Therapy of SAH
In case of SAH due to an acutely ruptured intracranial aneurysm, there are two therapeutic goals: First, to prevent a rebleeding, and, secondly, to treat and to prevent the primary and secondary complications of the bleeding (Gilsbach, Poeck and Piscol, 1993). In case of SAH without a proven source of the bleeding, the emphasis is put on the renewed attempt to identify the source of the bleeding as well as on the treatment of the primary and secondary consequences of the bleeding. The time course is in many ways essential in aneurysmal SAH and determines therapeutic decisions. Maintenance of vital functions and vegetative stabilization of the patient is essential in the first few hours after SAH. In this phase, especially after severe bleedings, respiratory dysregulation and hypertensive crises, as the consequence of vegetative dysregulation, are particularly critical. Only in case of space-occupying hematomas with a rapidly progressive clouding of consciousness, an acute surgical removal of the hematoma is indicated. In approximately 25% of all patients, hydrocephalus with an additional impairment of cerebral perfusion caused by a blockade of the subarachnoid space due to the hemorrhage or blood clots, occurs within hours. In this case, an external ventriculostomy is required to lessen the intracranial pressure. Those cases are critical in which an increase of brain volume caused by the bleeding impedes the dilatation of the ventricles. Nevertheless, in this case a disturbance of CSF circulation with a substantial increase of intracranial pressure exists (Bailes et al., 1990). The concept of early aneurysm surgery (within 72 hours after the ictus) that has evolved within the last 20 years implies that angiography must be carried out as early as possible. The surgical clipping of an aneurysm means the exclusion of re-rupture with a certainty of about 98%. Beside the operative clipping of an aneurysm, in the last years endovascular forms of therapy aiming to obstruct the aneurysmal lumen with so-called “coils” with the intent to provoke secondary thrombosis of the aneurysm have become of increasing interest (Guglielmi et al., 1991; Hodes et al., 1991). Next to the fact that these therapies are still in the experimental stage and cannot be applied in clinical routine to all cases, some studies demonstrate that this form of therapy may be problematical and that a permanent elimination of the aneurysm by means of endovascular procedures remains questionable (Reul et al., 1997; Spetzger et al., 1996). Coil embolisation has the advantage that the patient is spared the intracranial surgical intervention. The procedure bears, however, its own risks.
KeywordsIntracranial Aneurysm Early Surgery Cerebral Aneurysm Cerebral Vasospasm Aneurysm Rupture
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