Treatment of intracranial aneurysm


 * rupture of aneurysmhere causes subarachnoid hemorrhage
 * the only rational way to prevent recurrent bleeding from an aneurysm is to close its neck with a clamp or to obliterate its sac endovascularly
 * the greatest risk of a new rupture is within 48 h after the first bleeding
 * 4.-10. the day after the bleeding, a strong vasospasm often occurs, which can cause ischemia and the operation could only become more difficult at this time → the operation must therefore be well timed
 * for early surgery we therefore have a period of the first 72 hours after bleeding
 * for the indication for surgery, the time since SAK, the patient's condition, CT finding is decisive
 * selection of patients - if we find an expansive hematoma on CT, we always operate, the goal is not only to clamp the aneurysm, but also to evacuate the hematoma acutely
 * if no hematoma is present (on CT only blood in cerebral fluid - i.e. only SAH...) - grade I to III. we operate immediately (within 72 hours)
 * for patients in IV. and SAK degree V - it is recommended to wait for an improvement of at least one degree
 * the patient's serious condition is not caused by brain compression, but by ischemic changes, we would not be able to help him now by closing the aneurysm
 * timing of surgery - important to prevent rerupture and prevent vasospasm
 * early operations (before the onset of vasospasm) generally have a higher operative mortality, but late operations (up to 21 days after SAH, i.e. after vasospasm has subsided) carry a high risk of repeated bleeding and overall have a worse outcome
 * operation between the 4th and 7th day after SAH is not at all suitable, due to vasospasm

Preoperative Procedure

 * even when diagnosing SAK, one must think about the risk of rebleeding → we will ensure absolute bed rest, head elevated to 30°, transport on a stretcher (even if the patient could escape...)
 * after confirmation of SAK by CT, he should be transported to neurosurgery, we will perform panangiography


 * preoperative care - absolute rest, administration of laxatives (difficulty defecation promotes reruptures), dexamethasone (prevention of edema), antihypertensives, nimodipine ( Ca channel blocker, prevention of vasospasm), anticonvulsants (prevention, an epileptic seizure could lead to rerupture), the patient is in the ICU
 * after SAH, there is often a finding on the ECG that looks like subendocardial ischemia, it is caused by catecholamine washout caused by ischemia of the hypothalamus after SAH, this may manifest as a latent ICH

Conservative therapy

 * for postponed operations – includes the measures mentioned above
 * if coagulum blocks the CSF channels, we introduce external ventricular drainage

Surgical therapy

 * closure of the neck of the aneurysm while maintaining blood flow through other vessels
 * performance is rerupture prevention, does not repair damage caused by previous SAK
 * early operations are among the most complex neurosurgical operations

Endovascular methods

 * coiling – obliteration of the bulge bag with metal spirals
 * spirals have shape memory and coil themselves in the aneurysm, a coagulum forms on them and the entrance to the aneurysm is re-epithelialized
 * it is done angiographically, under an x-ray lamp, little burden for the patient
 * limitations of coiling – reachability of the aneurysm by catheterization, neck-to-sac ratio (when it is large, coils escape)
 * if the aneurysm has a wide neck, a stent is usually implanted first and coils are inserted through it to prevent leakage

Complications

 * ischemia from vasospasm, cerebral edema, bleeding in the operative field, hemostasis disorders, hyporesorptive hydrocephalus

Postoperative Care

 * the basis is the monitoring of the neurological condition, in case of deterioration of consciousness or accentuation of focal symptomatology - always CT
 * prevention of postoperative vasospasm - "hyperdynamic therapy" - "3 H": hypervolemia, hypertension, hemodilution
 * only if the aneurysm is reliably closed and the patient has a healthy heart

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