What are the guidelines for managing a patient with a ruptured left posterior communicating artery (PCA) aneurysm and an unruptured ophthalmic artery aneurysm?

Management of Ruptured Left Posterior Communicating Artery Aneurysm with Unruptured Ophthalmic Aneurysm

The ruptured left posterior communicating artery aneurysm requires emergency treatment within 2-3 hours of admission via either endovascular coiling or surgical clipping to prevent rebleeding, while the unruptured ophthalmic aneurysm should be addressed during the same intervention if technically feasible, or managed with close surveillance if treatment would significantly increase procedural risk. 1

Immediate Management of the Ruptured PComA Aneurysm

Timing of Intervention

• Emergency treatment should be initiated within 2-3 hours of admission to minimize the risk of catastrophic rebleeding, which carries the highest mortality. 2
• Catheter angiography should begin within 2 hours of admission, with definitive treatment (coiling or clipping) started within 3 hours. 2
• This emergency protocol reduces in-hospital rebleeding from 7.4% to 2.1% and improves favorable outcomes (mRS 0-3) from 79.7% to 87.9% at 1 month. 2

Treatment Modality Selection for Ruptured PComA

• Endovascular coiling should be considered as first-line treatment for the ruptured PComA aneurysm if technically amenable to both approaches, as it offers lower procedural morbidity and mortality. 1
• The multidisciplinary team (experienced cerebrovascular surgeon and endovascular specialist) must make this determination based on aneurysm characteristics, patient age, and clinical grade. 1
• Surgical clipping may receive increased consideration if the patient is young (<60 years), has good clinical grade, or if simultaneous treatment of both aneurysms is planned. 1

Adjunctive Medical Management

• Nimodipine should be administered to reduce the incidence and severity of ischemic deficits following subarachnoid hemorrhage, regardless of clinical grade (Hunt and Hess I-V). 3

Management of the Unruptured Ophthalmic Aneurysm

Decision Framework for Concurrent Treatment

If the patient has good clinical grade (WFNS I-III) and the ophthalmic aneurysm is >7mm:

• Strong consideration should be given to treating both aneurysms during the same procedure if technically feasible without significantly increasing risk. 1
• This approach prevents future rupture risk and eliminates the need for a second intervention. 1

If the patient has poor clinical grade (WFNS IV-V) or the ophthalmic aneurysm is <7mm:

• Secure only the ruptured PComA aneurysm emergently. 1
• Defer treatment of the small ophthalmic aneurysm and manage with surveillance imaging. 1
• The 5-year rupture risk for anterior circulation aneurysms <7mm without prior SAH is approximately 0.5% per year, making observation reasonable in this acute setting. 1

Treatment Considerations Specific to Ophthalmic Aneurysms

For symptomatic ophthalmic aneurysms (causing visual symptoms):

• Surgical clipping is preferred over endovascular treatment because aneurysm sac decompression may relieve optic nerve compression and restore vision. 4
• Endovascular coiling of large ophthalmic aneurysms may fail to decompress the optic apparatus and can lead to continued aneurysm growth despite treatment. 4

For asymptomatic ophthalmic aneurysms:

• If >7mm in a patient <65 years old, treatment is recommended given the higher rupture risk. 1
• Endovascular treatment with flow-diverting stents may be considered for uncoilable lesions, though this requires dual antiplatelet therapy. 5
• If 5-7mm, factors including patient age, aneurysm morphology, and family history should guide decision-making. 1

Post-Treatment Surveillance Protocol

Immediate Post-Procedure Assessment

• Complete aneurysm obliteration should be documented immediately after treatment for both aneurysms. 1
• Any residual filling or neck remnant requires documentation to guide surveillance frequency. 1

Long-Term Follow-Up Strategy

For clipped aneurysms:

• Delayed follow-up vascular imaging is mandatory, with timing and modality individualized based on completeness of obliteration. 1
• Long-term surveillance is particularly important for incompletely obliterated aneurysms given risk of recurrence and de novo aneurysm formation. 1

For coiled aneurysms:

• Close long-term surveillance is warranted due to durability concerns, with aneurysm regrowth or recurrence occurring in 24.4% of cases. 1
• Retreatment should be strongly considered if clinically significant (growing) remnants develop, using either repeat coiling or microsurgical clipping. 1
• For PComA aneurysms specifically, delayed recurrence of third nerve palsy may indicate aneurysm refilling requiring additional treatment. 6

Critical Pitfalls to Avoid

• Do not delay treatment of the ruptured aneurysm beyond 24 hours, as rebleeding risk is highest in this period and carries 50-80% mortality. 1, 2
• Do not choose endovascular treatment for large ophthalmic aneurysms causing visual symptoms, as coiling may fail to decompress the optic nerve and can lead to continued growth requiring complex salvage procedures. 4
• Do not use flow-diverting stents in the acute SAH setting due to the mandatory dual antiplatelet therapy requirement, which significantly increases hemorrhagic complications. 1
• Do not assume complete obliteration without imaging confirmation, as incomplete treatment significantly increases rebleeding risk and necessitates more frequent surveillance. 1
• Treatment should be performed at high-volume centers (>20 cases annually) where outcomes are superior for both ruptured and unruptured aneurysms. 1