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A CT scan should be performed immediately to confirm that hemorrhage has occurred and to search for clues regarding its source It is preferable to MRI because it is faster and more sensitive in detecting hemorrhage in the first 24 hours CT findings sometimes are normal in patients with suspected hemorrhage, and the cerebrospinal fluid must then be examined for the presence of blood or xanthochromia before the possibility of subarachnoid hemorrhage is discounted Cerebral arteriography may be undertaken to determine the source of bleeding; it is not performed unless or until the patient s condition has stabilized and is good enough so that operative treatment is feasible In general, bilateral carotid and vertebral arteriography are necessary because aneurysms are often multiple, while arteriovenous malformations may be supplied from several sources MR angiography may also permit these vascular anomalies to be visualized but is less sensitive than conventional arteriography
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The measures outlined below in the section on stupor and coma are applied to comatose patients Conscious patients are confined to bed, advised against any exertion or straining, treated symptomatically for headache and anxiety, and given laxatives or stool softeners If there is severe hypertension, the blood pressure can be lowered gradually, but not below a diastolic level of 100 mm Hg Phenytoin is generally prescribed routinely to prevent seizures Further comment concerning the specific operative management of arteriovenous malformations and aneurysms follows
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The CT scan generally confirms that subarachnoid hemorrhage has occurred, but occasionally it is normal Angiography (bilateral carotid and vertebral studies) generally indicates the size and site of the lesion, sometimes reveals multiple aneurysms, and may show arterial spasm If subarachnoid hemorrhage is confirmed by lumbar puncture or CT scanning but arteriograms show no abnormality, the examination should be repeated after 2 weeks, because vasospasm may have prevented detection of an aneurysm during the initial study
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Subarachnoid hemorrhage or focal deficit Abnormal imaging studies
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The cerebrospinal fluid is bloodstained The electroencephalogram sometimes indicates the side or site of hemorrhage but frequently shows only a diffuse abnormality Electrocardiographic evidence of arrhythmias or myocardial ischemia has been well described and probably relates to excessive sympathetic activity Peripheral leukocytosis and transient glycosuria are also common findings
General Considerations
Saccular aneurysms ( berry aneurysms) tend to occur at arterial bifurcations, are frequently multiple (20% of cases), and are usually asymptomatic They may be associated with polycystic kidney disease and coarctation of the aorta Risk factors for aneurysm formation include smoking, hyperten-
Treatment
The major aim of treatment is to prevent further hemorrhages Definitive treatment requires surgical clipping of the aneurysm base or endovascular treatment (coil embolization) by inter-
CMDT 2008
ventional radiologists; the latter is sometimes feasible even for inoperable aneurysms Otherwise, medical management as outlined above for subarachnoid hemorrhage is continued for about 6 weeks and is followed by gradual mobilization The risk of further hemorrhage is greatest within a few days of the first hemorrhage; approximately 20% of patients will have further bleeding within 2 weeks and 40% within 6 months Attempts have been made to reduce this risk pharmacologically Treatment with an antifibrinolytic agent such as aminocaproic acid during the first 14 days reduces the risk of recurrent hemorrhage but is associated with such an increase in cerebral ischemic complications that the mortality rate and the degree of disability among survivors are unchanged Thus, early operation (ie, within about 2 days of hemorrhage) is preferred for good operative candidates Calcium channel-blocking agents have helped reduce or reverse experimental vasospasm, and nimodipine has been shown to reduce, in neurologically normal patients, the incidence of ischemic deficits from arterial spasm without producing any side effects The dose of nimodipine is 60 mg every 4 hours orally for 21 days After surgical obliteration of any aneurysms, symptomatic vasospasm may also be treated by intravascular volume expansion, induced hypertension, or transluminal balloon angioplasty of involved intracranial vessels; aspirin provides no benefit With regard to unruptured aneurysms, those that are symptomatic merit prompt treatment, either surgically or by endovascular coil embolization, whereas small asymptomatic ones discovered incidentally are often monitored arteriographically and corrected surgically only if they increase in size to over 10 mm
Doerfler A et al Endovascular treatment of cerebrovascular disease Curr Opin Neurol 2004 Aug;17(4):481 7 [PMID: 15247546] Molyneux AJ et al International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion Lancet 2005 Sep 3 9;366(9488):809 17 [PMID: 16139655] Nieuwkamp DJ et al Subarachnoid haemorrhage in patients 75 years: clinical course, treatment and outcome J Neurol Neurosurg Psychiatry 2006 Aug;77(8):933 7 [PMID: 16638789] Pouratian N et al Endovascular management of unruptured intracranial aneurysms J Neurol Neurosurg Psychiatry 2006 May;77(5):572 8 [PMID: 16614015]
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