INTRACRANIAL ANEURYSM

INTRACRANIAL ANEURYSM
Also called Cerebral Aneurysm Localized dilatation of a cerebral artery resulting from weakness in the arterial wall

CAUSES
Atherosclerosis Congenital defect of vessel wall Hypertensive vascular disease Head trauma Advancing age

RISK FACTORS
Smoking HTN Previous family history CT disorder Older age Females Over 40 y/o

PATHOPHYSIOLOGY
Artery enlarges, presses on surrounding cranial nerves of brain tissue Aneurysm ruptures, causing subarachnoid hemorrhage o Normal brain metabolism disrupted by brain being exposed to blood o Increased ICP due to blood occupying space sudden entry o Ischemia from reduced perfusion and vasospasm o Most occur at the Circle of Willis and look like berries 10-20cc bleed 50cc Massive bleed

CLINICAL MANIFESTATIONS
Sudden, Very severe headache worst headache ever had Loss of consciousness Nuchal rigidity Pain and rigidity in back of neck and spine o Meningeal Irritation Visual disturbances, visual loss, diplopia, ptosis o Aneurysm adjacent to oculomotor nerve Tinnitus, dizziness, hemiparesis Aneurysm may leak blood, clot off and have no symptoms May have 50% mortality from subarachnoid hemorrhage

Prognosis depends on: Neurologic condition, age, any associated diseases, and extent / location of aneurysm

Major Threats: Initial bleed, Rebleed, Vasospasm

DIAGNOSTIC TESTS
CT Scan o Shows location/size, information about affected artery, vessels, vascular branches Cerebral angiography Lumbar Puncture o Only if no evidence of Increased ICP(Danger of herniation) and CT scan is negative confirm hemorrhage by the blood in the LP

MEDICAL MANAGEMENT
Recover From Initial Bleed o Is the goal of treatment Stable enough for surgery o Stages of Aneurysms 1-3 are OK and 4,5 are pretty bad ?????????? Prevent Rebleeding o Minimize risk o 3-11 days with peak on 7th day they are at high risk for rebleed o May be given Amicar to prevent rebleed. Amicar is a Antifibronolytic Cannot give if clotting problems Control Vasospasm o When the aneurysm ruptures it releases certain substances that cause vasospasm o Resulting in cerebral ischemia due to decreased blood flow o Death/disability; headache, LOC or new deficit o Risk for Vasospasm peaks on 7th day o Nemotop (CCB) is given to prevent vasospasm. Not when a vasospasm is occurring Monitor for LOC May signal that a vasospasm is occurring CCB Lowers BP and if you have a vasospasm---nothing is happening When a person has a vasospasm they want the BP to be higher, so maybe given a medication to elevate the BP, (Dopamine, Fluid Volume Expanders) Keep the blood flowing

Treat Acute Hydrocephalus o Results when free blood obstructs reabsorption of CSF o CT Scan will show dilated ventricles with temporary shunt, sign LOC; drain temporary

MEDICAL CARE
Drug Therapy

Steroids Osmotic Diuretics Antihypertensives Antipyretics Stool Softeners Anticonvulsants Sedatives Antifibrinolytic Agent (Amicar)

Surgical Management
Aneurysm clip o Before rupture ASAP Trapping of aneurysm o Clipped above and below the aneurysm o You would need good collateral circulation Wrapping of aneurysm o Reinforcement, induce scarring Interventional Neuroradiology o Perform lab; small coils to solidify and prevent rebleeding; cath through femoral artery o Home within 24 hours

NURSING PLAN OF CARE

SUBARACHNOID PRECAUTIONS Same as ICP o Airway o Neuro and VS checks o Bed rest with limited activity o Dark, quiet private room NO TV or Phone o Elevate HOB 20-30 degrees or keep flat (depends on MD) o Turn every 2 hrs Deep breathe, ROM o No external stimuli o Visitors restricted o Light sedation or analgesic NO Narcotics, or Sedatives Codeine & Tylenol are OK o No coughing, sneezing, straining (valsava) o No enemas, Give stool softeners o Safety measures o Anti-embolism stockings o DO not restrain o I&O; avoid overhydration o Seizure precautions

DANGER SIGNALS

LOC Unilateral enlarged pupil Onset of hemiparesis BP, Pulse Sudden new headache

Renewed nuchal rigidity; Renewed vomiting