What is the management approach for a 55-year-old female with a ruptured aneurysm leading to subarachnoid hemorrhage and symptoms of recurrent headache?

Management of Ruptured Aneurysm with Subarachnoid Hemorrhage in a 55-Year-Old Female

The management of a ruptured aneurysm causing subarachnoid hemorrhage (SAH) requires immediate evaluation and urgent treatment to secure the aneurysm, preferably within 24 hours of presentation, to prevent rebleeding and improve outcomes. 1

Initial Diagnosis and Assessment

• The cornerstone of SAH diagnosis is a non-contrast cranial CT scan, which has 98-100% sensitivity in the first 12 hours after hemorrhage 2
• If CT is negative but clinical suspicion remains high, lumbar puncture should be performed to look for xanthochromia or bilirubin in the cerebrospinal fluid 2
• The severity of the initial bleed should be rapidly determined using validated scales such as Hunt and Hess or World Federation of Neurological Societies scale, as this is the most useful indicator of outcome 2, 3
• Cerebral angiography (digital subtraction angiography with 3D reconstruction) is indicated to detect the aneurysm and plan treatment 2, 3

Acute Management

• Secure the aneurysm as early as possible (ideally within 24 hours) to prevent rebleeding, which carries a mortality rate of 70% 1, 3
• For posterior circulation aneurysms, endovascular coiling is preferred over surgical clipping 3, 4
• For anterior circulation aneurysms in good-grade patients, coiling is recommended to improve functional outcomes at 1 year 3, 4
• Administer nimodipine 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of SAH onset to reduce the incidence and severity of ischemic deficits 5
• If the patient cannot swallow, the nimodipine capsule can be punctured and the contents administered via nasogastric tube (NEVER administer intravenously) 5

Blood Pressure Management

• Control blood pressure with a titrable agent to balance the risk of stroke, rebleeding related to hypertension, and maintenance of cerebral perfusion pressure 3
• Gradual reduction of blood pressure is recommended in severely hypertensive patients, strictly avoiding hypotension 3

Management of Complications

Hydrocephalus

• Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion via external ventricular drain or lumbar drainage 3, 4
• Chronic symptomatic hydrocephalus requires permanent CSF shunting 3, 4

Vasospasm

• Monitor for vasospasm, which typically develops 3-14 days after hemorrhage 6
• Transcranial Doppler sonography and cerebral angiography can help assess the degree of vasospasm 6
• For symptomatic vasospasm after aneurysm securing, maintain euvolemia or hypervolemia and consider vasopressors to maintain cerebral perfusion 6

Seizures

• Seizures occur in up to 20% of patients after SAH, most commonly in the first 24 hours 2, 4
• Patients treated with endovascular coiling have a lower incidence of seizures compared to surgical clipping 4

Follow-up Care

• After aneurysm repair, immediate cerebrovascular imaging is recommended to identify remnants or recurrence that may require treatment 2, 3
• Long-term follow-up imaging is necessary, particularly for coiled aneurysms, which have higher rates of incomplete occlusion and recurrence 2, 4
• Patients with incompletely treated aneurysms should be considered for retreatment to prevent rebleeding 2, 3

Care Setting

• Patients should be treated in a high-volume center with experienced cerebrovascular surgeons and multidisciplinary neurointensive care services 3
• Low-volume hospitals should consider early transfer of SAH patients to specialized centers 3

Prognosis

• The risk of recurrent SAH from treated aneurysms remains non-zero even after 5 years, with endovascularly treated aneurysms having slightly higher rebleeding rates than surgically treated ones 2
• Patients with good clinical grades who receive emergency treatment have better outcomes and lower rebleeding rates compared to those with delayed treatment 1

The management of recurrent headaches in this patient should focus on treating the underlying SAH and securing the aneurysm, as these headaches may represent warning leaks or sentinel hemorrhages that precede catastrophic rupture 2.