What is the recommended treatment for a patient diagnosed with a saccular aneurysm?

Management of Saccular Aneurysms

For patients with saccular aneurysms, endovascular coiling should be considered as the first-line treatment when technically feasible, particularly for ruptured aneurysms, as it is associated with better neurological outcomes compared to surgical clipping. 1

Diagnostic Approach

When a saccular aneurysm is suspected:

1. Initial imaging:

   • Non-contrast head CT as first-line imaging 1
   • If CT is negative but clinical suspicion remains high, perform lumbar puncture 1
   • Xanthochromia evaluation (most sensitive after 12 hours from headache onset) 1

2. Vascular imaging:

   • High-quality CTA is preferable initially 1
   • Digital subtraction angiography (DSA) with 3D rotational angiography if CTA is negative or for definitive treatment planning 1

3. Clinical assessment:

   • Determine severity using validated scales: World Federation of Neurological Surgeons (WFNS), Hunt and Hess, or Fisher Scale 1

Treatment Algorithm

For Ruptured Saccular Aneurysms:

1. Initial stabilization:

   • Transfer to high-volume center (>35 aSAH cases/year) with experienced cerebrovascular surgeons and endovascular specialists 1, 2
   • Control blood pressure with titratable agents to prevent rebleeding while maintaining cerebral perfusion 1
   • Start nimodipine within 96 hours of SAH and continue for 14-21 days 1, 3

2. Definitive treatment:

   • Secure aneurysm urgently within 24-48 hours 1
   • Endovascular coiling is preferred when technically feasible 1, 4
   • Surgical clipping may be more appropriate for:
     • Large (>50 mL) intraparenchymal hematomas 1
     • Middle cerebral artery aneurysms 1, 2
     • Very small aneurysms (≤3 mm) that may be technically challenging for coiling 5

3. Management of complications:

   • Place external ventricular drain for symptomatic hydrocephalus 1
   • Maintain euvolemia to prevent vasospasm 1
   • For symptomatic vasospasm, use induced hypertension (if aneurysm is secured) 1

For Unruptured Saccular Aneurysms:

Treatment decision should consider:

• Aneurysm size and location
• Patient age and health status
• Morphological and hemodynamic characteristics 1

Post-Treatment Management

1. Immediate post-procedure:

   • Perform immediate cerebrovascular imaging to identify remnants 1, 2
   • Complete obliteration should be the goal 1

2. Follow-up:

   • Schedule delayed vascular imaging (timing individualized) 1
   • Consider retreatment if clinically significant remnant is detected 1

Outcomes and Prognosis

• Endovascular coiling is associated with a 7% absolute risk reduction in poor outcomes compared to surgical clipping 4
• The benefit of coiling is even greater for posterior circulation aneurysms (27% absolute risk reduction) 4
• Saccular morphology itself may indicate higher rupture risk compared to fusiform aneurysms 6, 7

Important Considerations

• Multidisciplinary decision-making between experienced cerebrovascular surgeons and endovascular specialists is essential 1
• The location of the aneurysm significantly impacts treatment choice and outcomes
• Smaller aneurysms (≤3 mm) may still require surgical clipping due to technical limitations of coiling 5
• Eccentric saccular aneurysms result from focal weakness of the arterial wall and may have higher rupture risk 6

Pitfalls to Avoid

• Delaying treatment of ruptured aneurysms increases rebleeding risk 1
• Failing to transfer patients to high-volume centers with experienced teams 1, 2
• Overlooking the need for follow-up imaging to detect aneurysm recurrence 1
• Not starting nimodipine promptly for patients with subarachnoid hemorrhage 1, 3
• Using hypervolemia for vasospasm prevention (euvolemia is recommended) 1