European Stroke Organization Guidelines for

the Management of Intracranial Aneurysms

and Subarachnoid Haemorrhage

Steiner, et al *

Departments of Neurology and Neurosurgery, Heidelberg University, Heidelberg ,

and Department of
Radiology, University of Essen, Essen , Germany; Department of Clinical Neurosciences,
University of Helsinki, Helsinki , Finland; Department Neurology, Utrecht University,
Utrecht , The Netherland

Cerebrovasc Dis 2013;35:93112rit Care Med 2013; 41:263306.

_______________________________________________________________
Recopilacion y Traduccin:

JC. Vergara.

(2013)

General Considerations

Consideraciones generales

Definitions Terminology

Definiciones Terminologa

Statement on Definition
We differentiate ruptured intracranial aneurysm (RIA) from
unruptured intracranial aneurysm (UIA); the latter can either
be asymptomatic or symptomatic

Declaracin sobre la definicin

Nosotros diferenciamos 'aneurisma intracraneal roto' (RIA)
de 'aneurisma intracraneal no roto' (UIA), este ltimo puede
ser "asintomtica" o "sintomtico"

A symptomatic UIA usually causes brain nerve palsy or

rarely can cause arterial embolism

Un UIA sintomtico suele causar afectacin neural cerebral

o raramente puede causar embolia arterial

Asymptomatic UIAs are usually found incidentally

(incidentalaneurysm) because of symptoms unrelated to
aneurysm (long-term headache, dizziness, etc.) or can be
discovered after SAH as an additional aneurysm, which is
not the bleeding source

Los UIAs asintomticos generalmente son hallazgos

casuales ("incidental aneurisma ') debido a sntomas no
relacionados con el aneurisma (dolor de cabeza de larga
evolucin, mareos, etc) o puede ser descubierto tras una
HSA como un "aneurisma adicional", que no haya sido la
fuente del sangrado .

Clinical Appearance and Grading

Presentacin clnica y Graduacin

Recommendation
It is recommended that the initial assessment of SAH
patients, and therefore the grading of the clinical condition, is
done by means of a scale based on the GCS

Recomendacin
Se recomienda que la evaluacin inicial de los pacientes
con Hay por lo tanto la graduacin de la condicin clnica, se
haga por medio de una escala basada en el GCS

The PAASH scale performs slightly better than the WFNS

scale, which has been used more often (class III, level C)

La escala PAASH evala un poco mejor que la escala

WFNS, utilizada ms frecuentemente (clase III, nivel C)

Risk Factors

Factores de riesgo

Statement
Hypertension can be considered to be an important risk
factor for SAH and possibly for aneurysm formation and fatal
aneurysm rupture

Declaracin
La Hipertensin puede considerarse un factor de riesgo
importante para la HSA y posiblemente para la formacin de
aneurismas y la ruptura fatal de aneurisma

Cigarette smoking is the most important modifiable risk

factor for aneurysm formation, growth and rupture, and
should be discouraged

Fumar es el factor de riesgo modificable ms importante

para la formacin, crecimiento y ruptura de los aneurismas y
debe ser desalentado

Alcohol abuse and particularly sudden intake of high

quantities is a risk factor for aneurysm rupture and should be
desisted (class III, level C)

El Abuso de alcohol y particularmente la repentina ingesta

de altas cantidades es un factor de riesgo para ruptura de
aneurisma y debe ser desalentado (clase III, nivel C)

Family History

Historia familiar

Recommendation
Screening should in general not be advised in the case of
only 1 affected first-degree relative

Recomendacin
El screening a parientes de primer grado en general no se
recomienda en el caso de slo 1 afectado

If 2 or more first-degree relatives are affected, the lifetime

risk of SAH in the other relatives is considerable, and
screening should be considered. (class III, level C)

Si 2 o ms familiares de primer grado son afectados, el

riesgo de HSA en los otros parientes es considerable, y debe
considerarse el screening. (clase III, nivel C)

Diagnosis

Diagnstico

Recommendation for Diagnosis

Recomendaciones para el diagnstico

CT/CTA and MRI with multiple sequences are equally

suitable for the diagnosis of SAH within 24 h
(class II, level B)

CTA/CT (angioTAC/TAC) y MRI con mltiples proyecciones

son igualmente convenientes para el diagnstico de HSA
dentro de las primeras 24 h (clase II, nivel B)

CT/CTA and multisequential MRI/MRA may confirm the

underlying cause

CTA/CT y MRI/MRA multisequencial pueden confirmar la

causa subyacente

Lumbar puncture must be performed in a case of clinically

suspected SAH if CT or MRI does not confirm the diagnosis
(class II, level B);
however, within the first 612 h the differentiation between
genuine subarachnoidal blood and traumatic admixture of
blood may be difficult

La Puncin Lumbar debe realizarse en caso de HSA

clnicamente sospechoso si la CT o MRI no confirma el
diagnstico (clase II, nivel B);
sin embargo, en las primeras 6 a 12 h la diferenciacin entre
hemorragia subaracnoidea genuina y mezcla de sangre
traumtica puede ser difcil

DSA (DSA: digital subtraction angiography ) of all cerebral

arteries should be performed if a bleeding source was not
found on CTA and the patient has a typical basal SAH pattern
on CT (class II, level B)

La DSA de todas las arterias cerebrales debe realizarse si

no se encuentra una fuente de sangrado en CTA y el
paciente tiene un patrn tpico de HSA basal en el CT (clase
II, nivel B)

If no aneurysm was found, CTA or DSA should be repeated

as described below: SAH without aneurysm
(class III, level C)

Si no se encuentra aneurisma, la CTA o DSA debe

repetirse como se describe en: HSA sin aneurisma
(clase III, nivel C)

Treatment

Tratamiento

Statement on Physical Management

To avoid situations that increase intracranial pressure, the
patient should be kept in bed and the application of
antiemetic drugs, laxatives and analgetics should be
considered before occlusion of the aneurysm (GCP)

Declaracin sobre el manejo fsico

A fin de evitar situaciones que aumenten la presin
intracraneal, el paciente se debe mantener en la cama y
aplicarse antiemticos, laxantes y analgsicos que deben ser
considerados antes de la oclusin del aneurisma (GCP)

Recommendation for Blood Glucose Management

Hyperglycemia over 10 mmol/l should be treated (GCP)

Recomendacin para el control de glucemia

La Hiperglucemia > 180 mg/dL debe ser tratada (GCP)

Recommendation for Temperature Management

Increased temperature should be treated medically and
physically (GCP) (Good Clinical Practice).

Recomendacin para la gestin de la temperatura

El aumento de temperatura debe tratarse mdica y
fsicamente (GCP)

Blood pressure

Presin arterial

Stop antihypertensive medication that the patient was using

Do not treat hypertension unless it is extreme; limits for
extreme blood pressures should be set on an individual basis,
taking into account age of the patient, pre-SAH blood
pressures and cardiac history;
systolic blood pressure should be kept below 180 mm Hg,
only until coiling or clipping of ruptured aneurysm, to reduce
risk for rebleeding

- Detener la medicacin antihipertensiva que el paciente

estaba usando
- No tratar la HTA a menos que sea extrema, los lmites
extremos de TA deben establecerse individualmente, segn
la edad, las TA del paciente pre-SAH, y la historia cardiaca.
La presin arterial sistlica debe mantenerse por debajo de
180 mm Hg, slo hasta que se realice el coiling or clipping
del aneurisma, para reducir el riesgo de resangrado

Recommendation for Blood Pressure Management

Until coiling or clipping, systolic blood pressure should be
kept below 180 mm Hg; this may be already achieved by
applying analgetics and nimodipine (GCP)

Recomendacin para el manejo de la presin arterial

Hasta el coiling or clipping, la TAS debe mantenerse por
debajo de 180 mm Hg; Esto puede lograrse aplicando
analgsicos y nimodipina (GCP)

If systolic pressure remains high despite these treatments

further lowering of blood pressure should be considered
(class IV, level C)

Si la presin sistlica permanece alta a pesar de estos

tratamientos debe considerarse bajar ms la presin arterial
(clase IV, nivel C)

If blood pressure is lowered the mean arterial pressure

should be kept at least above 90 mm Hg (GCP)

Si se baja la presin arterial TA media arterial debe

mantenerse al menos por encima de 90 mm Hg (GCP)

Recommendation for Thromboprophylaxis

Patients with SAH may be given thromboprophylaxis with
pneumatic devices and/or compression stockings before
occlusion of the aneurysm (class II, level B)

Recomendacin para la tromboprofilaxis

Los pacientes con HSA pueden recibir profilaxis con
dispositivos neumticos o medias de compresin antes de la
oclusin del aneurisma (clase II, nivel B)

In case deep vein thrombosis prevention is indicated,

lowmolecular-weight heparin should be applied not earlier
than 12 h after surgical occlusion of the aneurysm and
immediately after coiling (class II, level B)

En caso de que la profilaxis de trombosis venosa profunda

se indique, la HBPM debe aplicarse no antes de 12 h
despus de la oclusin quirrgica del aneurisma e
inmediatamente despus del coiling (clase II, nivel B)

Recommendation for Seizure Management

Antiepileptic treatment should be administered in patients
with clinically apparent seizures (GCP)

Recomendacin para el manejo de las convulsiones

El Tratamiento antiepilptico debe administrarse en
pacientes con convulsiones clnicamente aparentes (GCP)

There is no evidence that supports the prophylactic use of

antiepileptic drugs (class IV, level C)

No hay evidencias que apoyen el uso profilctico de

frmacos antiepilpticos (clase IV, nivel C)

Statement on the Use of Steroids

There is no proof that steroids are effective in patients with
SAH (class IV, level C)

Declaracin sobre el uso de esteroides

No hay pruebas de que los esteroides sean eficaces en
pacientes con HSA (clase IV, nivel C)

Specific Prevention of Rebleeding

Prevencin del sangrado

Recommendation for Timing of Intervention

Aneurysm should be treated as early as logistically and
technically possible to reduce the risk of rebleeding; if
possible it should be aimed to intervene at least within 72 h
after onset of first symptoms

Recomendacin sobre el momento de la intervencin

El Aneurisma debe ser tratado tan pronto como sea posible
logstica y tcnicamente para reducir el riesgo de resangrado;
Si es posible se debe intervenir dentro de las 72 h despus
de la aparicin de los primeros sntomas

This decision should not depend on grading

(class III, level C)

Esta decisin no debe depender de su grado

(clase III, nivel C)

Recommendation for Interventional Prevention of Rebleeding

The best mode of intervention should be discussed in an
interdisciplinary dialogue between Neurosurgery and
Neuroradiology

Recomendacin de intervencin para prevenir el resangrado

El modo mejor de intervencin debe discutirse en un dilogo
interdisciplinario entre Neurociruga y Neurorradiologa

Basado en esta discusin los pacientes deben ser

Based on this discussion patients should be informed and
informados e incluidos en las decisiones cuando sea posible
included in the process of decision making whenever possible
En casos donde el aneurisma parece ser igualmente eficaz
In cases where the aneurysm appears to be equally
tratado con coiling o clipping, el coiling es el tratamiento
effectively treated either by coiling or clipping, coiling is the
preferido (clase I, nivel A)
preferred treatment (class I, level A)
En general, la decisin sobre clip o coil depende de varios
In general, the decision on whether to clip or coil depends
factores relacionados con tres componentes principales:
onseveral factors related to 3 major components:
(1) Paciente: edad, comorbilidades, presencia de ICH, grado
(1) Patient: age, comorbidity, presence of ICH, SAH grade,
HSA, tamao del aneurisma, localizacin y configuracin, as
aneurysm size, location and configuration, as well as on
como el estado de vasos colaterales (clase III, nivel B)
status of collaterals (class III, level B)
(2) Procedimiento: competencias, habilidades tcnicas y
(2) Procedure: competence, technical skills and availability
disponibilidad (clase III, nivel B)
(class III, level B)
(3) Logistics: the grade of interdisciplinarity (class III, level B) (3) Logstica: grado de interdisciplinariedad (clase III, nivel B)

En pacientes con HSA por aneurisma:

In patients with aneurysmal SAH:
Factors in favour of operative intervention (clipping) are:
younger age, presence of space occupying ICH (class II,
level B), and aneurysm-specific factors such as:
location: middle cerebral artery and pericallosal aneurysm
(class III, level B)
wide aneurysm neck (class III, level B)
arterial branches exiting directly out of the aneurysmal
sack (class III, level B)

other unfavourable vascular and aneurysmal

configuration for coiling (class IV, level C)
Factors in favour of endovascular intervention
(coiling) :
age above 70 years, (class II, level B),
space occupying ICH not present (class II, level B),
and aneurysm-specific factors such as:
posterior location
small aneurysm neck
unilobar shape (class III, level B)

Factores a favor de la intervencin operativa (clipping) son:

menor edad, presencia de HIC ocupante de espacio (clase II,
nivel B) y factores especficos del aneurisma, tales como:
Ubicacin: arteria cerebral media y aneurisma pericalloso
(clase III, nivel B)
cuello amplio del aneurisma (clase III, nivel B)
ramas arteriales saliendo directamente fuera del saco
aneurismtico (clase III, nivel B)
otra configuracin vascular y aneurismtica desfavorable
para el coiling (clase IV, nivel C)
Factores a favor de la intervencin endovascular (coiling) :
edad por encima de 70 aos, (clase II, nivel B),
HIC ocupante de espacio no presente (clase II, nivel B),
y factores especficos del aneurisma tales como:
localizacin posterior
cuello pequeo aneurisma
forma unilobular (clase III, nivel B)
Los Pacientes ancianos per no se deben ser excluidos del
tratamiento; las decisiones de tratar o no depende de la
condicin fsica y clnica de los pacientes

Elderly patients should not per se be excluded

from treatment; decisions whether or not to treat
depend on the clinical and physical condition of the
Tratamiento antifibrinoltico. Factor VIIa recombinante
patients
Antifibrinolytic Treatment. Recombinant Factor VIIa.
There is currently no medical treatment that improves
outcome by reducing rebleeding (class I, level A)

No hay actualmente ningn tratamiento mdico que mejore

el resultado reduciendo el resangrado (clase I, nivel A)
Los resultados de algunos ensayos pequeos que utilizan
agentes hemostticos sugieren ms investigaciones con
protocolos modificados (clase II, nivel C)

Results from some small trials that used haemostatic agents

suggest further investigations with modified protocols (class
Hidrocefalia
II, level C)
Hydrocephalus
Recommendations for Hydrocephalus Management
In patients with CT-proven hydrocephalus and the third or
fourth ventricle filled with blood, an external ventricular
drain should be applied; this drain can be used to reduce and
monitor pressure and to remove blood;
for this last reason the level of evidence is low (GCP)
In patients who are not sedated and who deteriorate from
acute hydrocephalus, lumbar puncture might be considered
if the third and fourth ventricle are not filled with blood and
supratentorial herniation is prevented (class IV, level C)
In patients who are sedated and have CT-proven
hydrocephalus,
lumbar drainage should be considered if the third and
fourth ventricles are not filled with blood (class IV, level C)
Patients with symptomatic chronic hydrocephalus require
ventriculo-peritoneal or ventriculo-atrial shunting (GCP)

Prevention of Delayed Ischemic Deficit

Recommendation on Pharmacological Prevention of Delayed

Recomendaciones para el Manejo de la Hidrocefalia

En pacientes con hidrocefalia CT-probada y tercer o
cuarto ventrculo lleno de sangre, debe colocarse un drenaje
ventricular externo; este drenaje se puede utilizar para
reducir y controlar la presin y para eliminar la sangre;
por esta ltima razn, el nivel de evidencia es bajo (GCP)
En pacientes que no estn sedados y que se deterioran por
hidrocefalia aguda, la puncin lumbar podra ser considerada
si el tercer y cuarto ventrculo no estn llenos de sangre y
se previene la hernia supratentorial (clase IV, nivel C)
En pacientes que estn sedados y tienen hidrocefalia CTprobada, se debe considerar drenaje lumbar si el tercero y
cuarto ventrculos estn llenos de sangre (clase IV, nivel C)
Los pacientes con hidrocefalia crnica sintomtica requieren
derivacin ventrculo-peritoneal o ventrculo-atrial (GCP)

Prevencin del dficit isqumico retardado

Recomendacin sobre la prevencin farmacolgica de dficit
isqumico retrasado con nimodipina
Debe administrarse Nimodipino por va oral (60 mg/4 h)
para prevenir eventos isqumicos retrasados (clase I, nivel A)
En caso de que la administracin oral no sea posible , el

Ischemic Deficit with Nimodipine

Nimodipine should be administered orally (60 mg/4 h) to
prevent delayed ischaemic events (class I, level A)

Nimodipino debe aplicarse por va intravenosa (GCP)

Recomendacin sobre otras medidas farmacolgicas para

prevenir eventos isqumicos retrasados
In case oral administration is not possible nimodipine should El Sulfato de magnesio no se recomienda para la
be applied intravenously (GCP)
prevencin de la DCI (clase I, nivel A)
Recommendation on Other Pharmacological Measures to
Las estatinas son objeto de estudio
Prevent Delayed Ischaemic Events
Magnesium sulphate is not recommended for the prevention Declaracin sobre manejo hemodinmico de retraso dficit
of DCI (class I, level A)
isqumico
No hay evidencia en estudios controlados sobre que la
Statins are under study
hipertensin inducida o la hipervolemia mejoren el resultado
en pacientes con dficit isqumico retrasado
Statement on Hemodynamic Management of Delayed
(clase IV, nivel C)
Ischaemic Deficit
There is no evidence from controlled studies for induced
--hypertension or hypervolaemia to improve outcome in
patients with delayed ischaemic deficit
(class IV, level C)
HSA sin aneurisma
---

SAH without Aneurysm

Perimesencephalic SAH (PMSAH)
Non- Perimesencephalic SAH
Non-Traumatic SAH of Other Causes
Recommendation on Diagnostic Procedure in SAH without
Aneurysm
In patients with PMSAH a DSA* should only be performed if
the CTA was not considered to be sufficient or if there is
doubt on the perimesencephalic pattern of the SAH
(class II, level B)

HSA Perimesenceflica
HSA no Perimesenceflica
HSA no traumtica de otras causas
Recomendacin sobre el procedimiento de diagnstico en
HSA sin aneurisma
En pacientes con PMSAH un DSA slo debe realizarse si la
CTA no se consideraba suficiente o si hay duda sobre el
patrn de perimesencephalic de la HSA (clase II, nivel B)
En el caso de sangrado no-perimesenceflico con patrn
tpico de HSA, la CTA o DSA debe repetirse no antes de las 3
semanas despus de la hemorragia inicial si no hay ninguna
otras indicacin teraputica para realizar los estudios
anteriores (clase III, nivel B)

In the case of non-perimesencephalic location of the

bleeding with typical pattern of SAH, CTA or DSA should be
repeated not earlier than 3 weeks after the initial bleeding if
there are no other therapeutic indications to perform the
studies earlier (class III, level B)
Aneurismas Intracraniales sin ruptura
* digital subtraction angiography
Tratamiento: clipping o coiling
Unruptured Intracranial Aneurysms (UIA)
Treatment: Clipping or Coiling
Statement on Intervention in UIA
Although endovascular procedures might be associated with
less immediate risk, the long-term risk and durability of
treatment are not known and data from prolonged follow-up of
treated patients are needed
Data indicate there exists a state of clinical equipoise in the
management of a significant proportion of UIAs; this
impression is reinforced by the broad variation in
management for UIAs in the participating institutions
Recommendation on Intervention in UIA
The larger the aneurysm the higher the chance of rupture
(class II, level B)
Considering risk (procedural risk, range 550%, vs.
spontaneous rupture risk, 010%, per year) and benefit (life
expectancy with or without minor deficit), the decision for or
against intervention is a decision of the individual case taking

Declaracin sobre la intervencin en la UIA

Aunque los procedimientos endovasculares podran estar
asociados a menor riesgo inmediato, el riesgo a largo plazo y
la durabilidad del tratamiento no se conocen, precisndose
datos de seguimiento de los pacientes tratados
Los datos indican que existe un estado de equipoise (no
superioridad) clnico en el manejo de una proporcin
significativa de UIAs; Esta impresin se ve reforzada por la
amplia variacin en el manejo de los UIAs entre las
instituciones participantes
Recomendacin sobre la intervencin en la UIA
Cuanto mayor sea el aneurisma, mayor ser la posibilidad
de ruptura (clase II, nivel B)
Considerando el riesgo (el riesgo del procedimiento vara
del 550%, frente al riesgo de ruptura espontnea, 0 10%
anual) y el beneficio (esperanza de vida con o sin dficit
menor), la decisin a favor o en contra de la intervencin es
una decisin individualizada teniendo en cuenta los factores
dependientes del paciente (edad, tabaquismo y tal vez la
ruptura de otro aneurisma), factores aneurismticos (tamao,
ubicacin) y el riesgo asumido de la intervencin; por lo tanto,
la decisin debe basarse en una discusin multidisciplinar de

into account patient-dependent factors (age, cigarette

smoking and perhaps rupture from other aneurysm),
aneurysmal factors (size, location), and the assumed risk of
the intervention; therefore, the decision should be based on a
multidisciplinary discussion of the individual case
(class III, level C)

cada caso individual (clase III, nivel C)

Poor outcome defined as Glasgow outcome scale 13 or modified Rankin score 46. WFNS = World
Federation of Neurological Surgeons Grading Scale for Subarachnoid Haemorrhage [5].
PAASH = Prognosis on Admission of Aneurysmal Subarachnoid Haemorrhage grading scale [7]. GCS =
Glasgow Coma Score [157].
Data in this table are adapted from van Heuven et al. [8].
WFNS:
Glasgow Coma Score

Motor Deficit

Grade

15

absent

13 - 14

absent

13 - 14

present

7 - 12

present or absent

3-6

present or absent

*Un deficit motor se refiere a un dficit focal importante.

Interpretacin:
La puntuacin mxima de 15 tiene el mejor pronstico
Puntuacin mnima de 3 tiene el peor pronstico
Las puntuaciones de 8 o superior tienen una buena oportunidad para la recuperacin

 Scores de 3-5 son potencialmente mortales, sobre todo si se acompaan de pupilas fijas o respuestas oculovestibular
ausentes

Summary of the Hunt and Hess Scale, the World Federation of Neurological Surgeons Scale, and the Prognosis on Admission
of Aneurysmal Subarachnoid Hemorrhage Scale
Grade
I
II
III
IV
V

Hunt and Hess Scale

Asymptomatic, or minimal headache and slight nuchal rigidity
Moderate to severe headache, nuchal rigidity, no neurological deficit other
than cranial nerve palsy

WFNS Scale
PAASH Scale
GCS score 15
GCS score 15
GCS score 1314 without
GCS score
focal deficit
1114
GCS score 1314 with focal GCS score 8
Drowsiness, confusion, or mild focal deficit
deficit
10
Stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity,
GCS score 4
GCS score 712
and vegetative disturbances
7
Deep coma, decerebrate rigidity, moribund appearance
GCS score 35
GCS score 3
GCS indicates Glasgow Coma Scale; PAASH, Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage;
WFNS, World Federation of Neurological Surgeons.

Coiling - Clipping