Cerebral Aneurysms Treatment & Management

  • Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Oct 29, 2010
 

Medical Care

  • Prehospital care should include assessment of vital signs and neurological status. Airway, breathing, and circulation should be addressed with endotracheal intubation, if necessary, and establishment of intravenous access.
  • Medical therapy of cerebral aneurysms involves general supportive measures and prevention of complications for individuals who are in the periprocedural period or are poor surgical candidates. Treatment decisions should be based on the clinical status of the patient, vascular anatomy of the aneurysm, and surgical or endovascular considerations.
    • Medical management of aneurysmal SAH is orchestrated in the ICU, with cardiac monitoring and placement of an arterial line.
    • Prior to definitive aneurysm treatment, medical approaches involve control of hypertension, administration of calcium channel blockers, and prevention of seizures.
    • Following surgical or endovascular aneurysm treatment, blood pressure is maintained at higher levels to diminish complications associated with vasospasm. Vasospasm usually occurs between days 3 and 21, presenting with headache, decreased level of consciousness, and variable neurological deficits. Serial TCD may be employed to detect trends in cerebral blood flow during this period.
    • Induced hypertension, hypervolemia, and hemodilution (ie, "triple-H therapy") aims to maintain adequate cerebral perfusion pressure in the setting of impaired cerebrovascular autoregulation.
    • Intraarterial papaverine or endovascular balloon angioplasty may be used to treat vasospasm in select patients.
  • Infectious aneurysms are friable, with an increased propensity for hemorrhage. Anticoagulation is avoided in this setting. As these lesions resolve with antibiotic therapy, surgical approaches usually are deferred. Regression or evolution of these aneurysms is monitored with serial angiography.
  • The management of unruptured intracranial aneurysms is highly controversial. The International Study of Unruptured Intracranial Aneurysms (ISUIA) indicated a relatively low risk of rupture in small aneurysms without history of SAH. Aneurysms less than 10 mm in size had an annual rupture rate of approximately 0.05%. For posterior communicating, vertebrobasilar/posterior cerebral, or basilar tip aneurysms less than 10 mm, the risk of rupture over 7.5 years approximated 2%, with all other locations harboring a risk of almost 0%. Recent guidelines and an evidence-based systematic review of the literature have formulated recommendations for the care of patients with unruptured intracranial aneurysms, principally based on age, history, and aneurysm size.
    • The anatomical characterization and morphology of unruptured aneurysms are not readily standardized, however. Some investigators have advocated endovascular or surgical treatment of all aneurysms less than 10 mm if age is less than 50 years, in the absence of contraindications. The presence of cigarette smoking, family history of aneurysms, polycystic kidney disease, or systemic lupus erythematosus may elevate the risk of rupture and should be considered. Asymptomatic aneurysms greater than 10 mm should also be considered for treatment, accounting for age, coexisting medical conditions, and relative risks for treatment.
    • Considerable surgical mortality and morbidity rates at 1 year (as high as 3.8% and 15.7%, respectively) have been demonstrated in preventive treatment of unruptured aneurysms. The surgeon's experience may be a significant and highly variable factor in operative morbidity rate and functional outcome. More recently, application of diffusion-weighted MRI has demonstrated silent thromboembolic events associated with endovascular treatment of unruptured cerebral aneurysms. Quality-of-life issues, including the psychological morbidity of living with an unruptured intracranial aneurysm, also must be addressed.
    • Therapeutic decision making must balance endovascular or surgical morbidity and mortality rates with the risk of hemorrhage and other considerations on an individual basis. Future studies in the management of unruptured intracranial aneurysms may systematically account for the evolving technology of advanced endovascular approaches, detailed aneurysm morphology, novel neuroimaging correlates, ethnic and geographical variation, neurocognitive impairment following endovascular or surgical treatment, and quality-of-life issues.
Next

Surgical Care

  • Microsurgical techniques focus on exclusion of the aneurysm from the cerebral circulation and reduction of mass effects on adjacent structures. Various approaches have been developed and tailored to the anatomy and location of the aneurysm. A surgical clip usually is placed across the aneurysm neck with preservation of the parent vessel, eliminating any aneurysmal rests that may redevelop subsequently. Alternative surgical techniques involve proximal or Hunterian ligation, wrapping of the aneurysm, or trapping (ie, a combination of proximal and distal vessel occlusion).
  • Adjunctive measures have been developed to reduce operative morbidity and to provide cerebral protection. Aneurysmal rupture, the principal surgical complication, may be avoided with induced hypotension, CSF drainage, diuretics, hyperventilation, and use of minimal brain retraction. Hypothermia, with or without circulatory arrest, and systemic hypotension are used commonly. A large recent study of mild intraoperative hypothermia, however, failed to demonstrate benefit of this adjunctive technique. Lumbar spinal drainage allows for relaxation of brain parenchyma and provides a clean surgical field. Postoperative angiography is performed routinely to check for major vessel occlusion or persistence of an aneurysmal rest. Operative morbidity rate increases with aneurysm size (2.3% for < 5 mm; 6.8% for 6-15 mm, 14% for 16-25 mm) and varies by location.
  • Optimal timing of aneurysm surgery depends on the clinical status of the patient and associated factors. Early surgery (ie, < 48-96 h after SAH) is favored for candidates in good condition or those with unstable blood pressure, seizures, mass effect from thrombus, large amounts of blood, or evidence of aneurysm growth or rebleeding. Early surgery carries an increased operative morbidity, although the risks of vasospasm and rebleeding are reduced considerably. Delayed surgery (ie, 10-14 d after SAH) may be considered for large aneurysms in difficult locations or for candidates in poor clinical condition. Surgery is indicated for ruptured or symptomatic aneurysms in patients without extenuating contraindications or considerably advanced age. Surgery generally is precluded if the clinical status is poor, corresponding to Hunt and Hess grade 4 or 5.
  • Advances in endovascular techniques have provided novel therapeutic alternatives that may be employed even in the setting of acute aneurysmal SAH. These techniques allow for parent vessel preservation and may be combined with surgical approaches. Electrolytically detachable platinum coils (eg, Guglielmi detachable coils [GDC]) may be deployed strategically within the aneurysm, promoting thrombosis and eventual obliteration. Wide-neck aneurysms may be more difficult to occlude with these devices. Other materials, such as balloons or glue, also may be used. Complications include vessel perforation, hemorrhage, or distal thromboembolism.
  • Endovascular therapy or coiling of cerebral aneurysms has proliferated during the last several years. The respective roles of coiling versus surgical clipping of particular cerebral aneurysms are likely influenced by numerous factors. The International Subarachnoid Aneurysm Trial (ISAT) demonstrated the superiority of coiling with improved clinical outcomes. Seizures were also less common in patients with endovascular treatment, yet late rebleeding was also more common. Selection bias may also have influenced ISAT and, therefore, treatment for a given individual must still be tailored to each case.
  • Progressive refinement in endovascular techniques and devices tailored for the cerebrovasculature have expanded therapeutic options available for definitive treatment of cerebral aneurysms. More pliable, low profile stents may be used for stent-assisted coiling for obliteration of wide-necked aneurysms.
    • Self-expanding or balloon-expandable covered stents may be used for treatment of selected carotid or vertebral artery pseudoaneurysms.[4]
    • Large or giant intracranial aneurysms may be treated with a combination of devices, such as stent-assisted coil placement.[5] However, the requirement of dual antiplatelet therapy in stent-assisted coiling may increase the risk of intracranial hemorrhage.[6]
    • Refinement of endovascular techniques for very small intracranial aneurysms has expanded treatment options, yet complications may also increase in this particular subset.[7]
Previous
Next

Consultations

A multidisciplinary approach to the treatment of cerebral aneurysms is recommended. The following specialists should be a part of the multidisciplinary team:

  • Neurosurgeon
  • Interventional neuroradiologist
  • Neurologist
  • Rehabilitation specialist
Previous
Next

Diet

  • Restrict possible surgical candidates to taking nothing by mouth (NPO).
  • Employ nasogastric feedings for individuals with a decreased level of consciousness.
  • Recommend a soft, high-fiber diet to alert patients; patients should avoid caffeine.
Previous
Next

Activity

  • Advise bed rest in a quiet dark environment during the initial week following aneurysmal SAH.
  • Perform passive range of motion exercises and frequent turning.
  • Assist patients with self-care activities, followed by slow advancement in activity as tolerated.
Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

David S Liebeskind, MD  Associate 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, 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.

Specialty Editor Board

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, Canadian Congress of Neurological Sciences, Canadian Congress of Neurological Sciences, Canadian Congress of Neurological Sciences, Canadian Critical Care Society, Canadian Medical Protective Association, Canadian Neurocritical Care Society, Neurocritical Care Society, Royal College of Physicians and Surgeons of Canada, and Society of Critical Care Medicine (USA)

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; 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; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

References

  1. 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. Nov 1 2007;357(18):1821-8. [Medline].

  2. 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. Aug 2008;29(7):1288-95. [Medline].

  3. 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. May 2008;29(5):976-9. [Medline].

  4. Yi AC, Palmer E, Luh GY, Jacobson JP, Smith DC. Endovascular treatment of carotid and vertebral pseudoaneurysms with covered stents. AJNR Am J Neuroradiol. May 2008;29(5):983-7. [Medline].

  5. 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. Jul 2008;30(6):598-602. [Medline].

  6. 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. Jun 2008;108(6):1122-9. [Medline].

  7. 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. Jun 2008;108(6):1088-92. [Medline].

  8. 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. Sep 2008;29(8):1530-6. [Medline].

  9. 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. Oct 2000;21(9):1618-28. [Medline].

  10. Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database. J Neurosurg. Jun 2008;108(6):1163-9. [Medline].

  11. Anson JA, Lawton MT, Spetzler RF. Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms. J Neurosurg. Feb 1996;84(2):185-93. [Medline].

  12. 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. Mar-Apr 2001;21(2):87-96. [Medline].

  13. Becker KJ. Epidemiology and clinical presentation of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. Jul 1998;9(3):435-44. [Medline].

  14. 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. Nov 2000;31(11):2742-50. [Medline].

  15. 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. Feb 2006;58(1 Suppl):ONS-E172. [Medline].

  16. Brennan JW, Schwartz ML. Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria. Neurosurgery. Dec 2000;47(6):1359-71; discussion 1371-2. [Medline].

  17. Brilstra EH, Rinkel GJ, van der Graaf Y. Treatment of intracranial aneurysms by embolization with coils: a systematic review. Stroke. Feb 1999;30(2):470-6. [Medline].

  18. Broderick JP. Coiling, clipping, or medical management of unruptured intracranial aneurysms: time to randomize?. Ann Neurol. Jul 2000;48(1):5-6. [Medline].

  19. 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. May 2007;38(5):1538-44. [Medline].

  20. 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. Feb 2006;58(2):217-23; discussion 217-23. [Medline].

  21. Chyatte D, Fode NC, Sundt TM. Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg. Sep 1988;69(3):326-31. [Medline].

  22. Chyatte D, Porterfield R. Functional outcome after repair of unruptured intracranial aneurysms. J Neurosurg. Mar 2001;94(3):417-21. [Medline].

  23. Connolly ES, Mohr JP, Solomon RA. Unruptured intracranial aneurysms. N Engl J Med. May 6 1999;340(18):1440-1; discussion 1441-2. [Medline].

  24. 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. Jan 2007;30(1):22-30; discussion 30-1. [Medline].

  25. Donnan GA, Davis SM. Patients with small, asymptomatic, unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively. Stroke. Feb 2005;36(2):407. [Medline].

  26. Gonzalez N, Murayama Y, Nien YL. Treatment of unruptured aneurysms with GDCs: clinical experience with 247 aneurysms. AJNR Am J Neuroradiol. Apr 2004;25(4):577-83. [Medline].

  27. Haley EC, Kassell NF, Torner JC. The International Cooperative Study on the Timing of Aneurysm Surgery. The North American experience. Stroke. Feb 1992;23(2):205-14. [Medline].

  28. 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. Feb 2000;92(2):278-83. [Medline].

  29. 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. Jan 2008;39(1):120-5. [Medline].

  30. Johnston SC, Wilson CB, Halbach VV. Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol. Jul 2000;48(1):11-9. [Medline].

  31. Johnston SC, Zhao S, Dudley RA. Treatment of unruptured cerebral aneurysms in California. Stroke. Mar 2001;32(3):597-605. [Medline].

  32. Juvela S. Recommendations for the management of patients with unruptured intracranial aneurysms. Stroke. Mar 2001;32(3):815-6. [Medline].

  33. Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms: a long-term follow-up study. Stroke. Feb 2001;32(2):485-91. [Medline].

  34. Karmonik C, Strother CM, Chen X. Stent-assisted coiling of intracranial aneurysms aided by virtual parent artery reconstruction. AJNR Am J Neuroradiol. Oct 2005;26(9):2368-70. [Medline].

  35. Kim DH, Haney CL, Van Ginhoven G. Utility of outcome measures after treatment for intracranial aneurysms: a prospective trial involving 520 patients. Stroke. Apr 2005;36(4):792-6. [Medline].

  36. Kurre W, Berkefeld J. Materials and techniques for coiling of cerebral aneurysms: how much scientific evidence do we have?. Neuroradiology. Nov 2008;50(11):909-27. [Medline].

  37. Lavine SD, Meyers PM. Application of new techniques and technologies: stenting for cerebral aneurysm. Clin Neurosurg. 2007;54:64-9. [Medline].

  38. Le Roux PD, Winn HR. Management of the ruptured aneurysm. Neurosurg Clin N Am. Jul 1998;9(3):525-40. [Medline].

  39. Lylyk P, Ferrario A, Pasbon B. Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg. Feb 2005;102(2):235-41. [Medline].

  40. Mayberg MR. Cerebral vasospasm. Neurosurg Clin N Am. Jul 1998;9(3):615-27. [Medline].

  41. 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. Mar 2008;29(3):594-602. [Medline].

  42. 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. Mar 2008;108(3):437-42. [Medline].

  43. 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. Oct 26 2002;360(9342):1267-74. [Medline].

  44. 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. Jan 2004;25(1):39-51. [Medline].

  45. [Best Evidence] 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. Sep 3-9 2005;366(9488):809-17. [Medline].

  46. Niimi Y, Song J, Madrid M. Endosaccular treatment of intracranial aneurysms using matrix coils: early experience and midterm follow-up. Stroke. Apr 2006;37(4):1028-32. [Medline].

  47. 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. Mar 2005;56(3):476-84; discussion 476-84. [Medline].

  48. 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. Sep 2008;39(9):2497-504. [Medline].

  49. Pluta RM, Dejam A, Grimes G. Nitrite infusions to prevent delayed cerebral vasospasm in a primate model of subarachnoid hemorrhage. JAMA. Mar 23 2005;293(12):1477-84. [Medline].

  50. Qureshi AI, Mohammad Y, Yahia AM. Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature. Neurosurgery. Feb 2000;46(2):282-9; discussion 289-90. [Medline].

  51. 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. Dec 1999;173(6):1469-75. [Medline].

  52. 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. Aug 2007;21(4):318-23; discussion 323-7. [Medline].

  53. Rinkel GJ. Medical management of patients with aneurysmal subarachnoid haemorrhage. Int J Stroke. Aug 2008;3(3):193-204. [Medline].

  54. 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. Jan 2001;22(1):5-10. [Medline].

  55. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care. 2005;2(2):110-8. [Medline].

  56. 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. Oct 2008;39(10):2720-6. [Medline].

  57. Salary M, Quigley MR, Wilberger JE Jr. Relation among aneurysm size, amount of subarachnoid blood, and clinical outcome. J Neurosurg. Jul 2007;107(1):13-7. [Medline].

  58. 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. Jun 2008;62(6):1236-49; discussion 1249-53. [Medline].

  59. Schievink WI. Genetics and aneurysm formation. Neurosurg Clin N Am. Jul 1998;9(3):485-95. [Medline].

  60. 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. Jun 2006;58(6):1054-65; discussion 1054-65. [Medline].

  61. Sherlock M, O'sullivan E, Agha A. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol (Oxf). Mar 2006;64(3):250-4. [Medline].

  62. Sluzewski M, van Rooij WJ. Early rebleeding after coiling of ruptured cerebral aneurysms: incidence, morbidity, and risk factors. AJNR Am J Neuroradiol. Aug 2005;26(7):1739-43. [Medline].

  63. Sluzewski M, van Rooij WJ, Beute GN. Late rebleeding of ruptured intracranial aneurysms treated with detachable coils. AJNR Am J Neuroradiol. Nov-Dec 2005;26(10):2542-9. [Medline].

  64. 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. Jun 1995;23(6):1007-17. [Medline].

  65. Solomon RA, Fink ME, Pile-Spellman J. Surgical management of unruptured intracranial aneurysms. J Neurosurg. Mar 1994;80(3):440-6. [Medline].

  66. 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. Mar 2008;39(3):899-904. [Medline].

  67. Todd MM, Hindman BJ, Clarke WR. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med. Jan 13 2005;352(2):135-45. [Medline].

  68. [Best Evidence] van den Bergh WM, Algra A, van Kooten F. Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial. Stroke. May 2005;36(5):1011-5. [Medline].

  69. 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. Nov 1999;91(5):761-7. [Medline].

  70. Vespa PM, Gobin YP. Endovascular treatment and neurointensive care of ruptured aneurysms. Crit Care Clin. Oct 1999;15(4):667-84. [Medline].

  71. 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].

  72. 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. Apr 2008;108(4):832-9. [Medline].

  73. 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. Oct 2005;128(Pt 10):2421-9. [Medline].

  74. White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. Nov 2000;217(2):361-70. [Medline].

  75. Wiebers DO, Torres VE. Screening for unruptured intracranial aneurysms in autosomal dominant polycystic kidney disease. N Engl J Med. Sep 24 1992;327(13):953-5. [Medline].

  76. Yuki I, Murayama Y, Vinuela F. Development of medical devices for neuro-interventional procedures: special focus on aneurysm treatment. Expert Rev Med Devices. Sep 2005;2(5):539-46. [Medline].

  77. 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. Jul 2008;63(1 Suppl 1):ONS55-61; discussion ONS61-2. [Medline].

  78. 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. Aug 4 2008;[Medline].

 
Previous
Next
 
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
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.