Review Question - QID 106404

Vasospam, secondary to the inflammatory response, is an important complication of ruptured aneurysms, as seen in this patient. As a result, nimodipine, a calcium channel blocker, is an important part of therapy to prevent this complication.

Berry aneurysms form as a result of congenital weaknesses in the blood vessels. They present with a sentinel bleed (subarachnoid hemorrhage or SAH) that is felt as the "worst headache" of the patient's life. Vomiting, signs of meningismus, cranial nerve palsies, and seizures can follow. Rebleed and vasospam are common complications over the next few days. Certain genetic conditions place individuals at increased risk of having them: Marfan syndrome, Ehlers-Danlos syndrome, autosomal dominant polycystic kidney disease (ADPKD), and neurofibromatosis type I, among others.

Vega et al. review current evidence and clinical practice surrounding intracranial aneurysms. Notably, despite a relatively high prevalence in the general population (around 6%), screening for unruptured aneurysms is controversial, as the interventions are not benign and many aneurysms may never rupture. The two groups that may benefit from early screening are those with a history of aneurysmal subarachnoid hemorrhage and those with ADPKD.

Molyneux et al. undertook a randomized controlled trial - International Subarachnoid Aneurysm Trial (ISAT) - to assess outcomes in patients (n = 2143) assigned to either surgical clipping or endovascular coiling from 1994 to 2002. In this 2009 paper, they assess the long term outcomes of these groups. After a mean follow-up of 9 years, they found that those with a coiled aneurysm were at higher risk of rebleeding than those with a clipped one, but that the risk of death at 5 years out was lower in the coiled group.

Figure A shows a subarachnoid hemorrhage (SAH) as seen on CT (arrow points to the blood, which appears white on the image). Illustration A diagrams the frequency of various locations for saccular (berry) aneurysms. Note the the most common locations are in the Circle of Willis. Illustration B depicts the endovascular coiling procedure, which introduces the coil via a catheter introduced into an artery in the groin.

Incorrect answers:
Answer 1: Although the patient will certainly need to be admitted and closely observed, this alone is insufficient. Rebleeding is a common complication; as such, the patient will need to undergo either surgical clipping or endovascular coiling of the aneurysm.
Answer 2: Increased intracranial pressure (ICP) is a complication in aneurysms that should be managed with raising (not lowering) the head of the bed, treating hypertension, limiting fluids, and giving calcium channel blockers.
Answer 3: Permissive hypertension is part of the initial treatment for ischemic strokes, but in hemorrhagic strokes such as a ruptured aneurysm, blood pressure should be controlled to help control ICP.
Answer 5: Although nitroprusside would lower blood pressure, it also can increase ICP. As a result, calcium channel blockers are preferred for BP control.