Types of Subarachnoid Hemorrhage Surgery

Introduction

A subarachnoid hemorrhage (SAH) is a life-threatening medical emergency that occurs when bleeding happens in the space between the brain and its protective membranes. In most cases, it is caused by a ruptured brain aneurysm, trauma, or an arteriovenous malformation (AVM). Immediate treatment is crucial to prevent re-bleeding, stroke, and long-term neurological damage. One of the most important steps in SAH management is choosing the right surgical approach. Modern neurosurgery offers multiple techniques, each tailored to the underlying cause, patient condition, and the severity of the bleed. In this blog, we explain the types of subarachnoid hemorrhage surgery, how each procedure works, and what patients and families can expect.

Understanding the Need for Surgery in Subarachnoid Hemorrhage

The primary goals of surgery for subarachnoid hemorrhage are

1. To stop the bleeding at its source
2. To secure the blood vessel and prevent re-bleeding
3. To relieve pressure on the brain
4. To stabilize the patient and minimize neurological damage

Not all cases of SAH require immediate surgery. However, when an aneurysm is involved, surgical intervention becomes urgent. Two main surgical strategies are used: microsurgical clipping and endovascular coiling, along with additional supportive procedures like external ventricular drainage and decompressive craniectomy.

Types of Subarachnoid Hemorrhage Surgery

1. Microsurgical Clipping :- Microsurgical clipping is one of the oldest and most definitive procedures for treating aneurysmal subarachnoid hemorrhage. It involves a neurosurgeon placing a tiny metal clip at the base (neck) of the aneurysm to stop blood flow into it.

How the Procedure Works

• A craniotomy (small opening in the skull) is performed.
• Using an operating microscope, the surgeon locates the ruptured aneurysm.
• A titanium clip is placed across the aneurysm neck.
• The clip permanently seals the aneurysm from circulation.

Benefits

• Provides a permanent and durable solution.
• Ideal for wide-neck aneurysms.
• Reduces the risk of future ruptures.

Limitations

• More invasive than endovascular procedures.
• Longer recovery time.
• Not suitable for patients who are medically unstable.

This technique is usually preferred for younger patients, complex aneurysms, or aneurysms located in surgically accessible regions.

2. Endovascular Coiling :- Endovascular coiling is a minimally invasive procedure and the leading modern technique used globally for ruptured aneurysms.

How It Works

• A catheter is inserted through the femoral or radial artery.
• Under X-ray guidance, the surgeon navigates the catheter to the aneurysm.
• Tiny platinum coils are released into the aneurysm sac.
• These coils promote clotting and effectively seal off the aneurysm.

Benefits

• Minimally invasive with no need for a skull opening.
• Faster recovery and shorter hospital stay.
• Best for deep or hard-to-reach aneurysms.

Limitations

• May require follow-up procedures if the aneurysm reopens.
• Not suitable for all aneurysm shapes and sizes.

Endovascular coiling is often the first-line approach in elderly patients or those with multiple medical risks.

3. Flow Diverter Stents :- Flow diverters are newer devices used mainly for large, wide-neck, or complex aneurysms that cannot be treated with standard coiling or clipping.

How the Surgery Works

• A special stent is placed inside the diseased blood vessel.
• It redirects blood flow away from the aneurysm.
• Over time, the aneurysm shrinks and seals off naturally.

Advantages

• Highly effective for giant aneurysms.
• Minimally invasive.
• Reduces need for open surgery.

Drawbacks

• Requires the patient to take blood-thinning medications.
• Not typically used in unstable emergency situations.

Flow diverters are commonly chosen when other surgical options are not possible due to aneurysm structure or location.

4. External Ventricular Drainage (EVD) :- Many patients with subarachnoid hemorrhage develop hydrocephalus, a condition where excess cerebrospinal fluid (CSF) builds up in the brain. EVD is a crucial life-saving procedure that helps reduce brain pressure.

Procedure Overview

• A small catheter is placed into one of the brain’s ventricles.
• Excess CSF and blood are drained externally.
• This relieves pressure and prevents further neurological damage.

Why It’s Needed

• Controls elevated intracranial pressure (ICP)
• Prevents brain herniation
• Stabilizes the patient for definitive aneurysm treatment

EVD is often used alongside coiling or clipping to support patient recovery.

5. Decompressive Craniectomy :- In severe cases of SAH, brain swelling may become uncontrollable. A decompressive craniectomy may be performed to allow the brain to expand safely without getting compressed.

How It Works

• A large portion of the skull bone is temporarily removed.
• This gives the swollen brain room to expand.
• The bone flap is replaced after the swelling reduces.

When It Is Used

• Severe cerebral edema
• Refractory intracranial hypertension
• When other methods fail to control pressure

While not a direct treatment for the aneurysm, decompressive craniectomy helps prevent life-threatening brain damage.

6. Surgical Bypass Procedures :- In rare and complex cases, especially when an aneurysm is difficult to access or treat, neurosurgeons may perform an EC-IC (extracranial-intracranial) bypass.

What It Involves

• A healthy blood vessel is taken from another part of the body.
• It is connected to a brain artery to reroute blood flow.
• The aneurysm is then surgically trapped or closed off.

This advanced procedure is only done in specialized centers and is reserved for highly complex vascular problems.

How Surgeons Choose the Right Procedure

The choice of surgery depends on

1. Location and size of the aneurysm
2. Severity of the hemorrhage
3. Patient’s age and medical condition
4. Presence of complications like hydrocephalus or vasospasm
5. Availability of endovascular technology

Often, a multidisciplinary team of neurosurgeons, interventional radiologists, and critical care specialists work together to determine the safest approach.

Recovery After Subarachnoid Hemorrhage Surgery

Recovery varies depending on the type of surgery, severity of the bleed, and the patient’s neurological status. Most patients require

1. ICU stay for close monitoring
2. Blood pressure control
3. Management of vasospasm
4. Physical therapy and rehabilitation
5. Follow-up imaging to ensure the aneurysm remains secure

Early detection, timely surgery, and comprehensive rehabilitation significantly improve long-term outcomes.

Conclusion

Subarachnoid hemorrhage is a serious condition that requires rapid, expert intervention. Understanding the different types of subarachnoid hemorrhage surgery clipping, coiling, flow diversion, bypass procedures, EVD, and decompressive craniectomy helps patients and families make informed decisions during a critical time. With advancements in neurosurgery and early intervention, survival rates and recovery outcomes continue to improve. If you or your loved one has been diagnosed with SAH, seeking treatment at a specialized neurovascular center is essential for the best possible care.