From the Guidelines
For a patient with a history of cerebral aneurysms presenting with persistent dizziness, nausea, and headache, I strongly recommend urgent neuroimaging with CT angiography (CTA) of the head as the first-line imaging study, followed by MRI with MR angiography (MRA) if CTA is negative, as suggested by the most recent guidelines 1. This approach is crucial because the patient's symptoms could indicate a life-threatening condition such as subarachnoid hemorrhage, aneurysm growth, or new aneurysm formation. The use of CTA as the initial imaging study is supported by its ability to provide rapid assessment of vascular abnormalities and potential bleeding, as highlighted in the guidelines for the management of aneurysmal subarachnoid hemorrhage 1. Additionally, MRI with MRA offers superior soft tissue detail to evaluate for other neurological causes and should be considered if CTA is negative, as recommended in the guidelines for the management of patients with unruptured intracranial aneurysms 1. Laboratory tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation studies (PT/INR, PTT), and inflammatory markers (ESR, CRP), should also be conducted to assess for infection, electrolyte abnormalities, or other systemic issues that might contribute to symptoms, in line with the principles outlined in the Canadian Stroke Best Practice Recommendations 1. A lumbar puncture may be necessary if imaging is negative but clinical suspicion for subarachnoid hemorrhage remains high, emphasizing the importance of a thorough diagnostic approach in such cases. Given the potential severity of these conditions, this workup should be conducted urgently, prioritizing the patient's safety and the need for immediate intervention if necessary.
From the Research
Imaging Studies
To evaluate the patient's condition, the following imaging studies can be considered:
- Noncontrast CT scan to establish the diagnosis of subarachnoid hemorrhage (SAH) 2
- Conventional contrast angiography, which is the gold standard for establishing the presence of intracranial aneurysms 2
- Magnetic Resonance Angiography (MRA) to detect unruptured intracranial aneurysms, with 3D time-of-flight (3D-TOF) and contrast-enhanced (CE-MRA) MRA having similar diagnostic accuracy 3
- CT angiography (CTA) to detect cerebral aneurysms in subarachnoid hemorrhage, with a sensitivity of 62% and specificity of 91% for detecting aneurysms of any size 4
- Brain computed tomography angiographic scans as the sole diagnostic examination for excluding aneurysms in patients with perimesencephalic subarachnoid hemorrhage 5
Laboratory Studies
There is no specific laboratory study mentioned in the provided evidence that is directly relevant to the patient's condition. However, laboratory studies may be ordered to rule out other potential causes of the patient's symptoms, such as:
- Complete blood count (CBC) to evaluate for infection or inflammation
- Electrolyte panel to evaluate for electrolyte imbalances
- Liver function tests to evaluate for liver disease
Additional Considerations
The patient's symptoms of persistent dizziness, nausea, and headache, along with a history of cerebral aneurysms, suggest the need for further evaluation to rule out aneurysmal rupture or other complications. The choice of imaging study will depend on the patient's clinical presentation and the availability of imaging modalities. It is essential to consider the patient's overall clinical picture and medical history when ordering imaging and laboratory studies 6