If you encounter a patient with a ruptured intracranial aneurysm, knowing these 8 points can save your life

*For medical professionals to read for reference only.
In patients with sudden severe headache and positive meningeal irritation signs, the diagnosis of aneurysmal subarachnoid hemorrhage should be highly suspected.
Intracranial aneurysm is a localized pathological expansion of the intracranial artery wall.
There is a tendency to rupture
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Ruptured intracranial aneurysm (RIA) is the most common cause of spontaneous subarachnoid hemorrhage (SAH)
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As a disease that causes serious damage to the central nervous system and even other systems, SAH has high mortality, complex clinical symptoms, unclear natural history and outcome, poor treatment methods and effects, diverse complications, and inconsistent follow-up.
a series of questions
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For this reason, the author organizes the following according to the "Guidelines for Diagnosis and Treatment of Intracranial Ruptured Aneurysms in China 2021": What is the outcome of 01RIA? (1) After rupture of an intracranial aneurysm, the risk of early re-rupture is high and the prognosis is poor, which needs attention (Class I recommendation, Level B evidence)
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(2) Clinical disease grading is an important factor in predicting the prognosis of RIA patients.
Patients with severe clinical grades can still benefit from treatment and achieve good prognosis (level I recommendation, level B evidence)
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(3) The occurrence of rebleeding in RIA patients is an important factor affecting their prognosis, and special attention should be paid to the clinical classification because it indicates the risk of rebleeding (Class II recommendation, Level B evidence)
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(4) Two-thirds of surviving patients after intracranial aneurysm rupture can restore their ability to live independently, but 40% to 70% of these patients may have long-term cognitive impairment (level II recommendation, level B evidence)
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02What are the clinical evaluations of RIA patients? (1) For patients with sudden severe headache and positive meningeal irritation signs, the diagnosis of aneurysmal SAH should be highly suspected (Class I recommendation, Level B evidence)
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(2) The clinical status of patients with aneurysmal SAH can be evaluated by applying the Hunt-Hess classification or based on the WFNS classification, which can evaluate its severity and prognosis, and provide information for the formulation of treatment strategies (level I recommendation, level B evidence)
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(3) Plain CT scan of the head is recommended as the main method for diagnosing aneurysmal SAH, which has good sensitivity (Class I recommendation, Level B evidence)
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(4) The risk of delayed cerebral infarction and cerebral vasospasm can be assessed by using imaging grading scales such as modified Fisher grading (level II recommendation, level B evidence)
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03What are the auxiliary examinations of RIA? (1) For patients suspected of RIA, head CT scan should be performed as soon as possible (level I recommendation, level A evidence)
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(2) If the results of head CT are negative, head MRI and lumbar puncture are effective to further confirm the diagnosis (level I recommendation, level B evidence)
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(3) CTA has good sensitivity and specificity, and can be used as the first choice for auxiliary examination of aneurysmal SAH (Class II recommendation, Level B evidence)
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(4) DSA is the "gold standard" for diagnosing aneurysmal SAH, and has a higher sensitivity for the imaging of small aneurysms with a maximum diameter of less than 3 mm and the surrounding small blood vessels, so it is suitable for patients who have not found the cause of SAH in CTA examination.
, DSA examination is recommended (level I recommendation, level B evidence)
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04What is the timing of RIA treatment? (1) Early treatment of RIA can reduce the rebleeding rate, and early intervention should be performed for most patients, but early and delayed surgery may have no effect on the overall prognosis of RIA patients (Class II recommendation, Level B evidence)
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(2) For patients with good clinical condition and low disease grade (Hunt-Hess class I-III or WFNS class I-III), aneurysm clipping or interventional embolization should be performed as soon as possible to reduce the risk of rebleeding (class I).
recommendation, level of evidence B)
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(3) High-grade RIA has a higher risk of rebleeding.
For young and high-grade (Hunt-Hess grade IV-V or WFNS grade IV-V) patients, early surgical intervention is suitable (level II recommendation, level D evidence).
)
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(4) For high-grade (Hunt-Hess grade IV-V or WFNS grade IV-V) patients, after intensive care treatment, if the condition improves, surgical intervention is suitable as soon as possible (level II recommendation, level D evidence)
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05What are the principles of preoperative treatment for RIA? (1) For patients with severe headache, active symptomatic treatment should be performed to maintain smooth stool, avoid force and excessive movement, and avoid blood pressure fluctuations as much as possible (Class I recommendation, Level C evidence)
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(2) ECG monitoring helps to protect cardiac function (Class II recommendation, Level B evidence)
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(3) Airway patency needs to be maintained (level I recommendation, level B evidence)
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(4) It is reasonable to control blood pressure so that systolic blood pressure is less than 160 mmHg (Class II recommendation, Level C evidence)
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Calcium channel blockers such as nicardipine can be administered intravenously to maintain reasonable blood pressure levels (Class I, Level of Evidence B)
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(5) Symptomatic treatment should be given in case of fever, but the treatment of mild hypothermia is still controversial (level III recommendation, level B evidence)
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(6) Water and electrolyte balance should be maintained, and hyponatremia or hypernatremia should be corrected in a timely manner (Class I recommendation, Level B evidence)
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(7) Tendency to fasting blood glucose <10mmol/L, while avoiding hypoglycemia (level II recommendation, level C evidence)
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(8) Although antifibrinolytic preparations can reduce the risk of rebleeding in aneurysmal SAH, they cannot improve the overall prognosis of patients, and are not recommended for the prevention of rebleeding in RIA (Class IV, Level of Evidence B)
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(9) The use of nimodipine is recommended to improve the prognosis of RIA (Class I recommendation, Level A evidence)
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(10) Erythropoietin may also improve prognosis by reducing vasospasm damage (level III recommendation, level of evidence C)
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06 Principles of endovascular treatment and surgical treatment of RIA? Table 107 What are the special drugs used in the perioperative period? Table 208 About follow-up (1) The first imaging review after treatment is 3 to 6 months after treatment, followed by imaging follow-up at 1, 2, 3, and 5 years after treatment, and every 3 to 5 years thereafter.
Follow-up imaging (Class II recommendation, Level B evidence)
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(2) The "gold standard" of imaging follow-up is DSA, which is recommended for wide application.
Due to factors such as invasiveness and the need for hospitalization, its use is limited to a certain extent (Class I recommendation, Level A evidence)
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For patients who cannot complete DSA, simple coil embolization can be followed up with TOF-MRA; for patients with simple FD or aneurysm clipping, the parent artery needs to be evaluated, and CTA follow-up is also feasible (level II).
recommendation, level of evidence B)
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(3) In terms of postoperative HRQoL, the scores after interventional embolization were significantly better than those of patients with craniotomy and clipping (level II recommendation, level B evidence)
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(4) Aneurysm recurrence is related to aneurysm size and treatment methods.
Interventional embolization has a higher prognosis for patients with aneurysm recurrence (Class II recommendation, Level B evidence)
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References: [1] Neurointerventional Professional Committee of Chinese Medical Doctor Association; Chinese Intracranial Aneurysm Project Research Group.
Chinese Guidelines for Diagnosis and Treatment of Intracranial Ruptured Aneurysms 2021.
Chinese Journal of Cerebrovascular Disease 18(8); 546-574.
Neurology Channel of the Medical Community Author: Zhang Qunying Review of this article: Li Tuming, Deputy Chief Physician Responsible Editor: Mr.
Lu Li The medical community strives to be accurate and reliable when the published content is approved, but it does not care about the timeliness of the published content and the cited materials (if any) accuracy and completeness, etc.
, and do not assume any responsibility due to the outdated content, the possible inaccuracy or incompleteness of the cited materials
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