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Summer 2013

Treatment Options for Subarachnoid Hemorrhage

Dr. Wade Smith

Dr. Wade Smith

"When you're treating subarachnoid hemorrhage (SAH), experience determines outcomes," says neurologist Wade Smith, M.D., Ph.D., director of neurovascular services at UCSF Medical Center, one of the busiest centers for treating SAH in the world. In 2011, the center treated 134 aneurysmal SAH patients and 62 nonaneurysmal SAHs, with a combined mortality rate of only 15 percent.

Smith and his colleagues believe that to have that level of success, there must be an expert team and dedicated beds available 24/7 for patients with a subarachnoid hemorrhage. The team should include neurologists, interventional neuroradiologists and vascular neurosurgeons with deep experience treating SAH.

Dr. Michael Lawton

Dr. Michael Lawton

Michael Lawton, M.D., vhief of Cerebrovascular Surgery says, "At UCSF, because we have a wide array of expertise readily available and a collaborative approach, patients and their families can make the choices that suit their situation best."

Given the often-critical nature of SAH and other vascular pathologies, it's essential that patients be evaluated and treated as quickly as possible, says interventional neuroradiologist Randall Higashida, M.D. "With our dedicated ICU bed, we can immediately evaluate using advanced imaging studies and then triage for coiling, surgery or medical management."

Dr. Randall Higashida

Dr. Randall Higashida

Smith says, "We have a triumvirate of experts in the ICU dedicated to taking care of these patients."

As many hospitals have moved away from open surgery for aneurysms and other cerebrovascular conditions, experienced surgeons can be especially hard to find. That’s disturbing, because with the move to less invasive procedures, what’s left to open surgery are the more complex cases, including:

  • Giant or fusiform aneurysms
  • Aneurysms with a clot inside them
  • Aneurysms not appropriate for endovascular coiling

The majority of these cases may be treated with direct clipping, says Lawton, but the most complex cases require bypass procedures that use arteries or grafts to reroute blood flow. If the aneurysm has a clot inside, before beginning the repair, the surgeon must first remove or soften the clot.

Lawton says, "There’s no gold standard for making the decision about which approach is best. For younger or healthier people, surgery might make more sense; others might be better served by less invasive procedures. The point is that patients should have a choice, understand what each choice implies and have a team of experienced experts available who give them the best chance for a successful outcome."

Knowing When to Treat and When Not to Treat

Aneurysms don't always require treatment, but deciding when to treat is a complex calculation. "That's why we have multidisciplinary screening and periodic follow-up," Smith says. "And it's why we're doing research to figure out what aneurysms are most likely to grow and eventually rupture."

ruptured aneurysm of the  distal vertebral artery

Ruptured aneurysm of the
distal vertebral artery

One study carefully follows patients with untreated intracranial aneurysms, either because the aneurysm's size or location puts the patient at too great a risk for surgery, or because the patient chooses not to have treatment. For the past eight years, David Saloner, PhD, has been following close to a hundred of these patients, with follow-up MRI brain scans at six-month intervals.

"The bottom line is that only 15 percent of the patients’ aneurysms show relatively rapid growth, and these are the aneurysms we think are most likely to rupture, " says Saloner. He and his team are now characterizing these rapidly growing aneurysms.

Aneurysm after treatment

Aneurysm after treatment

"There are a lot of factors that our study can't get at, such as biochemical activity, but we have been able to assess friction of blood on the vessel wall," says Saloner. "The surprising thing is that where blood friction is low, that's where the aneurysm appears to grow over time; the early data indicate a fairly strong correlation."

If with further studies the correlation holds, physicians could have a new diagnostic tool in their armamentarium to fight the dangers of cerebrovascular illness.

For more information, contact Dr. Smith at (415) 353-8897, Dr. Lawton at (415) 353-7500 or Dr. Higashida at (415) 353-1863.

     

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