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

Management of Stroke Due to Ruptured Aneurysm

Secure the ruptured aneurysm within 24 hours of symptom onset to prevent catastrophic rebleeding, which carries 50-80% mortality if the aneurysm remains unsecured. 1

Immediate Priorities: Aneurysm Securing (Within 24 Hours)

The primary goal is complete aneurysm obliteration, as incomplete treatment substantially increases rebleeding and retreatment risks. 2

Treatment Modality Selection

For anterior circulation aneurysms in good-grade patients:

• Endovascular coiling is recommended over surgical clipping to improve 1-year functional outcomes. 1
• Both treatment options require evaluation by specialists with expertise in endovascular and surgical techniques to optimize risk-benefit assessment. 2

For posterior circulation aneurysms:

• Coiling is mandatory over clipping, demonstrating a relative risk of 0.41 (95% CI 0.19-0.92) for death or dependency compared to surgical clipping. 2, 1

Critical exception - Large intracerebral hematoma with mass effect:

• If the patient has severely decreased consciousness but maintains spontaneous respiration and pain response, emergency surgical clot evacuation with concomitant aneurysm clipping reduces mortality from 80% to 27% and increases independent outcome from 20% to 53%. 2
• The need for rapid clot evacuation generally favors surgery without delay rather than coiling followed by delayed evacuation. 2

Timing Considerations

• Treatment within 24 hours from ictus demonstrates superior outcomes compared to >24 hours. 2
• The rebleeding risk is 3-4% in the first 24 hours (possibly higher), with many rebleeds occurring within 2-12 hours of initial rupture. 2
• If patients present during the 4-7 day window, treatment should not be postponed beyond the typical delayed cerebral ischemia period. 2

Medical Management (Initiated Immediately)

Nimodipine - The Only Proven Pharmacologic Intervention

Administer nimodipine 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of symptom onset, to reduce the incidence and severity of ischemic deficits. 1, 3

• This is FDA-approved for improving neurological outcomes in patients with subarachnoid hemorrhage from ruptured aneurysms regardless of Hunt and Hess grade (I-V). 3
• Nimodipine is the primary pharmacologic intervention for delayed cerebral ischemia prevention. 1

Blood Pressure Management

• Control blood pressure with titratable agents (avoid fixed-dose regimens) to balance three competing risks: stroke from hypoperfusion, rebleeding from hypertension, and maintenance of adequate cerebral perfusion pressure. 1
• Avoid aggressive blood pressure reduction before aneurysm securing. 1
• Once the aneurysm is secured, induced hypertension can be used if ischemic signs develop from vasospasm. 4

Management of Acute Complications

Hydrocephalus

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

Delayed Cerebral Ischemia (Days 4-14)

• Early aneurysm securing facilitates aggressive treatment of delayed cerebral ischemia without rebleeding risk. 1
• Cerebral vasospasm can cause delayed ischemic stroke days after the initial hemorrhage, presenting identically to other stroke causes. 5
• Critical pitfall: Do NOT administer thrombolytics or anticoagulants if stroke symptoms develop after SAH, as this can cause catastrophic rebleeding from an unsecured aneurysm. 5
• Maintain euvolemia and induce hypertension if ischemic signs occur; consider endovascular therapy for patients with continued ischemia despite induced hypertension. 4

Post-Treatment Surveillance

Immediate perioperative cerebrovascular imaging is mandatory to identify aneurysm remnants or recurrence requiring further treatment. 1

• If complete obliteration was not feasible initially, retreatment within 1-3 months is advisable to prevent future rebleeding. 2
• Long-term follow-up imaging is required to detect recurrence, regrowth, changes in other aneurysms, or de novo aneurysm formation. 1

Systems of Care

Transfer patients from low-volume hospitals to high-volume centers with experienced cerebrovascular surgeons, neurointerventionalists, and neurointensive care units staffed by multidisciplinary teams. 1

• The evaluation and treatment of ruptured aneurysms requires specialists with expertise in both endovascular and surgical techniques, either individually or as a team. 2
• Care should be provided in neurointensive care units by multidisciplinary teams to optimize outcomes. 1

Key Clinical Pitfalls to Avoid

• Misdiagnosis occurs in 12-64% of SAH cases, most commonly from failure to obtain non-contrast head CT when patients present with severe headache. 2
• Misdiagnosis is associated with nearly 4-fold higher likelihood of death or disability at 1 year. 2
• Never delay aneurysm treatment in patients presenting during the vasospasm period (days 4-14) - secure the aneurysm to enable aggressive vasospasm management. 2
• Approximately 20% of patients report a sentinel headache before major rupture - take these warnings seriously. 2