Aneurysms
FACTS
- peak age 55-60 yo --> although 20% between 15-45 yrs
- 10-15% die befor getting care
CONSULT
HPI
Labs:
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FOCUSED EXAMHunt Hess calculator: HH/MF - XWiki Neck pain or lumbar back pain (more pertinent if sentinel bleed, from runoff gravity) More important in the unruptured setting vision exam (compressive optic neuropathy from Opth A --> nasal quadrantopsia) CN III exam facial pain evaluation |
IMGCTH non-con impossible to use this to diagnose aneurysm location, however there are some patterns:
CTA H&N:
CT C-spine - should be included on CTA H&N, but this is necessary to clear a C-collar which is often placed when a person is found down after rupture MRA will not be more useful than CTA, however can be done if patient has a real and serious allergy to contrast or whatever contraindication. Pretty poor sensitivity for aneurysms < 3mm in diameter |
A/PI. Acute management - HOB > 30 - Clear C-collar ASAP - Ventriculostomy as indicated: EVD at 20AMB, cannot drain to aggressively, you actually want the high ICP to "tamponade" the bleeding, SBP CAP at 140 - Ask CCM to place a Left radial a-line while you do the EVD to get ready for DSA II. Secure the aneurysm DSA vs. OR After securing aneurysm, EVD to 5 or 10, CAP liberalized III. Managing Spasm / Neuro ICU admission orders - Euvolemia: avoid hypotension, check IOs at 4am and 4pm, place foley if needed - SAH precautions: minimize stimulations - HA management: can be very intractable, steroids often the only thing that help if not other contraindications - HOB > 30 degrees - Nimotop 30q2 or 60q4 (more frequent = to avoid periodic dips in BP) - TCDs to monitor MCA, ACA, ICA velocities and Lindegaard ratio if available at your institution Angio negative SAH: repeat DSA or MRI Brain and pan-spine in about a week Spasm watch |
Sentinel Bleed workup without SAH
sometimes people have a thunderclap HA w/o clear SAH on a low-quality CT. These are managed as SAH until proven otherwise, especially if the patient has a known aneurysm
How to prove otherwise
1) MRI Brain w/wo contrast - higher definition picture to evaluate for presence of blood however this is not sensitive until 2-3 days post-bleed
+/- MRI pan-spine to evaluate for gravity dependent blood
2) Lumbar puncture: send CSF in 4 tubes, very important to be as atraumatic as possible
* if RBCs stable or downtrending from tubes 1-4 --> unlikely SAH
* if RBCs uptrending or xanthochromic supernatant --> more likely SAH
- if this is traumatic, its a useless test
- this is not without risk, if there is an actual ruptured aneurysm can precipitate rebleeding
- if a person is jaundiced, this can be false-positive
Specific Aneurysms
Cavernous Sinus Carotid Aneurysms
- For unruptured, most likely symptom is a CN6 palsy (closest proximity to abducens nerve in cavernous sinus)
- facial pain syndromes in the maxillary nerve distribution
Mycotic Aneurysms
Opthalmic Aneurysms
- may present with chiasmal syndrome
Acomm Aneurysms
- may present with chiasmal syndrome
Basilar Apex Aneurysms
- may present with chiasmal syndrome
P-comm Aneurysms
- 10% of these aneurysms p/w non-pupil sparing CN 3 palsy
Infundibulum vs Aneurysms
infundibulum = funnel shaped initial artery segment, most commonly at Pcomm origin
Associated Syndromes
PCKD
PCKD is associated with intracranial aneurysms, cervical arterial dissections, intracranial dolichoectasia, spinal meningeal diverticula
- general mechanism is abnormal collagen/proteoglycans produced --> weaken
Marfan Syndrome
Subarachnoid hemorrhage mimic
This is a very rare mimic of subarachnoid hemorrhage - if you see someone who is wide awake with what looks like a modified fisher 7 subarachnoid hemorrhage, ask them if they recently got a myelogram!
Intracranial accumulation of contrast agent after myelography | Radiology Case | Radiopaedia.org
Figure 1 - Saccular (berry) aneurysms and locations: most commonly at branch points. Fusiform aneurysms more common in vertebrobasilar system.