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Cerebral Aneurysms Follow-up

  • Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Aug 06, 2015
 

Further Outpatient Care

See the list below:

  • After hospital discharge, continue physical, occupational, and speech therapy.
  • Administer medications for vasospasm and to prevent complications such as seizures, urinary tract infections, or venous thromboses.
  • Following definitive treatment of a cerebral aneurysm with either endovascular or surgical obliteration, serial imaging studies should be obtained as an outpatient. Various imaging modalities, including CTA, 1.5 or 3T MRA, and conventional angiography may be used. The use of noninvasive angiographic techniques for serial evaluation has grown in recent years.[16]
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Further Inpatient Care

Following neurosurgical or endovascular intervention, continued care in the ICU generally includes the following:

  • Serial neurologic examinations
  • Avoidance of hypotension or hypertension (mean arterial pressure [MAP] should be in the range of 70-130 mm Hg)
  • Use of isotonic solutions, such as normal saline, to minimize cerebral edema
  • Treatment or prophylaxis of seizures
  • Treatment of urinary tract infections
  • Prevention of venous thrombosis
  • Prophylaxis for gastric ulcers
  • Physical, occupational, and speech therapy
  • Repeat CT scan in case of clinical deterioration
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Inpatient & Outpatient Medications

See the list below:

  • Nimodipine for vasospasm
  • Phenytoin for prevention or treatment of seizures
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Transfer

Immediately after prehospital evaluation and emergent stabilization, transfer patients with aneurysmal SAH to a center with neurosurgical expertise.

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Deterrence/Prevention

See the list below:

  • Prevention of neurological injury necessitates definitive treatment of a diagnosed cerebral aneurysm.
  • Patient education regarding symptoms of aneurysmal rupture may be important, as 10% of individuals die before reaching medical attention.
  • Noninvasive screening with CTA or MRA is important in patients with medical conditions associated with cerebral aneurysms or a family history of SAH or aneurysms.
  • Recent data showing superior functional outcomes and reduced complications for those on statins prior to aneurysmal SAH may promote the use of statins.
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Complications

See the list below:

  • Vasospasm
  • Recurrent hemorrhage
  • Seizures
  • Hydrocephalus
  • Hyponatremia
  • Cardiac arrhythmia, myocardial infarction, or congestive heart failure
  • Neurogenic pulmonary edema, pneumonia, or atelectasis
  • Gastrointestinal bleeding
  • Anemia
  • Venous thromboembolism
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Prognosis

See the list below:

  • Prognosis of aneurysmal SAH has been associated with the following:
    • Age
    • Neurological status on admission
    • Aneurysm location
    • Number of days after SAH of admission (ie, delay from SAH to hospital admission)
    • Presence of hypertension and other medical illnesses
    • Degree of vasospasm
    • Degree of SAH
    • Extent of intraparenchymal or intraventricular hemorrhage
  • Outcome assessments following aneurysmal SAH may not be properly evaluated with the use of a single scale or measure. Cognitive dysfunction and subjective experience of recovery should also be considered.
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Patient Education

See the list below:

  • Educate regarding the warning signs and symptoms of SAH.
  • Educate regarding potential risk factors for aneurysmal SAH, including the following:
    • Hypertension
    • Cigarette smoking
    • Illicit drug use
    • Alcohol
  • For excellent patient education resources, visit eMedicineHealth's Headache Center. Also, see eMedicineHealth's patient education article, Brain Aneurysm.
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Contributor Information and Disclosures
Author

David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center

David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, Stroke Council of the American Heart Association, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

Draga Jichici, MD, FRCP, FAHA Associate Clinical Professor, Department of Neurology and Critical Care Medicine, McMaster University School of Medicine, Canada

Draga Jichici, MD, FRCP, FAHA is a member of the following medical societies: American Academy of Neurology, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Canadian Medical Protective Association, Neurocritical Care Society, Canadian Critical Care Society, Canadian Critical Care Society, Canadian Neurocritical Care Society, Canadian Neurological Sciences Federation

Disclosure: Nothing to disclose.

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Cerebral aneurysms. Volume-rendered CT angiography of a left middle cerebral artery aneurysm.
Cerebral aneurysms. CT angiography of a right middle cerebral artery aneurysm.
Cerebral aneurysms. Sagittal multiplanar reformatted view of a left internal carotid artery aneurysm.
Cerebral aneurysms. Basilar tip aneurysm illustrated on CT scan (left) and T2-weighted MRI (right).
Cerebral aneurysms. Volume-rendered CT angiography of a basilar tip aneurysm.
Cerebral aneurysms. Aneurysm associated with an arteriovenous malformation (AVM) shown on T1-weighted MRI (left), 3D-time-of-flight MRI (middle), and conventional angiography (right).
Table 1. Clinical Condition at Presentation
GradeClinical Condition at Presentation
0Unruptured aneurysm
1Asymptomatic or minimal headache and slight nuchal rigidity
2Moderately severe or severe headache and nuchal rigidity; cranial neuropathy, no focal deficit
3Drowsiness, confusion, or mild focal deficit
4Stupor, moderate to severe hemiparesis
5Deep coma, decerebrate posturing, moribund appearance
Table 2. World Federation of Neurological Surgeons Scale
GradeGlasgow Coma Scale ScoreClinical Findings
I15No headache or focal signs
II15Headache, nuchal rigidity, no focal signs
III13-14Headache, nuchal rigidity, no focal signs
IV7-12Headache, rigidity, focal signs
V3-6Headache, rigidity, focal signs
Table 3. Fisher Grade
GradeCT Findings
1No blood detected
2Diffuse thin layer of subarachnoid blood
3Localized thrombus or thick layer of subarachnoid blood
4Intracerebral or intraventricular hemorrhage with diffuse or no subarachnoid blood
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