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.^[17]

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

Inpatient & Outpatient Medications

See the list below:

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

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.

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

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.

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.

Questions

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Media Gallery

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).
Cerebral aneurysms. Clipping vs coiling.

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Table 1. Clinical Condition at Presentation

Grade	Clinical Condition at Presentation
0	Unruptured aneurysm
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

Table 2. World Federation of Neurological Surgeons Scale

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

Table 3. Fisher Grade

Grade	CT Findings
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

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Author

David S Liebeskind, MD, FAAN, FAHA, FANA Professor of Neurology and Director, Neurovascular Imaging Research Core, Director, Vascular Neurology Residency Program, Department of Neurology, University of California, Los Angeles, David Geffen School of Medicine; Director, UCLA Outpatient Stroke and Neurovascular Programs; Director, UCLA Cerebral Blood Flow Laboratory; Associate Neurology Director, UCLA Stroke Center

David S Liebeskind, MD, FAAN, FAHA, FANA 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, Stroke Council of the American Heart 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; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Additional Contributors

Draga Jichici, MD, FRCPC, FAHA Associate Clinical Professor, Division of Medicine, Department of Critical Care Medicine and Neurology, Co-Director, Neurosurgical Intensive Care Unit, Co-Director, Transcranial Doppler Ultrasound, Hamilton Health Sciences, McMaster University School of Medicine, Canada

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

Disclosure: Nothing to disclose.