Interventional neuroradiology on call: the need for emergency coiling of ruptured intracranial aneurysms.

Subarachnoid hemorrhage is a serious disease with a case fatality of approximately 50%. Aneurysms are the cause of SAH in 85% of cases. Rebleeding is the most imminent concern; therefore, the first aim is occlusion of the ruptured aneurysm. In our institution with 150 –200 SAHs annually, 3 interventional neuroradiologists, and 13 neurosurgeons (3 with vascular expertise), the diagnostic and therapeutic logistics to achieve this goal are as follows: Patients with SAH are admitted to the emergency department by neurologic or neurosurgical residents. Most patients come from outside hospitals. After stabilization, native brain CT and CT angiography are performed, followed by angiography on short notice during office hours. In poor-grade or intubated patients, angiography is performed with the patient under general anesthesia. If an aneurysm is found, coiling is the first treatment option. If coiling seems technically difficult, neuroradiologic and neurosurgical colleagues are consulted about the best treatment (coiling, balloonor stent-assisted coiling, parent vessel occlusion, or clipping) and the best treating physician for this particular patient. Subsequently, coiling is performed with the patient under general anesthesia immediately following angiography, or clipping is scheduled for the next day in good-grade patients and is postponed in poor-grade patients. In the past 2 decades, since the introduction of coiling, this diagnostic and therapeutic pathway has been firmly established and all patients with ruptured aneurysms who are admitted on weekdays are coiled within 24 hours. On the basis of adequate logistics, a general perception of caretakers in the hospital (emergency department, intensive care, neurodivision) is that a patient with an SAH should be coiled immediately; if not, he or she will probably die from a rebleed. For the weekend, this implies that whenever a patient with SAH is admitted, the interventional neuroradiologist is consulted immediately for diagnosis and treatment. However, during the weekend, the optimal logistics of weekdays cannot always be met. Anesthesia is difficult to get, deliberation with radiologic and neurosurgical colleagues about the most appropriate treatment is usually not possible, experienced technicians may not be on call, and the mindset of the operating team may not be optimal because of private circumstances. At that time, it is the individual decision of the interventional neuroradiologist whether to treat and with which technique. When complications occur, there is no help at hand. Therefore, during the weekend, the chances of making a wrong decision that negatively affects outcome is higher than on weekdays. The following case may be instructive: A 20-year-old medical student experienced sudden severe headache early Sunday morning. CT in another hospital showed an SAH (Fig 1A), and the patient was transferred to our institution, arriving at noon. CT angiography demonstrated a vertebral junction aneurysm (Fig 1B). The neurosurgeon on call requested early coiling. However, at that time, anesthesia in the angiography suite was impossible because of busy operating rooms. Because the patient became gradually drowsy from a developing hydrocephalus, it was decided to place an external ventricular drain in the afternoon and postpone coiling until Monday morning. However, the caretakers in the hospital had informed the patient’s family about an imminent rebleed and had promised coiling that very day. Therefore, the family insisted compellingly on urgent coiling. Because the anesthesia team was too busy for coiling that afternoon, it was finally decided to do the coiling procedure directly following the ventricular drainage; the patient was to be transported intubated and sedated from the operating room. In the angiography suite, the intensivist would take care of deep sedation during the coiling procedure. When the patient arrived intubated and sedated in the angiography suite late in the afternoon, she was lifted onto the angiography table. At that moment, she regained consciousness and started to cough heavily while forcefully trying to remove the endotracheal tube. After several attempts, she suddenly dropped back on the table, returning comatose with bradycardia and hypertension. Apparently, the stress from the tube resulted in sudden hypertension and recurrent hemorrhage. Some 15 minutes later, 3D rotational angiography of the right vertebral artery demonstrated a vertebral junction aneurysm that was still bleeding (Fig 1C). After coiling, the bleeding had stopped, and the aneurysm was completely occluded. Her clinical course was complicated by drain-dependent hydrocephalus, vasospasm, and meningitis. Six months later, she is in a rehabilitation center with severe cognitive impairment, hemiparesis, untreatable central emesis, and bilateral abducens paresis. This case illustrates that whenever the necessary diagnostic http://dx.doi.org/10.3174/ajnr.A4134