What is the recommended treatment approach for a 50-year-old patient with two newly diagnosed aneurysms, presenting with dizziness and hypotension?

Management of Symptomatic Aneurysms with Hypotension

This patient requires immediate surgical evaluation and urgent aneurysm repair regardless of aneurysm size, as the combination of dizziness and low diastolic blood pressure in the context of newly diagnosed aneurysms represents symptomatic disease that mandates emergent intervention. 1

Immediate Assessment and Stabilization

Clinical Evaluation Priority

• The clinical triad of symptoms (dizziness), presence of aneurysms, and hypotension (low DBP) constitutes a surgical emergency requiring immediate evaluation. 1
• Dizziness in this context may represent sentinel bleeding, impending rupture, or hemodynamic instability from contained rupture. 1
• Obtain immediate non-contrast head CT to rule out subarachnoid hemorrhage, as this is the gold standard for detecting acute bleeding. 1

Blood Pressure Management Strategy

• Between symptom onset and aneurysm obliteration, blood pressure must be controlled with a titratable agent to balance stroke risk, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. 1
• Place an arterial line for continuous beat-to-beat blood pressure monitoring rather than intermittent cuff measurements, as precise control is essential. 2
• Target systolic BP <160 mmHg while strictly avoiding hypotension (MAP >65 mmHg), using short-acting titratable agents. 2, 3
• Use nicardipine (starting at 5 mg/hr, titrating by 2.5 mg/hr every 15 minutes) or clevidipine as first-line agents for gradual BP reduction. 2
• Labetalol or esmolol are acceptable alternatives; avoid sodium nitroprusside due to its tendency to raise intracranial pressure. 2

Urgent Diagnostic Workup

Imaging Protocol

• If head CT is negative for hemorrhage, proceed immediately to digital subtraction angiography (DSA) with 3-dimensional rotational angiography to characterize aneurysm anatomy and plan treatment. 1
• DSA is indicated for detection and treatment planning to determine whether aneurysms are amenable to coiling or require microsurgery. 1
• CTA head with IV contrast is an acceptable alternative if DSA is not immediately available. 1

Definitive Treatment Approach

Timing of Intervention

• Surgical clipping or endovascular coiling should be performed as early as feasible to reduce the rate of rebleeding after symptom onset. 1
• Emergency treatment protocols demonstrate that starting catheter angiogram at median 2.0 hours from admission and coiling at 2.9 hours significantly reduces in-hospital rebleeding (2.1% vs 7.4%) and improves outcomes. 4
• The risk of early aneurysm rebleeding is high and associated with very poor outcomes, making urgent evaluation and treatment mandatory. 1

Treatment Modality Selection

• For ruptured or symptomatic aneurysms judged technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered as the preferred approach. 1
• Complete obliteration of both aneurysms is recommended whenever possible. 1
• Open or endovascular repair is indicated in patients who are good surgical candidates. 1

Critical Management Considerations

Common Pitfalls to Avoid

• Do not delay treatment for "medical optimization" in symptomatic patients—the rebleeding risk far outweighs procedural risks. 1, 4
• Avoid rapid BP fluctuations (>70 mmHg drop in 1 hour), which increase rebleeding risk and compromise cerebral perfusion. 2
• Do not assume dizziness is benign—in the context of known aneurysms, this represents a warning sign requiring emergent action. 1
• Maintain euvolemia with isotonic fluids; avoid hypotonic solutions that may worsen cerebral edema. 3

Perioperative Adjunctive Therapy

• Administer oral nimodipine 60 mg every 4 hours to all patients, as this improves neurological outcomes (though not vasospasm specifically). 1
• Perioperative beta-adrenergic blocking agents are indicated to reduce risk of adverse cardiac events in patients with coronary artery disease undergoing aneurysm repair. 1

Transfer Considerations

• If this facility performs <10 aneurysm cases per year, immediate transfer to a high-volume center (>35 cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and neuro-intensive care is strongly recommended. 1

Post-Treatment Surveillance

• Immediate post-procedure cerebrovascular imaging is recommended to identify remnants or recurrence requiring treatment. 1
• Periodic long-term surveillance imaging should be performed to monitor for endoleak and document aneurysm sac stability after endovascular repair. 1
• Follow-up vascular imaging should be individualized by timing and modality, with strong consideration for retreatment if clinically significant remnants develop. 1