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Beyond survival: Christine Buckley on brain aneurysm awareness, recovery and the patient voice When a patient survives a ruptured brain aneurysm, the outcome cannot be captured by survival alone. Fatigue, sensory sensitivity, cognitive changes, altered relationships and difficulty returning to work may continue long after the patient has left hospital, and may be invisible to everyone around them. In this Neuro Resus interview, Oli Flower speaks with Christine Buckley, Executive Director of the Brain Aneurysm Foundation, about the gaps between successful treatment and meaningful recovery, the continuing need for public and professional awareness, and why patients and families must help define the outcomes that matter.

Chris Andersen has spent a career treating subarachnoid haemorrhage, and he opens this episode by admitting we might have wasted a fortune treating vasospasm without evidence to show for it. Host Oli Flower and Chris Andersen, co-conveners of ISAH 2026, dig into why SAH care hasn't seen the revolution ischaemic stroke has, why delayed cerebral ischaemia (DCI) is the field's great unsolved problem, and why fewer than 10% of SAH trials have ever asked patients what actually matters to them. Chris Andersen is a neurocritical care specialist and co-convener of ISAH 2026, the International Conference on Subarachnoid Haemorrhage, running 17–20 November in Sydney. In this episode: 02:56 — If you could solve one problem in SAH in the next decade, what would it be? 03:52 — Have outcomes actually improved in the last 15 years? 05:52 — The treatment we've poured money into without proof it works 08:53 — Is DCI the ARDS of subarachnoid haemorrhage? 10:30 — Precision medicine: substance or buzzword? 13:32 — What AI can realistically do for SAH care in the next 5 years 16:56 — The best debates coming to ISAH 2026 19:12 — Lumbar drains and the EARLYDRAIN trial, three years on 22:23 — Platform trials: the future, or an expensive way to spend grant money? 26:23 — What clinicians get wrong about recovery — and what patients actually want measured 32:11 — The tech that sounds like science fiction but might be routine in 10 years 35:40 — Why SAH needs a global alliance, not another society 39:26 — Lightning round: most overrated treatment, biggest unanswered question, and a prediction Chris might regret ISAH 2026 runs 17–20 November in Sydney. View the program and register at subarachnoid.org

In this NeuroResus episode, Oli Flower speaks with Keryn Davidson, vascular neurosurgeon at Royal North Shore Hospital, about aneurysmal subarachnoid haemorrhage, open cerebrovascular surgery, ICU-neurosurgery collaboration, and why the bedside exam still matters in an era obsessed with scans, monitors, and numbers. Keryn trained across Queensland and New South Wales before completing fellowship training at Royal North Shore with a focus on open cerebrovascular surgery. She is the first female neurosurgeon in the department's history, a fellowship examiner with the Royal Australasian College of Surgeons, and will be contributing to ISAH2026 in Sydney. The big theme: look at the patient, not just the numbers A recurring message throughout the conversation was deceptively simple: focus on the patient. In subarachnoid haemorrhage, teams can become fixated on ICP, arterial pressure, imaging, protocols, and monitors. Those things matter, obviously, because medicine has apparently decided numbers are comforting. But Keryn's strongest point was that subtle clinical change often comes first. The early warning sign may not be a dramatic drop in GCS or a dense focal deficit. It may be that the patient is "a bit off": mildly agitated, picky, confused, or subtly different in personality. Experienced nurses often detect this before the scan or angiogram confirms the problem. That has huge implications for DCI research, bedside care, and escalation culture. If our endpoints only capture obvious deterioration, we may be missing the earlier, more clinically meaningful phase of delayed cerebral ischaemia. The first hours: resuscitate before you prognosticate Keryn emphasised that early SAH management is not a recipe. The first questions are patient-centred: How old is the patient? How did they present? Are they intubated? Do they have hydrocephalus? Do they need an EVD? Do they need urgent clot evacuation? The concept of the resuscitated WFNS grade came up as particularly important. A poor-grade patient with hydrocephalus may look very different after CSF diversion. Prognosis should not be locked in before the brain has been given a chance to declare itself properly. What ICU does well Keryn highlighted the value of experienced ICU care in the first 24 hours: smooth resuscitation, avoiding prolonged hypotension or hypertension, preparing the patient for aneurysm treatment, and managing the shared territory of EVDs, physiology, and neurological observation. Her one gentle jab at ICU culture: asking too early how long a "not-too-sick" SAH patient will need ICU. Understandable, given bed pressure. Still, probably not the opening philosophical question while the aneurysm is still unsecured. Humanity survives another process failure. EVDs: the Goldilocks problem EVD management was framed as simple in principle but high stakes in practice. Too little drainage risks ongoing ventricular distension and impaired recovery. Too much drainage risks subdural collections and altered CSF dynamics. The target is "Goldilocks drainage": not blocked, not over-draining, not leaking, and not quietly ignored for four hours because the patient "seemed okay." The practical message: if an EVD is not draining when it should be, escalate early. Vasospasm: not over-obsessed, still unsolved Asked whether the field is too obsessed with vasospasm, Keryn's answer was clear: no. Her view is that vasospasm and DCI remain the part of SAH care we have not solved. At Royal North Shore, the unit has traditionally used DSA around day 5–7 to detect and treat vasospasm before it becomes clinically obvious. Keryn acknowledged that this approach is not universal and not backed by perfect evidence, but the rationale is pragmatic: DCI is multifactorial, but vasospasm is one potentially modifiable contributor. CT perfusion and TCDs were discussed as evolving or limited tools. CT perfusion has promise, but interpretation and actionability remain issues. TCDs can be useful in experienced hands, but interobserver variability and inadequate bone windows limit reliability. The holy grail remains a non-invasive test that reliably tells us who needs intervention, where the problem is, and when DSA is unnecessary. Apparently medicine has not yet delivered this obvious convenience. Rude. Sleep deprivation: are we helping or harming? The episode also explored the tension between intensive neuro-observation and sleep deprivation. Everyone wants to detect deterioration early. Nobody wants to turn the ICU into a neurological interrogation chamber. The practical compromise: cluster care where possible, combine observations with medications and other tasks, and protect blocks of real sleep when safe. This is especially relevant during the vasospasm window, when every tiny change can matter but exhaustion can also mimic or worsen clinical concern. Clip versus coil: rivalry is the wrong frame Keryn loves clipping aneurysms, but she was clear that the correct treatment is the one that best serves the patient. The clip-versus-coil debate is often misunderstood as rivalry, when in good units it should be a collegial decision. Some aneurysms still strongly favour open surgery, especially ruptured aneurysms with large haematoma, mass effect, blown pupil, or situations where surgery is needed anyway to decompress the brain. Conversely, some aneurysms are better treated endovascularly, especially when the anatomy makes open surgery high risk. A major nuance is the need for dual antiplatelet therapy after stent-assisted treatments, especially in patients with EVDs who may later need shunts. This is where SAH care becomes "boutique" medicine: aneurysm anatomy, CSF circulation, bleeding risk, and recovery trajectory all collide. Open vascular neurosurgery is not dead Although aneurysm clipping volumes are declining globally, Keryn argued that open cerebrovascular skills remain essential. The cases that still need clipping are often the difficult ones: complex aneurysms, mass effect, clot evacuation, and lesions not easily managed endovascularly. That creates a training challenge. If fewer cases are clipped, how do trainees develop the skill set needed for the hardest cases? Keryn's answer is deliberate training, courses, exposure, mentorship, and keeping open vascular surgery visible as a living craft rather than a museum exhibit with better lighting. What makes a great vascular neurosurgeon? Keryn's answer was not just technical. A great vascular neurosurgeon needs to be bold, brave, resilient, and comfortable being uncomfortable. But they also need humility: knowing limits, asking for help, and staying patient-centred. One of the most powerful parts of the conversation was her reflection on bad outcomes. You can do a technically perfect operation and still have a devastating result. The answer is not to become reckless or avoidant, but to reflect honestly, look after yourself, and keep learning without letting one case distort all future judgement. Women in neurosurgery Keryn spoke about training in a male-dominated specialty, the importance of visible role models, and the need to call out casual bias. Her advice to female trainees was direct: if you have the passion, pursue it. Neurosurgery is hard, but it should not be considered off-limits because of gender or outdated expectations about what a surgeon looks like. The unexpected bit: neurosurgery for dogs In the episode's most unusual detour, Keryn described how she became involved in complex veterinary neurosurgical cases, including a transpalatal approach to a pituitary tumour in a golden retriever. Yes, really. The story was funny, strange, and unexpectedly moving. It also reinforced a serious point: anatomy, preparation, humility, and adaptability matter across species. Dogs, Keryn observed, often recover with a kind of uncomplicated determination. They do not overthink illness. Humans, naturally, have turned suffering into a full-time interpretive project. Fast takeaways The most underrated bedside sign in SAH may be subtle confusion or personality change. Arterial blood pressure is important, but probably overcomplicated. A resuscitated neurological grade matters more than the first impression. EVDs need active attention: under-drainage and over-drainage both matter. Vasospasm remains central because it is one modifiable part of DCI. DSA-first vasospasm surveillance is not universal, but has a clear physiological rationale in experienced centres. Clip versus coil should be a patient-centred decision, not a turf war. Open vascular skills remain vital, especially for complex aneurysms. Bad outcomes require reflection, not denial or career-long overcorrection. The future is likely to involve better imaging, modelling, AI-supported prediction, and more precise vasospasm therapy. Why this matters for ISAH2026 This conversation captures exactly the kind of discussion ISAH2026 is designed to host: practical, multidisciplinary, honest, and focused on the unresolved questions in subarachnoid haemorrhage care. SAH management sits at the intersection of neurosurgery, interventional neuroradiology, neurocritical care, nursing, anaesthesia, imaging, rehabilitation, and long-term outcomes. The episode shows why the field needs more than protocols. It needs shared language, bedside wisdom, better evidence, and the humility to admit where current practice is still based on physiology, experience, and informed uncertainty. That is the space ISAH2026 aims to create: where consensus, controversies, and future trials are shaped.

In this episode of the Neuro Resus Podcast, Oli Flower speaks with Dr Andy Lindberg, neuroanaesthetist at Royal North Shore Hospital, about the anaesthetic management of aneurysmal subarachnoid haemorrhage. The conversation follows a high-grade SAH patient from emergency airway management through EVD insertion, aneurysm securing, clipping, coiling, intraoperative rupture, vasospasm management, and postoperative wake-up. Andy discusses the practical physiology that matters most: avoiding re-rupture, defending cerebral perfusion pressure, managing ICP, preventing major blood pressure swings, and staying one step ahead of the neurosurgical or neurointerventional procedure. The episode is particularly relevant for anaesthetists, intensivists, neurosurgeons, interventional neuroradiologists, and trainees involved in SAH care. It also highlights why anaesthetists should be part of the International Subarachnoid Haemorrhage Conference 2026 (#ISAH2026), where neurocritical care, neurosurgery, and interventional neuroradiology meet around one devastating disease.

Subarachnoid haemorrhage is one of the most time-critical and high-stakes emergencies in medicine. But in the real world, it rarely presents neatly. In this episode, Oli Flower is joined by two AI co-hosts — Simon (GPT-5.3) and Claude (Sonnet 4.6) — to work through the pre-hospital and emergency department management of SAH using a real-world scenario: a 42-year-old woman with a thunderclap headache, collapse, and reduced GCS. What follows is a mix of clinical reasoning, practical decision-making, and occasional AI overconfidence getting corrected in real time. What we cover: Airway decisions in SAH: Is GCS 8 an automatic intubation? Pre-hospital priorities and seizure management Blood pressure targets: physiology vs reality ED workflow: stabilise first or scan first? Hyperventilation and ICP: when it helps and when it harms Communicating with neurosurgery (and what actually matters) Nimodipine: what the evidence really says (and doesn't say) Why listen: This is not a guideline recitation. It's a practical, frontline discussion of how SAH actually presents and how decisions get made under pressure — including where the evidence is thin, debated, or misunderstood. Along the way: Dogma gets challenged Nuance matters And one AI model learns, the hard way, what happens when you misquote trials Key takeaways: SAH management is a balance between competing risks: perfusion vs rebleeding Early decisions in airway, blood pressure, and transport matter Much of what we do is still based on physiology and consensus, not definitive trials And yes — sometimes you're managing a brain with "buggered autoregulation" 🎧 If you work in emergency medicine, ICU, anaesthesia, or pre-hospital care, this episode will sharpen how you think about SAH from the moment the patient hits the floor to the CT scanner. 📍 ISAH 2026 — Sydney, 17–20 November Where these debates happen for real, with real humans.

This podcast episode features a conversation between Dr Oli Flower and his AI co-host, Simon (ChatGPT 4o), focusing on vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid haemorrhage (aSAH). The discussion covers: The distinction between radiological vasospasm (imaging finding) and DCI (clinical syndrome). The evolution of understanding DCI's multifactorial causes, beyond just vasospasm. Evidence and controversies around ICU management, including blood pressure targets, nimodipine use, and the role of other interventions. Screening and monitoring strategies: transcranial Doppler, CTA, CTP, and the limitations of each. Post-management assessment, therapeutic hypertension, and the emerging role of milrinone. The importance of multimodal monitoring and the future potential of AI and global data sharing. The episode closes with a lighthearted off-topic discussion about casting for the new Naked Gun movie. The conversation is rich in clinical nuance, highlights current evidence gaps, and emphasises the need for individualised patient care and ongoing research.

Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians. This presentation was delivered by Catherine Bell at CODA2022. Want more content about EVD? Visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. This presentation was delivered by Rob Loch MacDonald at CODA2022. Want more content about aSAH? Visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Lizzy suffered a substantial aneurysmal subarachnoid haemorrhage that left her critically unwell, requiring a long stay in intensive care recovering from the consequences and complications of this devastating form of stroke. Now a couple of years after her haemorrhage, Lizzy has come so far. She and her husband Gordon describe their experiences, right from the day it all began and through those tumultuous first few weeks, to where she is today. This open and honest account gives us all invaluable insight into what it's like to go through the subarachnoid haemorrhage journey from a patient and family's perspective, hopefully helping us empathise more and deliver better patient-centred care. This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail! More on BONANZA here More on BOOST3 here This presentation was delivered by Andrew Udy at CODA2022. Want more content about The Bonanza Trial? Visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last 20 years, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, partially due to the favorable effects on haemodynamics.  However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury. In this talk Toby Jeffcote initially takes us through all the sedatives currently used in brain injury and the evidence to support their use. He then covers the history of ketamine use and the background to new research in use as a therapeutic agent. This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury. This presentation was delivered by Toby Jeffcote at CODA2022. Want more content about CSD? Visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Andrew Chow vs Andrew Udy  This debate was set up to discuss the issues with categorising traumatic brain injury (TBI). The current system using GCS to divide patients into mild, moderate and severe has been criticised in recent times, with calls for a more nuanced approach. The debate was a just bit of fun but does highlight the key issues. Chowie didn't get to choose which side to argue for :) Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for TBI works, and makes sense! He tackles us through the history of this system, and why it's important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes the argument that biomarkers may better categorise the diffuse entity we call TBI. This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI).  This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.

Tania Farrar is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus. This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com or subscribe to be notified of new podcast releases via email. To express your interest in attending the 2024 Neuroresus live course, click here.