Cerebral Aneurysms Clinical Presentation
- Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more...
The clinical presentation of cerebral aneurysms includes symptoms associated with major aneurysmal rupture (eg, SAH), minor aneurysmal hemorrhage (eg, warning leak or sentinel bleed), nonhemorrhagic manifestations (eg, mass effects or cerebral ischemia), and asymptomatic scenarios (eg, incidental aneurysm detection or identification through screening ).
Although aneurysmal SAH has characteristic historical features, the constellation of symptoms may vary with location, size, shape, and direction of the aneurysm.
Aneurysmal rupture also may present with intraparenchymal hemorrhage (more common with distal aneurysms), intraventricular hemorrhage (13-28%), or subdural hematoma (2-5%).
Minor aneurysmal hemorrhage may precede rupture with a wide variation in latency, although these warning leaks also may be clinically silent.
Giant aneurysms may compress brain parenchyma, resulting in focal neurological complaints.
Aneurysmal expansion may produce pain or herald new neurological manifestations.
Traumatic aneurysms may have a delayed presentation, with intracranial hemorrhage or recurrent epistaxis.
Symptoms associated with cerebral aneurysms and SAH are as follows:
- Headache: This is characterized by the acute onset of severe pain, which patients often describe as "the worst headache of my life." Aneurysmal expansion, thrombosis, or intramural hemorrhage may cause a subacute, unilateral, periorbital headache. Headache does not always accompany aneurysmal SAH.
- Facial pain: Cavernous-carotid aneurysms may produce facial pain.
- Alterations in consciousness: The sudden elevation of intracranial pressure associated with aneurysmal rupture may lead to a precipitous decline in cerebral perfusion pressure, causing syncope (50% of cases). Confusion or mild impairment in alertness also may be noted.
- Seizures: Focal or generalized seizures are present in 25% of aneurysmal SAH cases, with most events occurring within 24 hours of onset.
- Manifestations of meningeal irritation: Neck pain or stiffness, photophobia, sonophobia, or other hyperesthesia may be noted with SAH.
- Autonomic disturbances: Subarachnoid accumulation of products of blood degradation may elicit fever. Nausea or vomiting, sweating, chills, and cardiac arrhythmias also may be present.
- Focal neurological complaints: Hemorrhage or ischemia may manifest with focal deficits including weakness, hemisensory loss, language disturbances, neglect, memory loss, or olfactory disturbances. Focal symptoms are more common with giant aneurysms.
- Visual symptoms: Blurring of vision, diplopia, or visual field defects may be present.
- Respiratory dysfunction or cardiovascular instability: These are ominous signs of brainstem compression.
- Hormonal dysfunction: Intrasellar aneurysms may interfere with pituitary function.
- Epistaxis: This is noted occasionally with traumatic aneurysms.
The general examination occasionally reveals manifestations of associated conditions such as subacute bacterial endocarditis, trauma, or collagen-vascular disease.
Specific physical examination findings may include prominent scalp veins, signs of congestive heart failure (eg, vein of Galen aneurysms), or orbital bruits (eg, cavernous carotid aneurysms).
Neurologic findings exhibit considerable variability, depending on aneurysm characteristics.
- Aneurysmal SAH may be accompanied by nuchal rigidity, decreased level of consciousness, subhyaloid hemorrhages, pupillary abnormalities (ie, typically dilated), ophthalmoplegia, cranial neuropathies, and other focal deficits.
- Giant aneurysms or dolichoectatic aneurysms may cause mass effects or distal thromboembolism with prominent focal deficits, optic atrophy or other cranial neuropathies, or brainstem compression.
Specific syndromes have been associated with particular aneurysmal locations.
- Anterior communicating artery: This is the most common site of aneurysmal SAH (34%). Usually, ACoA aneurysms are silent until they rupture. Suprachiasmatic pressure may cause altitudinal visual field deficits, abulia or akinetic mutism, amnestic syndromes, or hypothalamic dysfunction. Neurological deficits in aneurysmal rupture may reflect intraventricular hemorrhage (79%), intraparenchymal hemorrhage (63%), acute hydrocephalus (25%), or frontal lobe strokes (20%).
- Anterior cerebral artery: Aneurysms of this vessel, excluding ACoA, account for about 5% of all cerebral aneurysms. Most are asymptomatic until they rupture, although frontal lobe syndromes, anosmia, or motor deficits may be noted.
- Middle cerebral artery: Aneurysms of the middle cerebral artery, as shown below in the image and video, account for about 20% of aneurysms, typically at first or second division in the sylvian fissure. Aphasia, hemiparesis, hemisensory loss, anosognosia, or visual field defects may be noted.Cerebral aneurysms. Volume-rendered CT angiography of a left middle cerebral artery aneurysm.
- Posterior communicating artery: Aneurysms present at the junction of the termination of the ICA and PCoA account for 23% of cerebral aneurysms; they are directed laterally, posteriorly, and inferiorly. Pupillary dilatation, ophthalmoplegia, ptosis, mydriasis, and hemiparesis may result.
- Internal carotid artery: Besides PCoA aneurysms, aneurysms of the ICA, shown below, account for about 4% of all cerebral aneurysms. Supraclinoid aneurysms may cause ophthalmoplegia due to compression of cranial nerve (CN) III or variable visual defects and optic atrophy due to compression of the optic nerve. Chiasmal compression may produce bilateral temporal hemianopsia. Hypopituitarism or anosmia may be seen with giant aneurysms. Cavernous-carotid aneurysms exert mass effects within the cavernous sinus, producing ophthalmoplegia and facial sensory loss. Rupture of these aneurysms typically produces a carotid-cavernous fistula, SAH, or epistaxis.
- Basilar artery: Basilar tip aneurysms, shown in the image and the video below, are the most common in the posterior circulation, accounting for 5% of all aneurysms. Clinical findings usually are those associated with SAH, although bitemporal hemianopsia or an oculomotor palsy may occur. Dolichoectatic aneurysms may cause bulbar dysfunction, respiratory difficulties, or neurogenic pulmonary edema.Cerebral aneurysms. Volume-rendered CT angiography of a basilar tip aneurysm.
- Vertebral artery or posterior inferior cerebellar artery: Aneurysms at these arterial segments typically result in ataxia, bulbar dysfunction, or spinal involvement.
- False localizing signs: False localization may be associated with CN III palsy and hemiparesis in uncal herniation, CN VI palsy with elevated intracranial pressure, homonymous hemianopsia due to posterior cerebral artery compression along the tentorial edge, brainstem dysfunction associated with tonsillar herniation, and vasospasm in remote vessels.
See the list below:
- Congenital or familial inheritance
- Autosomal dominant inherited polycystic kidney disease
- Connective tissue disorders
- Sickle cell anemia
- Cigarette smoking
- Illicit drug use
Brooks M. Serial Screening for Cerebral Aneurysm Fruitful. Medscape Medical News. Available at http://www.medscape.com/viewarticle/824618. Accessed: May 14, 2014.
Bor AS, Rinkel GJ, van Norden J, Wermer MJ. Long-term, serial screening for intracranial aneurysms in individuals with a family history of aneurysmal subarachnoid haemorrhage: a cohort study. Lancet Neurol. 2014 Apr. 13(4):385-92. [Medline].
Brooks M. Does Coiling Beat Clipping for Ruptured Aneurysms? Medscape Medical News. Dec 31 2012. Available at http://www.medscape.com/viewarticle/776939. Accessed: Jan 16, 2013.
Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke. 2013 Jan. 44(1):29-37. [Medline].
Koroknay-Pál P, Laakso A, Lehto H, Seppä K, Kivisaari R, Hernesniemi J, et al. Long-term Excess Mortality in Pediatric Patients With Cerebral Aneurysms. Stroke. 2012 Aug. 43(8):2091-6. [Medline].
Vernooij MW, Ikram MA, Tanghe HL, Vincent AJ, Hofman A, Krestin GP, et al. Incidental findings on brain MRI in the general population. N Engl J Med. 2007 Nov 1. 357(18):1821-8. [Medline].
Yang CY, Chen YF, Lee CW, Huang A, Shen Y, Wei C, et al. Multiphase CT angiography versus single-phase CT angiography: comparison of image quality and radiation dose. AJNR Am J Neuroradiol. 2008 Aug. 29(7):1288-95. [Medline].
van Rooij WJ, Sprengers ME, de Gast AN, Peluso JP, Sluzewski M. 3D rotational angiography: the new gold standard in the detection of additional intracranial aneurysms. AJNR Am J Neuroradiol. 2008 May. 29(5):976-9. [Medline].
Yi AC, Palmer E, Luh GY, Jacobson JP, Smith DC. Endovascular treatment of carotid and vertebral pseudoaneurysms with covered stents. AJNR Am J Neuroradiol. 2008 May. 29(5):983-7. [Medline].
Berge J, Biondi A, Machi P, Brunel H, Pierot L, Gabrillargues J, et al. Flow-Diverter Silk Stent for the Treatment of Intracranial Aneurysms: 1-year Follow-Up in a Multicenter Study. AJNR Am J Neuroradiol. 2012 Feb 2. [Medline].
Yang X, Wu Z, Mu S, Li Y, Lv M. Endovascular treatment of giant and large intracranial aneurysms using the neuroform stent-assisted coil placement. Neurol Res. 2008 Jul. 30(6):598-602. [Medline].
Tumialán LM, Zhang YJ, Cawley CM, Dion JE, Tong FC, Barrow DL. Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report. J Neurosurg. 2008 Jun. 108(6):1122-9. [Medline].
Nguyen TN, Raymond J, Guilbert F, Roy D, Bérubé MD, Mahmoud M, et al. Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture. J Neurosurg. 2008 Jun. 108(6):1088-92. [Medline].
Harding A. Careful selection key to coiling in elderly aneurysm patients. Medscape Medical News. May 23, 2013. [Full Text].
Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular Treatment of Intracranial Aneurysms in Elderly Patients: A Systematic Review and Meta-Analysis. Stroke. 2013 May 16. [Medline].
Anzalone N, Scomazzoni F, Cirillo M, Righi C, Simionato F, Cadioli M, et al. Follow-up of coiled cerebral aneurysms at 3T: comparison of 3D time-of-flight MR angiography and contrast-enhanced MR angiography. AJNR Am J Neuroradiol. 2008 Sep. 29(8):1530-6. [Medline].
Adams WM, Laitt RD, Jackson A. The role of MR angiography in the pretreatment assessment of intracranial aneurysms: a comparative study. AJNR Am J Neuroradiol. 2000 Oct. 21(9):1618-28. [Medline].
Alg VS, Sofat R, Houlden H, Werring DJ. Genetic risk factors for intracranial aneurysms: A meta-analysis in more than 116,000 individuals. Neurology. 2013 Jun 4. 80(23):2154-65. [Medline].
Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database. J Neurosurg. 2008 Jun. 108(6):1163-9. [Medline].
Anson JA, Lawton MT, Spetzler RF. Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms. J Neurosurg. 1996 Feb. 84(2):185-93. [Medline].
Aoki N, Beck JR, Kitahara T. Reanalysis of unruptured intracranial aneurysm management: effect of a new international study on the threshold probabilities. Med Decis Making. 2001 Mar-Apr. 21(2):87-96. [Medline].
Becker KJ. Epidemiology and clinical presentation of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 1998 Jul. 9(3):435-44. [Medline].
Bederson JB, Awad IA, Wiebers DO. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke. 2000 Nov. 31(11):2742-50. [Medline].
Benndorf G, Klucznik RP, Meyer D. "Cross-over" technique for horizontal stenting of an internal carotid bifurcation aneurysm using a new self-expandable stent: technical case report. Neurosurgery. 2006 Feb. 58(1 Suppl):ONS-E172. [Medline].
Brennan JW, Schwartz ML. Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria. Neurosurgery. 2000 Dec. 47(6):1359-71; discussion 1371-2. [Medline].
Brilstra EH, Rinkel GJ, van der Graaf Y. Treatment of intracranial aneurysms by embolization with coils: a systematic review. Stroke. 1999 Feb. 30(2):470-6. [Medline].
Broderick JP. Coiling, clipping, or medical management of unruptured intracranial aneurysms: time to randomize?. Ann Neurol. 2000 Jul. 48(1):5-6. [Medline].
Campi A, Ramzi N, Molyneux AJ, Summers PE, Kerr RS, Sneade M, et al. Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke. 2007 May. 38(5):1538-44. [Medline].
Carter BS, Sheth S, Chang E. Epidemiology of the size distribution of intracranial bifurcation aneurysms: smaller size of distal aneurysms and increasing size of unruptured aneurysms with age. Neurosurgery. 2006 Feb. 58(2):217-23; discussion 217-23. [Medline].
Chyatte D, Fode NC, Sundt TM. Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg. 1988 Sep. 69(3):326-31. [Medline].
Chyatte D, Porterfield R. Functional outcome after repair of unruptured intracranial aneurysms. J Neurosurg. 2001 Mar. 94(3):417-21. [Medline].
Connolly ES, Mohr JP, Solomon RA. Unruptured intracranial aneurysms. N Engl J Med. 1999 May 6. 340(18):1440-1; discussion 1441-2. [Medline].
de Oliveira JG, Beck J, Ulrich C, Rathert J, Raabe A, Seifert V. Comparison between clipping and coiling on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev. 2007 Jan. 30(1):22-30; discussion 30-1. [Medline].
Donnan GA, Davis SM. Patients with small, asymptomatic, unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively. Stroke. 2005 Feb. 36(2):407. [Medline].
Gonzalez N, Murayama Y, Nien YL. Treatment of unruptured aneurysms with GDCs: clinical experience with 247 aneurysms. AJNR Am J Neuroradiol. 2004 Apr. 25(4):577-83. [Medline].
Haley EC, Kassell NF, Torner JC. The International Cooperative Study on the Timing of Aneurysm Surgery. The North American experience. Stroke. 1992 Feb. 23(2):205-14. [Medline].
Hashimoto H, Iida J, Hironaka Y. Use of spiral computerized tomography angiography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms. J Neurosurg. 2000 Feb. 92(2):278-83. [Medline].
Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARAT) study. Stroke. 2008 Jan. 39(1):120-5. [Medline].
Johnston SC, Wilson CB, Halbach VV. Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol. 2000 Jul. 48(1):11-9. [Medline].
Johnston SC, Zhao S, Dudley RA. Treatment of unruptured cerebral aneurysms in California. Stroke. 2001 Mar. 32(3):597-605. [Medline].
Juvela S. Recommendations for the management of patients with unruptured intracranial aneurysms. Stroke. 2001 Mar. 32(3):815-6. [Medline].
Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms: a long-term follow-up study. Stroke. 2001 Feb. 32(2):485-91. [Medline].
Karmonik C, Strother CM, Chen X. Stent-assisted coiling of intracranial aneurysms aided by virtual parent artery reconstruction. AJNR Am J Neuroradiol. 2005 Oct. 26(9):2368-70. [Medline].
Kim DH, Haney CL, Van Ginhoven G. Utility of outcome measures after treatment for intracranial aneurysms: a prospective trial involving 520 patients. Stroke. 2005 Apr. 36(4):792-6. [Medline].
Kurre W, Berkefeld J. Materials and techniques for coiling of cerebral aneurysms: how much scientific evidence do we have?. Neuroradiology. 2008 Nov. 50(11):909-27. [Medline].
Lavine SD, Meyers PM. Application of new techniques and technologies: stenting for cerebral aneurysm. Clin Neurosurg. 2007. 54:64-9. [Medline].
Le Roux PD, Winn HR. Management of the ruptured aneurysm. Neurosurg Clin N Am. 1998 Jul. 9(3):525-40. [Medline].
Lylyk P, Ferrario A, Pasbon B. Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg. 2005 Feb. 102(2):235-41. [Medline].
Mayberg MR. Cerebral vasospasm. Neurosurg Clin N Am. 1998 Jul. 9(3):615-27. [Medline].
McKinney AM, Palmer CS, Truwit CL, Karagulle A, Teksam M. Detection of aneurysms by 64-section multidetector CT angiography in patients acutely suspected of having an intracranial aneurysm and comparison with digital subtraction and 3D rotational angiography. AJNR Am J Neuroradiol. 2008 Mar. 29(3):594-602. [Medline].
Mitchell P, Kerr R, Mendelow AD, Molyneux A. Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?. J Neurosurg. 2008 Mar. 108(3):437-42. [Medline].
Molyneux A, Kerr R, Stratton I. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002 Oct 26. 360(9342):1267-74. [Medline].
Molyneux AJ, Cekirge S, Saatci I. Cerebral Aneurysm Multicenter European Onyx (CAMEO) trial: results of a prospective observational study in 20 European centers. AJNR Am J Neuroradiol. 2004 Jan. 25(1):39-51. [Medline].
Molyneux AJ, Kerr RS, Yu LM. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, a. Lancet. 2005 Sep 3-9. 366(9488):809-17. [Medline].
Niimi Y, Song J, Madrid M. Endosaccular treatment of intracranial aneurysms using matrix coils: early experience and midterm follow-up. Stroke. 2006 Apr. 37(4):1028-32. [Medline].
Parra A, Kreiter KT, Williams S. Effect of prior statin use on functional outcome and delayed vasospasm after acute aneurysmal subarachnoid hemorrhage: a matched controlled cohort study. Neurosurgery. 2005 Mar. 56(3):476-84; discussion 476-84. [Medline].
Pierot L, Spelle L, Vitry F. Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA study. Stroke. 2008 Sep. 39(9):2497-504. [Medline].
Pluta RM, Dejam A, Grimes G. Nitrite infusions to prevent delayed cerebral vasospasm in a primate model of subarachnoid hemorrhage. JAMA. 2005 Mar 23. 293(12):1477-84. [Medline].
Qureshi AI, Mohammad Y, Yahia AM. Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature. Neurosurgery. 2000 Feb. 46(2):282-9; discussion 289-90. [Medline].
Raaymakers TW, Buys PC, Verbeeten B. MR angiography as a screening tool for intracranial aneurysms: feasibility, test characteristics, and interobserver agreement. AJR Am J Roentgenol. 1999 Dec. 173(6):1469-75. [Medline].
Reeves BC, Langham J, Lindsay KW, Molyneux AJ, Browne JP, Copley L, et al. Findings of the International Subarachnoid Aneurysm Trial and the National Study of Subarachnoid Haemorrhage in context. Br J Neurosurg. 2007 Aug. 21(4):318-23; discussion 323-7. [Medline].
Rinkel GJ. Medical management of patients with aneurysmal subarachnoid haemorrhage. Int J Stroke. 2008 Aug. 3(3):193-204. [Medline].
Rordorf G, Bellon RJ, Budzik RE Jr. Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: prospective study applying diffusion-weighted imaging. AJNR Am J Neuroradiol. 2001 Jan. 22(1):5-10. [Medline].
Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care. 2005. 2(2):110-8. [Medline].
Ryttlefors M, Enblad P, Kerr RS, Molyneux AJ. International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients. Stroke. 2008 Oct. 39(10):2720-6. [Medline].
Salary M, Quigley MR, Wilberger JE Jr. Relation among aneurysm size, amount of subarachnoid blood, and clinical outcome. J Neurosurg. 2007 Jul. 107(1):13-7. [Medline].
Sanai N, Tarapore P, Lee AC, Lawton MT. The current role of microsurgery for posterior circulation aneurysms: a selective approach in the endovascular era. Neurosurgery. 2008 Jun. 62(6):1236-49; discussion 1249-53. [Medline].
Schievink WI. Genetics and aneurysm formation. Neurosurg Clin N Am. 1998 Jul. 9(3):485-95. [Medline].
Schmid-Elsaesser R, Kunz M, Zausinger S, Prueckner S, Briegel J, Steiger HJ. Intravenous magnesium versus nimodipine in the treatment of patients with aneurysmal subarachnoid hemorrhage: a randomized study. Neurosurgery. 2006 Jun. 58(6):1054-65; discussion 1054-65. [Medline].
Sherlock M, O'sullivan E, Agha A. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol (Oxf). 2006 Mar. 64(3):250-4. [Medline].
Sluzewski M, van Rooij WJ. Early rebleeding after coiling of ruptured cerebral aneurysms: incidence, morbidity, and risk factors. AJNR Am J Neuroradiol. 2005 Aug. 26(7):1739-43. [Medline].
Sluzewski M, van Rooij WJ, Beute GN. Late rebleeding of ruptured intracranial aneurysms treated with detachable coils. AJNR Am J Neuroradiol. 2005 Nov-Dec. 26(10):2542-9. [Medline].
Solenski NJ, Haley EC, Kassell NF. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995 Jun. 23(6):1007-17. [Medline].
Solomon RA, Fink ME, Pile-Spellman J. Surgical management of unruptured intracranial aneurysms. J Neurosurg. 1994 Mar. 80(3):440-6. [Medline].
Standhardt H, Boecher-Schwarz H, Gruber A, Benesch T, Knosp E, Bavinzski G. Endovascular treatment of unruptured intracranial aneurysms with Guglielmi detachable coils: short- and long-term results of a single-centre series. Stroke. 2008 Mar. 39(3):899-904. [Medline].
Todd MM, Hindman BJ, Clarke WR. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med. 2005 Jan 13. 352(2):135-45. [Medline].
van den Bergh WM, Algra A, van Kooten F. Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2005 May. 36(5):1011-5. [Medline].
Velthuis BK, Van Leeuwen MS, Witkamp TD. Computerized tomography angiography in patients with subarachnoid hemorrhage: from aneurysm detection to treatment without conventional angiography. J Neurosurg. 1999 Nov. 91(5):761-7. [Medline].
Vespa PM, Gobin YP. Endovascular treatment and neurointensive care of ruptured aneurysms. Crit Care Clin. 1999 Oct. 15(4):667-84. [Medline].
Vinuela F, Murayama Y, Duckwiler GR. Present and future technical developments on aneurysm embolization. Impact on indications and anatomic results. Clin Neurosurg. 2000. 47:221-41. [Medline].
Viñuela F, Duckwiler G, Mawad M. Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. 1997. J Neurosurg. 2008 Apr. 108(4):832-9. [Medline].
Wermer MJ, van der Schaaf IC, Velthuis BK. Follow-up screening after subarachnoid haemorrhage: frequency and determinants of new aneurysms and enlargement of existing aneurysms. Brain. 2005 Oct. 128(Pt 10):2421-9. [Medline].
White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. 2000 Nov. 217(2):361-70. [Medline].
Wiebers DO, Torres VE. Screening for unruptured intracranial aneurysms in autosomal dominant polycystic kidney disease. N Engl J Med. 1992 Sep 24. 327(13):953-5. [Medline].
Yuki I, Murayama Y, Vinuela F. Development of medical devices for neuro-interventional procedures: special focus on aneurysm treatment. Expert Rev Med Devices. 2005 Sep. 2(5):539-46. [Medline].
Zada G, Breault J, Liu CY, Khalessi AA, Larsen DW, Teitelbaum GP, et al. Internal carotid artery aneurysms occurring at the origin of fetal variant posterior cerebral arteries: surgical and endovascular experience. Neurosurgery. 2008 Jul. 63(1 Suppl 1):ONS55-61; discussion ONS61-2. [Medline].
Zaidat OO, Ionita CC, Hussain SI, Alexander MJ, Friedman AH, Graffagnino C. Impact of Ruptured Cerebral Aneurysm Coiling and Clipping on the Incidence of Cerebral Vasospasm and Clinical Outcome. J Neuroimaging. 2008 Aug 4. [Medline].
|Grade||Clinical Condition at Presentation|
|1||Asymptomatic or minimal headache and slight nuchal rigidity|
|2||Moderately severe or severe headache and nuchal rigidity; cranial neuropathy, no focal deficit|
|3||Drowsiness, confusion, or mild focal deficit|
|4||Stupor, moderate to severe hemiparesis|
|5||Deep coma, decerebrate posturing, moribund appearance|
|Grade||Glasgow Coma Scale Score||Clinical Findings|
|I||15||No headache or focal signs|
|II||15||Headache, nuchal rigidity, no focal signs|
|III||13-14||Headache, nuchal rigidity, no focal signs|
|IV||7-12||Headache, rigidity, focal signs|
|V||3-6||Headache, rigidity, focal signs|
|1||No blood detected|
|2||Diffuse thin layer of subarachnoid blood|
|3||Localized thrombus or thick layer of subarachnoid blood|
|4||Intracerebral or intraventricular hemorrhage with diffuse or no subarachnoid blood|