A 50-year-old woman presents acutely with severe headache ('thunderclap'), neck stiffness, and photophobia. CT brain is negative. LP shows xanthochromic CSF with >2000 red blood cells in tubes 1 and 4. CT angiography confirms a 7 mm posterior communicating artery (PCoA) aneurysm. The most appropriate definitive treatment within 24 hours is:
- A Endovascular coiling is preferred over clipping based on ISAT trial results showing lower 1-year dependency/death ✓
- B Surgical clipping of the aneurysm is preferred over coiling based on ISAT trial data
- C Conservative management with nimodipine and deferred treatment at 2–4 weeks
- D Microsurgical clipping is mandatory because PCoA aneurysms are not suitable for coiling
Correct answer: A. Endovascular coiling is preferred over clipping based on ISAT trial results showing lower 1-year dependency/death
Explanation
The ISAT trial (International Subarachnoid Aneurysm Trial) demonstrated that endovascular coiling of ruptured intracranial aneurysms was associated with significantly lower risk of death or dependency at 1 year compared to neurosurgical clipping (23.7% vs 30.6%, relative risk reduction 22.6%). Endovascular coiling is now the preferred treatment for most ruptured aneurysms amenable to both techniques, including PCoA aneurysms, which are generally coilable. Early treatment (<24–72 h) prevents rebleeding.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.