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The implications of ISAT and ISUIA for the management of cerebral aneurysms during pregnancy

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Abstract

Both the International Subarachnoid Aneurysm Trial (ISAT) and the International Study on Unruptured Intracranial Aneurysms (ISUIA) have been widely extrapolated to influence the management of actual or anticipated aneurysmal subarachnoid hemorrhage (SAH). However, it remains possible that sub-groups exist for which such extrapolation might subsequently prove premature. In this review, we discuss the implications that such extrapolation may potentially have for one such SAH sub-group: the clinically rare scenario of SAH in pregnancy.

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Authors and Affiliations

  1. Departments of Neurosurgery, Oldchurch Hospital, Waterloo Rd Romford, Essex, RM7 0BE, UK

    Laurence A. G. Marshman & A. Robert Aspoas

  2. Departments of Medical Physics, Oldchurch Hospital, Waterloo Rd Romford, Essex, RM7 0BE, UK

    Manjit S. Rai

  3. Departments of Neuroradiology, Oldchurch Hospital, Waterloo Rd Romford, Essex, RM7 0BE, UK

    Sanjiv J. Chawda

  4. Pollard Cottage, Church Rd Lingfield, Surrey, RH7 6AH, UK

    Laurence A. G. Marshman

Authors
  1. Laurence A. G. Marshman
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  2. A. Robert Aspoas
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  3. Manjit S. Rai
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  4. Sanjiv J. Chawda
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Correspondence to Laurence A. G. Marshman.

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Comments

Michael T. Lawton, San Francisco, CA

The management of a pregnant mother with an intracranial aneurysm is controversial. Should an unruptured aneurysm be treated or observed? Should a ruptured aneurysym be endovascularly coiled or microsurgically clipped? From their review of the literature, Marshman and colleagues suggest that pregnancy increases the risk of aneurysm rupture and that the management of unruptured aneuysms in pregnant women should be more aggressive than in non-pregnant women. Furthermore, the authors suggest that coil embolization presents unique problems for pregnant women, with danger to the fetus associated with prolonged radiation exposure and danger to the mother associated with systemic anticoagulation during labor and delivery. The International Subarachnoid Aneurysm Trial (ISAT) and the International Study on Unruptured Intracranial Aneurysms (ISUIA) might appear to address some of the controversy over these issues, but the authors caution against extrapolating data from these studies because neither one addressed aneurysm management during pregnancy. Unfortunately, there is no randomized, controlled trial that examines these special circumstances, and it is difficult to imagine that such a study could be conducted. Therefore, as with all unresolved clinical controversies, management decisions must be made by the patient after being informed of the options of observation, microsurgical clipping and endovascular coiling. Ultimately, her decision will be based on her gut reaction more than the hard science.

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Marshman, L.A.G., Aspoas, A.R., Rai, M.S. et al. The implications of ISAT and ISUIA for the management of cerebral aneurysms during pregnancy. Neurosurg Rev 30, 177–180 (2007). https://doi.org/10.1007/s10143-007-0074-8

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  • DOI: https://doi.org/10.1007/s10143-007-0074-8

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