eMedicine Specialties > Neurology > Neuro-vascular Diseases

Cerebral Aneurysms: Follow-up

Author: David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center
Contributor Information and Disclosures

Updated: Mar 10, 2009

Follow-up

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

Further Outpatient Care

  • 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.8

Inpatient & Outpatient Medications

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

Transfer

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

Deterrence/Prevention

  • 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.

Complications

  • 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

Prognosis

  • 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.

Patient Education

  • 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 eMedicine's Headache Center. Also, see eMedicine's patient education article, Aneurysm, Brain.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis of aneurysmal SAH
  • Failure to order a CT scan for a severe headache that is atypical for the patient
  • Failure to perform an LP if aneurysmal SAH is suspected and CT scan is negative
  • Failure to recognize signs and symptoms of cerebral vasospasm or rebleeding

Special Concerns

  • Aneurysmal SAH accounts for about 7% of maternal deaths during pregnancy. For women who are pregnant, the fetus should be shielded during CT scan and angiography.
  • The teratogenic potential of nimodipine is unknown; therefore, use caution in pregnant women.
  • Because of the risk of rebleeding, surgical or endovascular treatment of the aneurysm is recommended.
  • Ischemic lesions on follow-up CT after aneurysmal SAH may be predicted by the severity of bleeding, delayed cerebral ischemia, excess weight, duration of temporary artery occlusion, and occurrence of nocturnal aneurysm rupture.
 


More on Cerebral Aneurysms

Overview: Cerebral Aneurysms
Differential Diagnoses & Workup: Cerebral Aneurysms
Treatment & Medication: Cerebral Aneurysms
Follow-up: Cerebral Aneurysms
Multimedia: Cerebral Aneurysms
References
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Further Reading

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Keywords

intracranial aneurysm, intracerebral aneurysm, saccular aneurysm, berry aneurysm, giant aneurysm, fusiform aneurysm, dolichoectasia, infectious aneurysm, mycotic aneurysm

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Contributor Information and Disclosures

Author

David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; 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, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Draga Jichici, MD, FRCP, Associate Clinical Professor, Department of Medicine, Division of Neurology and Critical Care Medicine, McMaster University, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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 Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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