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      Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

      review-article
      , M.D., Ph.D. 1 , , M.D., Ph.D. 1 , , , M.D., Ph.D. 2 , , M.D., Ph.D. 3 , , M.D., Ph.D. 4 , , M.D. 5 , , M.D. 6 , , M.D., Ph.D. 7 , , M.D., Ph.D. 8 , , M.D., Ph.D. 9 , , M.D., Ph.D. 10 , , M.D., Ph.D. 11 , , M.D., Ph.D. 12 , , M.D., Ph.D. 13 , , M.D., Ph.D. 14 , , M.D., Ph.D. 15 , , M.D., Ph.D. 1 , , M.D., Ph.D. 16 , , M.D., Ph.D. 17 , , M.D., Ph.D. 10 , , M.D., Ph.D. 18 , Quality Control Committees from the Korean Society of Cerebrovascular Surgeons, Society of Korean Endovascular Neurosurgeons, Korean Society of Interventional Neuroradiology, Korean Stroke Society and Korean Academy of Rehabilitation Medicine
      Journal of Korean Neurosurgical Society
      Korean Neurosurgical Society
      Aneurysmal subarachnoid hemorrhage, Clinical practice guideline, Korean version

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          Abstract

          Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

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          Most cited references337

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          International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion.

          Two types of treatment are being used for patients with ruptured intracranial aneurysms: endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment. 2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or endovascular coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3-6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment. We report the 1-year outcomes for 1063 of 1073 patients allocated to endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23.5%) of 1063 patients allocated to endovascular treatment were dead or dependent at 1 year, compared with 326 (30.9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7.4% (95% CI 3.6-11.2, p=0.0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0.03). The risk of epilepsy was substantially lower in patients allocated to endovascular treatment, but the risk of late rebleeding was higher. In patients with ruptured intracranial aneurysms suitable for both treatments, endovascular coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after endovascular coiling than after neurosurgical clipping.
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            Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.

            The management of unruptured intracranial aneurysms is controversial. Investigators from the International Study of Unruptured Intracranial Aneurysms aimed to assess the natural history of unruptured intracranial aneurysms and to measure the risk associated with their repair. Centres in the USA, Canada, and Europe enrolled patients for prospective assessment of unruptured aneurysms. Investigators recorded the natural history in patients who did not have surgery, and assessed morbidity and mortality associated with repair of unruptured aneurysms by either open surgery or endovascular procedures. 4060 patients were assessed-1692 did not have aneurysmal repair, 1917 had open surgery, and 451 had endovascular procedures. 5-year cumulative rupture rates for patients who did not have a history of subarachnoid haemorrhage with aneurysms located in internal carotid artery, anterior communicating or anterior cerebral artery, or middle cerebral artery were 0%, 2. 6%, 14 5%, and 40% for aneurysms less than 7 mm, 7-12 mm, 13-24 mm, and 25 mm or greater, respectively, compared with rates of 2 5%, 14 5%, 18 4%, and 50%, respectively, for the same size categories involving posterior circulation and posterior communicating artery aneurysms. These rates were often equalled or exceeded by the risks associated with surgical or endovascular repair of comparable lesions. Patients' age was a strong predictor of surgical outcome, and the size and location of an aneurysm predict both surgical and endovascular outcomes. Many factors are involved in management of patients with unruptured intracranial aneurysms. Site, size, and group specific risks of the natural history should be compared with site, size, and age-specific risks of repair for each patient.
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              International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.

              Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomised, multicentre trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n=1070) or endovascular treatment by detachable platinum coils (n=1073). Clinical outcomes were assessed at 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale score of 3-6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. 190 of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) allocated neurosurgical treatment (p=0.0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.
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                Author and article information

                Journal
                J Korean Neurosurg Soc
                J Korean Neurosurg Soc
                jkns
                Journal of Korean Neurosurgical Society
                Korean Neurosurgical Society
                2005-3711
                1598-7876
                March 2018
                28 February 2018
                : 61
                : 2
                : 127-166
                Affiliations
                [1 ]Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
                [2 ]Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
                [3 ]Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
                [4 ]Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
                [5 ]Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
                [6 ]Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
                [7 ]Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
                [8 ]Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
                [9 ]Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
                [10 ]Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
                [11 ]Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
                [12 ]Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
                [13 ]Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
                [14 ]Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
                [15 ]Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
                [16 ]Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
                [17 ]Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
                [18 ]Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
                Author notes
                Address for reprints: Jeong Eun Kim, M.D., Ph.D. Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea, Tel : +82-2-2072-2354, Fax : +82-2-744-8459, E-mail : eunkim@ 123456snu.ac.kr
                Article
                jkns-61-2-127
                10.3340/jkns.2017.0404.005
                5853198
                29526058
                c4d46942-77ac-4c05-afd1-352267f4b151
                Copyright © 2018 The Korean Neurosurgical Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 07 April 2017
                : 05 June 2017
                : 09 June 2017
                Categories
                Review Article

                Surgery
                aneurysmal subarachnoid hemorrhage,clinical practice guideline,korean version
                Surgery
                aneurysmal subarachnoid hemorrhage, clinical practice guideline, korean version

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