH should ne referred to the neurosurgeons except in cases of extreme frailty where surgery would be inappropriate.
Decisions regarding surgery should be made by an expert neurological centre.
Surgery can involve urgent clipping or endovascular coiling
Clipping or coiling?
This is a complex decision and will be made on a case-by-case basis by the neurosurgeons.
ISAT trial: Coiling has less disability and epilepsy at seven years. More rebleeding though, and less complete occlusion on follow-up imaging. Coiling is difficult to do if very wide-necked.
Coiling should be done using 4-vessel DSA (digital subtraction MRA, sees carotids and vertebrals) in under 48 hours.
Clipping helps prevent cerebral ischaemia as the presence of subarachnoid blood is a powerful predictor of delayed cerebral ischaemia
For AVMs
Surgery to remove, embolism or ‘gamma knife’ radiotherapy
Follow up regularly with MRA or CT angio