Cerebral aneurysms have a prevalence of 3.2%. The majority are diagnosed incidentally and are asymptomatic. However they can be a focus for seizures and are at risk of rupture causing subarachnoid haemorrhage.
Incidental asymptomatic aneurysms can be managed conservatively or can be treated by endovascular coiling or neurosurgical clipping. Risks of rupture whilst being managed conservatively need to be weighed up against the perioperative risks of coiling or clipping.
Treated unruptured aneurysms have a good prognosis. However subarachnoid haemorrhage following aneurysm rupture is associated with significant morbidity and mortality (50% within 4 weeks). Re-bleeding, vasospasm, hydrocephalus, cardiovascular instability and electrolyte abnormalities are all potential complications.
Treatment of ruptured aneurysms focusses on rapidly securing the aneurysm whilst minimising and treating these complications. Aneurysms can be secured via interventional coiling or surgical clipping. Coiling is associated with reduced risk of mortality and dependency but with a higher risk of rebleeding.
Anaesthetic considerations for coiling or clipping include reducing risk of aneurysm rupture/rebleed, reducing the risk of secondary brain damage, management of aneurysm rupture if it does occur and optimising surgical operating conditions with brain relaxation.
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Vlaq MHM, Algra A, Brandenburg R, Rinkel GJ. The Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country and time period: a systemic review and meta-analysis. Lancet Neurol. 2011;10:626–36.CrossRefGoogle Scholar
Vernooij MW, Arfan Ikram M, Tanghe HL, et al. Incidental findings on brain MRI in the general population. N Engl J Med. 2007;357:1821–8.CrossRefPubMedGoogle Scholar
Keedy A. An overview of intracranial aneurysms. Mcgill J Med. 2006;9(2):141–6.Google Scholar
Lecours M, Gelb AW. Anesthesia for the surgical treatment of cerebral aneurysms. Rev Colomb Anestesiol. 2015;43(Supl1):45–51.Google Scholar
Al-Shahi R, White PM, Davenport RJ, Lindsay KW. Subarachnoid haemorrhage. Br Med J. 2006;333:235–40.CrossRefGoogle Scholar
Wermer MJ, van der Schaaf IC, Algra A, Rinkel GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. Stroke. 2007;38(4):1404–10. Epub 2007 Mar 1.CrossRefPubMedGoogle Scholar
Teasdale GM, Drake CG, Hunt W, et al. A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry. 1988;51(11):1457.CrossRefPubMedPubMedCentralGoogle Scholar
Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6(1):1–9.CrossRefPubMedGoogle Scholar
de Gans K, Nieuwkamp DJ, Rinkel GJ, et al. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery. 2002;50(2):336–40; discussion 340–2.PubMedGoogle Scholar
Molyneux A, Kerr R, Stratton I, Sandercock P, et al. International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74.CrossRefPubMedGoogle Scholar
Molyneux AJ, Kerr RS, Birks J. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009;8(5):427–33.CrossRefPubMedPubMedCentralGoogle Scholar
Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. Interv Neurol. 2013;2(1):30–51.CrossRefPubMedPubMedCentralGoogle Scholar
Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British Aneurysm Nimodipine Trial. BMJ. 1989;298:636–42.CrossRefPubMedPubMedCentralGoogle Scholar
Raabe A, Beck J, Keller M, et al. Relative importance of hypertension compared with hypervolemia for increasing cerebral oxygenation in patients with cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg. 2005;103:974–81.CrossRefPubMedGoogle Scholar
Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35:1844–51.CrossRefPubMedGoogle Scholar
Kim DH, Haney CL, van Ginhoven G. Reduction of pulmonary edema after SAH with a pulmonary artery catheter-guided hemodynamic management protocol. Neurocrit Care. 2005;3:11–5.CrossRefPubMedGoogle Scholar
Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355–65.CrossRefPubMedGoogle Scholar