{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzmude\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzmude\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/1\\\/25\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/1\\\/25\u0022}],\u0022ac\u0022:{\u0022spmdc;10\\\/1\\\/25\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;10\\\/1\\\/25\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThis article discusses the epidemiology of subarachnoid hemorrhage (SAH) and provided insight into patient outcomes, therapies, and treatments.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eischemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EMathew Flaherty, MD, University of Cincinnati, Cincinnati, OH, discussed the epidemiology of subarachnoid hemorrhage (SAH) and provided insight into patient outcomes. In most Western populations, the incidence of SAH is \u223c6- to 10 cases\/1,000,000 persons. In the United States, African- and Mexican-Americans have double the risk of SAH compared with Caucasians. The incidence in women averages 1.24 (range 1.09 to 1.42)-times higher than in men. This gender difference begins at age 55 years and increases thereafter [de Rooij NK et al. \u003Cem\u003EJ Neurol Neurosurg Psychiatry\u003C\/em\u003E 2007]. Smoking and hypertension are the most important risk factors for SAH [Feigin VL et al. \u003Cem\u003EStroke\u003C\/em\u003E 2005]. Despite only accounting for 5% of all strokes, SAH remains an important subtype, because it occurs in younger patients, carries a significant morbidity and mortality risk, and incurs higher costs compared with other subtypes.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPoor clinical status on admission is the most significant indicator of a poor outcome, followed by rebleeding. Overall, 10% to 15% of patients with an SAH die before hospitalization, with a 30-day case fatality of 20% to 45%. Lingering problems that are common among survivors at 1 year include memory, mood, and speech disturbances and difficulty with self-care [Hackett ML et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2000].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn concluding, Dr. Flaherty noted that things are not all doom and gloom. SAH case fatality is declining (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Decline in SAH Fatalities in Cincinnati.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-163808774\u0022 data-figure-caption=\u0022Decline in SAH Fatalities in Cincinnati.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11234\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EDecline in SAH Fatalities in Cincinnati.\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from M. Flaherty, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003ETreatment of SAH patients in the ICU typically involves preventing rebleeding and minimizing delayed ischemia from vasospasm. This approach was based on data from the International Cooperative Study on the Timing of Aneurysm Surgery, which found that vasospasm was the primary cause of death (7%) among SAH patients [Kassel NF et al. \u003Cem\u003EJ Neurosurg\u003C\/em\u003E 1990]. Much progress has been made in preventing vasospasm, however, such that today, that number is closer to 1%. Currently, the primary cause of death in these patients is the acute effects of a primary severe bleed (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). Ventriculostomy is often the only tool for acute brain protection in poor-grade SAH patients.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Causes of Hospital Death After SAH.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-163808774\u0022 data-figure-caption=\u0022Causes of Hospital Death After SAH.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11237\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003ECauses of Hospital Death After SAH.\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from S. Mayer, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EGlobal cerebral edema develops in 20% of SAH patients and is an independent risk factor for mortality, cognitive dysfunction, and poor outcome after SAH [Claassen J et al; Kreiter KT et al. \u003Cem\u003EStroke\u003C\/em\u003E 2002]. Infusion of 23.5% hypertonic saline 2 mL\/kg has been shown to be an effective treatment for brain swelling, in that it has been shown to decrease intracranial pressure (74%), decrease cerebral perfusion pressure (27%), and increase cerebral blood flow (23%) in a small group of 10 patients. Peak effect occurred between 20 and 60 minutes of infusion [Tseng M-Y et al. \u003Cem\u003EStroke\u003C\/em\u003E 2003].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe protocol for SAH at Dr. Mayer\u0027s institution is intravascular (IV) loading with epsilon aminocaproic acid (Amicar) upon diagnosis (4-g IV load and 1 g every hour until 72 hours or aneurysm repair). This protocol has been shown to decrease rebleeding in treated patients by 2.7% versus nontreated patients (11.4%). In the future, Dr. Mayer sees the use of more advanced monitoring of brain tissue oxygen and transplumonary thermodilution, which can indicate global end-diastolic volume.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe issue of whether an endovascular (coil) or microsurgical (clip) approach is a better way to treat aneurysmal SAH remains debatable, said B. Gregory Thompson, MD, University of Michigan, Ann Arbor, MI. The prevailing view is that interventional techniques are less invasive and less morbid at initial treatment. The superiority of coiling over clipping was shown in the International Subarachnoid Aneurysm Trial (ISAT), which reported an absolute risk reduction of 6.9% after 1 year with the use of coils compared with patients who received endovascular (clipping) treatment [Molyneux A et al. \u003Cem\u003ELancet\u003C\/em\u003E 2002]. Dr. Thompson argued that ISAT had methodological problems because of the subjective nature of the eligibility definition. Selection bias may have been compromised because of the use of clinical equipoise, which excluded 77% of patients. Documented experience of the surgeons was not required; thus, it was difficult to determine the equivalency of the technical expertise of the endovascular and surgical practitioners.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EExternal validity was not shown when the results of the ISAT were compared with other similar trials [Harbaugh RE. \u003Cem\u003ELancet\u003C\/em\u003E 2003]. The surgical morbidity appeared to be relatively high, particularly considering the clinical status of the patients at the time of randomization and the size of the aneurysms. The ISAT patient cohort, compared with other randomized, prospective aneurysm studies, had lower average Hunt and Hess (HH) scores, smaller aneurysm sizes, and a lower percentage of procedures in the posterior circulation location, a more difficult area to treat.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EAfter evaluating outcomes in other trials, Dr. Thompson cited specific factors that favored endovascular or microsurgical treatment. Factors that favor microsurgical treatment include: SAH HH grade between 1 and 3; an anterior circulation location (PICA, SCA, supraclinoid ICA, MCA); \u0026lt;3 mm in size or giant aneurysm with neck \u0026gt;5 mm; a saccular, fusiform, or abnormal branch morphology; younger patients (\u0026lt;60 years of age); and hematoma (mass effect or edema).\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EFactors that favor endovascular treatment include: all SAH HH grades; posterior circulation (basilar apex, paraclinoid ICA, petrocarvernous); small to medium in size with a narrow neck (\u0026lt;5 mm); morphology may include saccular and calcified aneurysms; \u0026gt;60 years of age; medical comorbidities; and no hematoma\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EGiuseppe Lanzino, MD, Mayo Clinic, Rochester, MN, followed Dr. Thompson and took the opposite point of view, arguing that the ISAT was a well-designed study that supported the use of coils and that coiling was superior to clipping, citing evidence from the Kuopie and BRAT studies.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EThe Kuopio study reported comparable outcomes at one year after early surgical and endovascular treatment of ruptured intracranial aneurysms. Though superficial brain retraction deficits (p\u0026lt;0.001) and ischemic lesions in the territory of the ruptured aneurysm (p=0.025) were more frequent in the surgical group, 39-month Kaplan-Meier analysis revealed equal survival in both treatment groups [Koivisto T et al. \u003Cem\u003EStroke\u003C\/em\u003E 2000].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EDr. Lanzino argued that the ISAT is notable, in that follow-up data at one year were available in a high percentage (98%) of eligible patients and that it was the only study of this nature to use patient self-assessment to score outcome. In the ISAT, coil embolization appeared to be safer than clip ligation at one year, while clip occlusion had better long-term efficacy at preventing rebleeding. Rebleeding rates were very low for both groups (\u003Ca id=\u0022xref-fig-2-2\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E), while endovascular patients had lower mortality rates compared with patients who received a clip (11% vs 14%; p\u0026lt;0.05).\u003C\/p\u003E\u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Cumulative Risk of Rebleed.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-163808774\u0022 data-figure-caption=\u0022Cumulative Risk of Rebleed.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/25\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11241\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003ECumulative Risk of Rebleed.\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced with permission from G. Lanzino, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-18\u0022\u003EAge affected outcome, in that better long-term protection from SAH that is afforded by clip placement may give this treatment an advantage in life expectancy for patients aged \u0026lt; 40 years [Mitchell P et al. \u003Cem\u003EJ Neurosurg\u003C\/em\u003E 2008]. Early evidence from the BRAT and other studies mirrored the results from the ISAT [van der Schaaf I et al. \u003Cem\u003ECochrane Database Syst Rev\u003C\/em\u003E 2005].\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EDr. Lanzino concluded that if a ruptured aneurysm is considered suitable for endovascular or surgical treatment, there is firm evidence that coiling is associated with better outcomes, while younger patients (\u0026lt;40 years) may benefit from surgery. From his own clinical experience, he believes that the durability of endovascular procedure is steadily improving.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/1\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmude\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmude\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}