Brain Aneurysms and Subarachnoid Haemorrhage: Surgical Clipping vs Endovascular Coiling

We work as a multidisciplinary team with a very respectful relationship with our neurosurgical colleagues. For aneurysms where both approaches are feasible, endovascular coiling is preferred under current guidelines, but we don't impose that on patients. We hold a multidisciplinary meeting, review the morphology together, discuss which endovascular option — coil, stent-assisted coil, or flow diversion — is most appropriate, and then meet the patient's family and explain the complexity, risk, and cost of each option in full so they can make an informed decision.

We need awareness at every level, not just among medical professionals but in the community, about the FAST acronym — facial drooping, arm weakness, speech disturbance, all occurring suddenly, and time. Any sudden neurological deficit, sudden severe headache, or sudden seizure requires urgent neuroimaging and immediate transfer to a centre with neuro care capability. A CT or MRI is mandatory, because you cannot distinguish an ischemic stroke from a haemorrhagic one clinically — the imaging is what tells you whether neurointervention is needed.

There are two distinct subsets. In the acute subset, the stroke is actively evolving and intervention has to happen locally — the thrombolytic drug window is 4.5 hours, and mechanical thrombectomy is 6 hours in all cases, extending to 24 hours in selected imaging-positive cases. Acute stroke care has to be developed in and around the patient's own locality; it can't depend on a distant specialist centre. The second subset is secondary prevention, where the stroke has already happened, the cause has been identified, and we're addressing it to prevent a future event. Those are the patients who can make a calculated decision to travel — most of our overseas patients fall into this category.

In haemorrhagic stroke, neurons aren't 100% dead — there's cytotoxic oedema, but if we can remove the blood and relieve the pressure on the brain, neurons can recover function. Our primary goal is to save the patient's life first; the first week to ten days after the bleed is life-threatening, so all effort goes into preventing death and disability, and neurological recovery happens over time through rehabilitation. That's different from ischemic stroke, where we're reversing the deficit on the table itself — rescuing neurons at the brink of death and restoring function immediately.

Not all intracranial haemorrhages require surgical evacuation — most are managed medically. When the bleed is causing raised intracranial pressure, because the brain is inside a closed skull and any extra volume risks herniation, we have to evacuate it. There are several techniques — minimally invasive surgery, stereotactic drainage, or open decompressive surgery — and that's the neurosurgeon's domain. Our endovascular role is in identifying and occluding the underlying vascular cause, the aneurysm or AVM, that caused the bleed in the first place.

In 85 percent of cases, subarachnoid haemorrhage is caused by a ruptured intracranial aneurysm, which may be saccular or fusiform in shape, and it classically presents as the sudden onset of the worst headache of the patient's life.

Securing the bleeding point to prevent the aneurysm from re-bleeding, and managing vasospasm, which typically occurs between day 4 and day 14 after the haemorrhage. Re-bleeding and vasospasm are the two leading causes of death and disability following subarachnoid haemorrhage.

Surgical clipping involves a neurosurgeon opening the skull, dissecting down to the aneurysm, and placing a metal clip across its neck. Endovascular coiling instead navigates catheters from the femoral or radial artery to the aneurysm and deposits platinum coils inside the sac, which promote clotting that occludes the aneurysm while preserving normal blood flow through the parent vessel.

Current guidelines recommend treatment within 24 hours of onset as Class I evidence, with the goal of complete aneurysm obliteration.