Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage

Abstract

Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.

Endovascular Management of Vertebrobasilar Trunk Artery Large Aneurysms: Complications and Long-Term Results

“…Flemming et al (12) studied the natural history of vertebrobasilar non-saccular aneurysms and found that the mortality and morbidity were 40 and 53% during the follow-up, respectively, with the median survival of 7.8 years. Due to the high risk of rupture and poor natural history of VBTLAs, once detected, it is important to individualize surgical intervention on the basis of the overall medical condition of the patient (1,(11)(12)(13). For patients with aneurysmal subarachnoid hemorrhage, aneurysm obliteration should be performed as soon as the patient is medically stabilized because of rebleeding (1,13).…”

“…Due to the high risk of rupture and poor natural history of VBTLAs, once detected, it is important to individualize surgical intervention on the basis of the overall medical condition of the patient (1,(11)(12)(13). For patients with aneurysmal subarachnoid hemorrhage, aneurysm obliteration should be performed as soon as the patient is medically stabilized because of rebleeding (1,13). In this study, the 5-year complication-free and overall cumulative survival rates were 82.0 and 89.8%, respectively, which indicated that the surgical intervention could benefit patients with vertebrobasilar aneurysms.…”

Role of hydrogen sulfide in subarachnoid hemorrhage

“…1,2 Moreover, survivors of SAH are often accompanied by multiple neurological deficits that severely affect patients' ability to work and their quality of life. 2,3 Existing treatments for SAH remain unsatisfactory. Recently, hydrogen sulfide (H 2 S), the third gaseous signaling molecule, has been found to play an important role in physiological processes.…”

Surgical Clipping Versus Endovascular Coiling in the Management of Intracranial Aneurysms

“…The four broad types of aneurysms are saccular, fusiform, dissecting, and mycotic, of which saccular (or berry) aneurysms are the most common, accounting for around 90% [2]. The prevalence of intracranial aneurysms in the general population is approximately 3.2%, though most are asymptomatic [3][4][5]. Berry aneurysms are most commonly located in the anterior circulation, at the junction between the anterior communicating artery (ACOM) and the anterior cerebral artery (ACA), the bifurcation of the middle cerebral artery (MCA), and the junction between the posterior communicating artery (PCOM) and the internal carotid artery (ICA) [6][7][8].…”