What are the treatment guidelines for brain aneurysms?

From the Guidelines

For ruptured brain aneurysms, endovascular coiling is now recommended over surgical clipping to improve 1-year patient outcomes, as stated in the 2023 guidelines for the management of patients with aneurysmal subarachnoid hemorrhage 1.

Key Considerations

• The decision between endovascular coiling and surgical clipping should be made based on patient-specific characteristics, including age, clinical grade, size, and location of the aneurysm.
• A multidisciplinary discussion involving experienced cerebrovascular surgeons and endovascular specialists is crucial in determining the best treatment approach for each patient.
• For patients with ruptured aneurysms that are not amenable to coiling or where there is equipoise, a multidisciplinary discussion considering both surgical and endovascular approaches should be considered.

Treatment Options

• Endovascular coiling: This involves using platinum coils inserted through blood vessels to fill the aneurysm and promote clotting.
• Surgical clipping: This involves placing a metal clip across the aneurysm's neck to prevent blood flow into it.

Additional Recommendations

• Immediate treatment is necessary for ruptured aneurysms, including medications to prevent vasospasm, control blood pressure, and manage increased intracranial pressure.
• Anti-seizure medications may be used prophylactically in the short term.
• Pain management typically includes acetaminophen and opioids as needed, while avoiding NSAIDs due to bleeding risk.

Importance of Recent Guidelines

The 2023 guidelines 1 provide the most recent and highest quality evidence for the management of brain aneurysms, superseding previous guidelines such as those from 2012 1 and 2009 1, and should be prioritized in clinical decision-making to ensure the best possible outcomes for patients.

From the FDA Drug Label

Nimodipine is indicated for the improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms regardless of their post-ictus neurological condition (i.e., Hunt and Hess Grades I to V) 2 The recommended oral dose is 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days 2

The treatment guidelines for brain aneurysms include the administration of nimodipine to improve neurological outcomes by reducing the incidence and severity of ischemic deficits. The recommended dose is 60 mg every 4 hours for 21 consecutive days.

• The treatment should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage.
• Oral administration is preferred, and the capsules should be swallowed whole with a little liquid.
• In cases where the capsule cannot be swallowed, the contents can be extracted and administered through a naso-gastric tube.
• Patients with severely disturbed liver function may require a reduced dose of one 30 mg capsule every 4 hours.
• Patients on CYP3A4 inhibitors or inducers should be closely monitored for lack of effectiveness or hypotension, and a nimodipine dose adjustment may be required. 2

From the Research

Treatment Guidelines for Brain Aneurysms

The treatment of brain aneurysms depends on various factors, including the size, location, and rupture status of the aneurysm. The following are some general guidelines for the treatment of brain aneurysms:

• Endovascular Coiling: This is a minimally invasive procedure where a catheter is inserted into the artery and guided to the aneurysm, where coils are deployed to block blood flow into the aneurysm 3, 4.
• Surgical Clipping: This is a surgical procedure where a clip is placed at the base of the aneurysm to prevent blood flow into the aneurysm 3, 4.
• Embolization: This is a procedure where a catheter is inserted into the artery and guided to the aneurysm, where a material is deployed to block blood flow into the aneurysm 5, 6.

Factors Influencing Treatment Choice

The choice of treatment depends on various factors, including:

• Aneurysm Size: Larger aneurysms are more likely to be treated with surgical clipping or embolization 6.
• Aneurysm Location: Aneurysms located at the basilar artery bifurcation are preferably treated with endovascular means 7.
• Rupture Status: Ruptured aneurysms require immediate treatment to prevent rebleeding and vasospasm 5, 7.

Treatment Outcomes

The outcomes of brain aneurysm treatment vary depending on the treatment modality and patient factors. Studies have shown that:

• Endovascular Coiling: Has a lower risk of complications and mortality compared to surgical clipping 4.
• Surgical Clipping: Has a higher risk of complications and mortality compared to endovascular coiling, but may be more effective in preventing rebleeding 3, 4.
• Embolization: Has a high success rate in occluding the aneurysm, but may have a higher risk of recanalization 6.