Epidemiological insights in management of aneurysmal subarachnoid hemorrhage

Spontaneous subarachnoid hemorrhage (SAH) is a devastating type of stroke, with the most frequent cause being a ruptured intracranial aneurysm. One of the most important things after the occurrence of a SAH, is the prevention of a rebleeding of the aneurysm. Therefore, the aneurysm needs to be occluded by either endovascular coiling or neurosurgical clipping, traditionally performed in the first 72 hours after the ictus. In this thesis, risk factors for early rebleeding after SAH are identified. Based on this, a new treatment paradigm for the acute phase of aSAH is proposed, recommending treatment of patients at high risk for rebleeding on an emergency base. Furthermore, this thesis highlights the importance of accurate identification of patients in a poor clinical condition for decisions regarding timing and type of treatment. The developed SAFIRE-grading scale is proposed as a new tool to assess the patients’ outcome soon after the ictus. Last, it revealed the impact of treatment delay and rebleeding on the outcomes of the International Subarachnoid Aneurysm Trial (ISAT), a large trial comparing both treatments, and found that after correcting for this, coiling and clipping could be considered comparable in long term based. All together, these new insights can lead to improved treatment of patients with aneurysmal SAH and a further decline in mortality and morbidity rates.