Aneurysmal Subarachnoid Hemorrhage Prevention

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Preventive strategies can significantly reduce the risk of aneurysm formation, growth, and rupture.

• Control Hypertension
  • Maintain BP <130/80 mmHg.
  • Use antihypertensive agents (e.g., ACE inhibitors, ARBs, calcium channel blockers).
• Smoking Cessation
  • Strongly associated with aneurysm formation and rupture.
  • Use nicotine replacement therapy, counseling, or medications (e.g., varenicline, bupropion).
• Alcohol Moderation
  • Limit to ≤1 drink/day (women) or ≤2 drinks/day (men).
• Healthy Diet and Exercise
  • Reduce cholesterol and saturated fat intake.
  • Exercise ≥150 min/week of moderate-intensity activity.
• Avoid Illicit Drugs (e.g., Cocaine, Methamphetamines)
  • These substances cause acute hypertension surges and increase rupture risk.

• Size and Location
  • Aneurysms >7 mm (especially in the posterior circulation) have a higher rupture risk.
• Patient-Specific Risk Factors
  • Family history of aSAH.
  • Previous aneurysm rupture.
  • Multiple aneurysms.
• Imaging Surveillance
  • Small aneurysms (<5 mm): Periodic surveillance (MRA or CTA).
  • Growing aneurysms: More aggressive monitoring or treatment.

• Blood Pressure Control
  • Maintain strict control, particularly in those with known aneurysms.
• Statin Therapy
  • May improve vascular integrity, though data on preventing rupture are inconclusive.
• Avoid Anticoagulants and NSAIDs
  • These medications may increase bleeding risk if an aneurysm ruptures.

• Endovascular Coiling vs. Surgical Clipping
  • Coiling: Preferred for posterior circulation aneurysms and older patients.
  • Clipping: Preferred for younger patients or aneurysms with broad necks.
• Flow Diverters
  • Used for large or complex aneurysms to redirect blood flow and promote thrombosis.

• Family History (First-Degree Relatives with aSAH)
  • Screening with MRA or CTA is recommended in individuals with ≥2 affected relatives.
• Connective Tissue Disorders
  • Patients with polycystic kidney disease, Marfan syndrome, or Ehlers-Danlos syndrome should be considered for screening.

• Control hypertension and quit smoking – the most important modifiable factors.
• Monitor unruptured aneurysms based on size, growth, and risk factors.
• Consider surgical or endovascular intervention in high-risk aneurysms.
• Screen high-risk individuals (e.g., those with a strong family history).

Surgical clipping and endovascular coiling are both effective in preventing aneurysmal subarachnoid hemorrhage, but the choice between these interventions remains controversial.

A systematic review and meta-analysis were conducted, including relevant two-arm clinical trials up to September 2023, sourced from Scopus, PubMed, Web of Science, and the Cochrane Library. The primary outcomes were complete occlusion rates during mid-term and long-term follow-ups. Standard mean differences and risk ratios were used to analyze variations in outcomes. Python meta-analysis with sensitivity testing and regional subgroup analysis was used to resolve heterogeneity.

The analysis included 139,485 participants. Clipping demonstrated significantly higher complete occlusion rates in midterm follow-up (RR = 0.83, 95% CI [0.75, 0.91], p = 0.0001) but was associated with a higher risk of procedural complications such as bleeding and ischemic stroke. Coiling showed a higher risk of retreatment (RR = 3.46, 95% CI [1.21, 9.86], p = 0.02), yet it had lower procedural complications (RR = 0.54, 95% CI [0.38, 0.78], p < 0.0009), shorter hospital stays (MD 4.36, 95% CI [2.96, 5.77], p = 0.0001), and better post-procedural outcomes as indicated by lower modified Rankin Scale scores (RR = 0.73, 95% CI [0.55, 0.97], p = 0.03). Long-term occlusion rates were comparable between the two methods.

While clipping achieves higher mid-term occlusion rates, coiling is associated with fewer complication rates, shorter hospital stays, and potentially better long-term outcomes. Treatment decisions should be individualized, considering patient-specific characteristics and procedural feasibility ¹⁾.