Learning objectives

• Describe the mechanisms of aneurysms and hemorrhage
• Describe the risk factors for aneurysms
• Recognize and treat aneurysmal hemorrhage
• Manage patients undergoing endovascular coiling

Definition & mechanisms

• Stroke is the second leading cause of death and the third most common cause of disability worldwide
• Hemorrhagic strokes account for about 32% of all strokes globally and can be caused by subarachnoid hemorrhage or intracerebral hemorrhage
• Most spontaneous (nontraumatic) subarachnoid hemorrhages are caused by ruptured saccular aneurysms
• Intracranial aneurysms are estimated to occur with a prevalence of 3.2% in the general population
• Aneurysmal subarachnoid hemorrhage accounts for approximately 5% of strokes and is caused by the rupture of an intracranial aneurysm, an acquired focal abnormal dilation of an arterial wall

Aneurysm risk factors 

• Smoking
• Hypertension
• Connective tissue disorders
• Autosomal dominant polycystic kidney disease
• Ehlers–Danlos syndrome type IV
• Neurofibromatosis type 1
• Marfan syndrome 
• Coarctation of the aorta
• Genetic predisposition

Hemorrhage: Signs & symptoms

• Sudden onset of “worst headache of life”
• Loss of consciousness
• Nausea and/or vomiting
• Nuchal rigidity
• Photophobia
• Seizure

Hemorrhage treatment

• Immediate management: Directed at stabilizing life-threatening conditions, minimizing neurologic injury, optimizing physiology and planning definitive care
  • Ensure a patent airway and adequate oxygenation and ventilation
  • External ventricular drain 
  • Control acute hypertension 
  • Control of headache with analgesics, anxiolysis, and bed rest
  • Stop and reverse anticoagulant therapy
  • Administer nimodipine (60mg orally or by nasogastric tube every 4h, starting within 48h of hemorrhage and continued for 21 days)
• Definitive care
  • Surgical clipping or endovascular coiling

Endovascular coiling: Anesthetic management

ICP, intracranial pressure; CPP, cerebral perfusion pressure

Keep in mind

• The optimal anesthetic technique depends on patient characteristics, severity of the aneurysm, and monitoring

Suggested reading

• Deepak Sharma; Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology 2020; 133:1283–1305
• Campos JK, Lien BV, Wang AS, Lin LM. Advances in endovascular aneurysm management: coiling and adjunctive devices. Stroke Vasc Neurol. 2020;5(1):14-21. Published 2020 Mar 15.
• Abd-Elsayed AA, Wehby AS, Farag E. Anesthetic management of patients with intracranial aneurysms. Ochsner J. 2014;14(3):418-425.