What is the management for a stroke due to a ruptured aneurysm?

Management of Stroke Due to Ruptured Aneurysm

The ruptured aneurysm must be secured emergently—within 24 hours of presentation—using either endovascular coiling or surgical clipping, with coiling preferred for good-grade anterior circulation aneurysms and mandatory for posterior circulation aneurysms, followed by immediate initiation of nimodipine 60 mg every 4 hours for 21 days. 1, 2

Immediate Aneurysm Securing (Priority #1)

Timing of Intervention

• Treat the ruptured aneurysm as soon as feasible, ideally within 24 hours of symptom onset to reduce rebleeding risk, which carries 50-80% mortality if untreated 1, 3
• Emergency treatment protocols demonstrate significantly reduced in-hospital rebleeding rates (2.1% vs 7.4%) and improved outcomes compared to delayed treatment 3
• Early treatment (<24 hours) shows superior outcomes compared to treatment >24 hours from ictus, though the difference between <24 hours and 24-72 hours is less pronounced 1

Treatment Modality Selection

For anterior circulation aneurysms in good-grade patients (Hunt-Hess I-III):

• Primary coiling is recommended over clipping to improve 1-year functional outcome 1
• Both modalities are reasonable for long-term outcomes, but coiling shows better short-term results 1

For posterior circulation aneurysms:

• Coiling is mandatory over clipping (relative risk 0.41 for death/dependency with coiling vs clipping) 1

For patients with large intraparenchymal hematoma causing depressed consciousness:

• Emergency surgical clot evacuation with concomitant aneurysm clipping should be performed immediately to reduce mortality (27% vs 80% with conservative management) 1
• This applies specifically to patients with spontaneous respiration and pain response despite severely decreased consciousness 1

For wide-neck aneurysms not amenable to primary coiling or clipping:

• Stent-assisted coiling or flow diverters are reasonable options 1
• However, avoid stents/flow diverters for standard saccular aneurysms amenable to primary coiling or clipping due to higher complication risk 1

Completeness of Obliteration

• The goal is complete aneurysm obliteration whenever technically feasible 1
• Incomplete obliteration carries substantially higher rebleeding risk (requires retreatment within 1-3 months) 1
• If complete obliteration is not feasible, partial treatment securing the rupture site is reasonable acutely, with planned retreatment after functional recovery 1

Medical Management (Priority #2)

Nimodipine Administration

• Administer nimodipine 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of SAH onset 4, 2
• This is FDA-approved and reduces the incidence and severity of ischemic deficits regardless of Hunt-Hess grade 2
• Nimodipine improves neurological outcomes even though it does not prevent arteriographic vasospasm 2

Blood Pressure Management

• Control blood pressure with titratable agents to balance stroke risk, rebleeding risk, and cerebral perfusion pressure maintenance 4
• For severely hypertensive patients, reduce blood pressure gradually while strictly avoiding hypotension 4
• Aggressive blood pressure reduction before aneurysm securing increases rebleeding risk 1

Management of Acute Complications

Hydrocephalus

• Acute symptomatic hydrocephalus requires immediate cerebrospinal fluid diversion via external ventricular drain or lumbar drainage 1, 4, 5
• Chronic symptomatic hydrocephalus requires permanent CSF diversion (ventriculoperitoneal shunt) 1, 4, 5

Delayed Cerebral Ischemia (DCI)

• Early aneurysm securing facilitates aggressive treatment of DCI 1
• Nimodipine is the primary pharmacologic intervention for DCI prevention 2

Seizures

• Seizure incidence ranges from 6-18% after aneurysmal SAH 5
• Risk factors include middle cerebral artery aneurysms, thick SAH clot, intracerebral hematoma, rebleeding, infarction, poor neurological grade, and hypertension history 5
• Endovascular coiling has lower seizure incidence than surgical clipping 5

Post-Treatment Surveillance

Immediate Post-Procedure Imaging

• Perioperative cerebrovascular imaging is mandatory to identify aneurysm remnants or recurrence requiring further treatment 1, 4, 5
• Incompletely occluded aneurysms have higher short-term rebleeding risk (1.9% at 30 days for endovascular treatment) 1

Long-Term Follow-Up

• Follow-up cerebrovascular imaging is required to detect recurrence, regrowth, changes in other aneurysms, or de novo aneurysm formation 1, 4
• Coiled aneurysms have higher recurrence rates than clipped aneurysms and require more frequent surveillance 1
• Even completely obliterated aneurysms carry long-term rerupture risk (0.5% at >5 years for endovascular treatment) 1

Critical Pitfalls to Avoid

• Never delay aneurysm treatment beyond 24 hours unless medically unstable 1, 3
• Never use surgical clipping for posterior circulation aneurysms amenable to coiling 1
• Never omit nimodipine administration 4, 2
• Never aggressively lower blood pressure before aneurysm securing 4
• Never skip immediate post-procedure angiography to verify complete obliteration 1, 5

Systems of Care Considerations

• Transfer patients from low-volume hospitals to high-volume centers with experienced cerebrovascular surgeons and neurointerventionalists 1, 4
• Care should be provided in neurointensive care units by multidisciplinary teams 4
• Both endovascular and surgical options must be available for optimal outcomes 1