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Sections Cerebral Aneurysms
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References

Medication

Medication Summary

Nimodipine has been demonstrated to improve outcome and decrease the incidence of delayed neurological deficits when administered for the first 21 days after aneurysmal SAH. Although the prophylactic role of antiepileptic medications in aneurysmal SAH is controversial, seizures may be treated with these medications. Antihypertensive medications may be needed to control blood pressure. After aneurysmal occlusion, these medications are held typically for 2 weeks. Sedatives and pain control may be needed for aneurysmal SAH. Antiemetics, antacids, and stool softeners also are used routinely.

Class Summary

These agents are administered to minimize sequelae of cerebral vasospasm.

Nimodipine (Nimotop)

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For improvement of neurological impairments resulting from spasms following SAH caused by ruptured congenital intracranial aneurysm in patients in good postictal neurological condition.

While studies show benefit in severity of neurological deficits caused by cerebral vasospasm following SAH, no evidence shows that the drug either prevents or relieves spasm of cerebral arteries. Actual mechanism of action unknown but may involve protection of brain against ischemia.

Therapy should start within 96 h of SAH. If capsule cannot be swallowed because patient undergoing surgery or unconscious, a hole can be made at both ends of capsule with 18-gauge needle, and contents extracted into a syringe. Contents then can be emptied into patient's nasogastric tube in situ and washed down tube with 30 mL isotonic saline.

Class Summary

These agents are administered for treatment and prevention of seizures.

Fosphenytoin (Cerebyx)

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Diphosphate ester salt of phenytoin that acts as water-soluble prodrug of phenytoin. Following administration, plasma esterases convert fosphenytoin to phosphate, formaldehyde, and phenytoin. Phenytoin, in turn, stabilizes neuronal membranes and decreases seizure activity.

To avoid need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses, express dose as phenytoin sodium equivalents (PE). Although can be administered IV and IM, IV is route of choice and should be used in emergency situations.

Concomitant administration of IV benzodiazepine usually necessary to control status epilepticus. Full antiepileptic effect of phenytoin, whether given as fosphenytoin or parenteral phenytoin, not immediate.

Class Summary

These agents help in controlling systemic blood pressure.

Labetalol (Normodyne, Trandate)

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Blocks beta1-, alpha-, and beta2-adrenergic receptor sites, thereby decreasing blood pressure.

Hydralazine (Apresoline)

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Decreases systemic resistance through direct vasodilation of arterioles.

Class Summary

These agents help in pain relief.

Morphine sulfate (MSIR, Duramorph, Astramorph, MS Contin)

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Drug of choice for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses used; commonly titrated until desired effect obtained.

Class Summary

These agents help in minimizing nausea and vomiting.

Prochlorperazine (Compazine)

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May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system. In addition to antiemetic effects, has advantage of augmenting hypoxic ventilatory response, acting as respiratory stimulant at high altitude.

Class Summary

These agents help in relieving gastrointestinal acid reflux.

Ranitidine (Zantac)

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Inhibits stimulation of H2 receptor in gastric parietal cells, which in turn reduces gastric acid secretion, gastric volume, and hydrogen-ion concentration.

Class Summary

These agents help in softening stools and minimizing straining.

Docusate sodium (Colace, Dialox, Surfak, Regulax, Sulfalax)

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For patients who should avoid straining during defecation; allows incorporation of water and fat into stool, causing stool to soften.

Follow-up

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.
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Brooks M. Serial Screening for Cerebral Aneurysm Fruitful. Medscape Medical News. Available at http://www.medscape.com/viewarticle/824618. Accessed: May 14, 2014.
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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. [QxMD MEDLINE Link].
Broderick JP. Coiling, clipping, or medical management of unruptured intracranial aneurysms: time to randomize?. Ann Neurol. 2000 Jul. 48(1):5-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Chyatte D, Fode NC, Sundt TM. Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg. 1988 Sep. 69(3):326-31. [QxMD MEDLINE Link].
Chyatte D, Porterfield R. Functional outcome after repair of unruptured intracranial aneurysms. J Neurosurg. 2001 Mar. 94(3):417-21. [QxMD MEDLINE Link].
Connolly ES, Mohr JP, Solomon RA. Unruptured intracranial aneurysms. N Engl J Med. 1999 May 6. 340(18):1440-1; discussion 1441-2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Johnston SC, Zhao S, Dudley RA. Treatment of unruptured cerebral aneurysms in California. Stroke. 2001 Mar. 32(3):597-605. [QxMD MEDLINE Link].
Juvela S. Recommendations for the management of patients with unruptured intracranial aneurysms. Stroke. 2001 Mar. 32(3):815-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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Le Roux PD, Winn HR. Management of the ruptured aneurysm. Neurosurg Clin N Am. 1998 Jul. 9(3):525-40. [QxMD MEDLINE Link].
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Mayberg MR. Cerebral vasospasm. Neurosurg Clin N Am. 1998 Jul. 9(3):615-27. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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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.

Sections Cerebral Aneurysms
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
Tables
References

Cerebral Aneurysms Medication

Medication Summary

Calcium channel blockers

Class Summary

Nimodipine (Nimotop)

Nimodipine (Nimotop)

Antiepileptics

Class Summary

Fosphenytoin (Cerebyx)

Fosphenytoin (Cerebyx)

Antihypertensives

Class Summary

Labetalol (Normodyne, Trandate)

Labetalol (Normodyne, Trandate)

Hydralazine (Apresoline)

Hydralazine (Apresoline)

Analgesics

Class Summary

Morphine sulfate (MSIR, Duramorph, Astramorph, MS Contin)

Morphine sulfate (MSIR, Duramorph, Astramorph, MS Contin)

Antiemetics

Class Summary

Prochlorperazine (Compazine)

Prochlorperazine (Compazine)

Antacids

Class Summary

Ranitidine (Zantac)

Ranitidine (Zantac)

Stool softeners

Class Summary

Docusate sodium (Colace, Dialox, Surfak, Regulax, Sulfalax)

Docusate sodium (Colace, Dialox, Surfak, Regulax, Sulfalax)

Cerebral Aneurysms Medication

Medication Summary

Calcium channel blockers

Class Summary

Nimodipine (Nimotop)

Antiepileptics

Class Summary

Fosphenytoin (Cerebyx)

Antihypertensives

Class Summary

Labetalol (Normodyne, Trandate)

Hydralazine (Apresoline)

Analgesics

Class Summary

Morphine sulfate (MSIR, Duramorph, Astramorph, MS Contin)

Antiemetics

Class Summary

Prochlorperazine (Compazine)

Antacids

Class Summary

Ranitidine (Zantac)

Stool softeners

Class Summary

Docusate sodium (Colace, Dialox, Surfak, Regulax, Sulfalax)

References

Tables

Contributor Information and Disclosures

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