A cerebral aneurysm is a weak, bulging spot in an artery at the base of the brain, and its rupture causes bleeding into the subarachnoid space. This hemorrhage is a neurosurgical emergency with a high early risk of rebleeding, vessel spasm and death.
Key symptoms
- Sudden thunderclap headache, the worst of the patient's life, peaking within a minute
- Nausea, vomiting and stiff neck
- Brief loss of consciousness or seizure
- Confusion or drowsiness
- Double vision or a drooping eyelid (third nerve palsy)
What you find on exam
- Glasgow Coma Scale and repeated neuro checks
- Neck stiffness
- Pupils and eye movements; third nerve palsy suggests a posterior communicating artery aneurysm
- Focal deficits and blood pressure
Tests
- Noncontrast CT head, most sensitive in the first 6 hours
- Lumbar puncture if CT is negative: xanthochromia or red cells that do not clear
- CT angiography or catheter angiography to find the aneurysm
- ECG, electrolytes (watch sodium), coagulation tests
Treatment basics
- Airway, ICU care and neurosurgery consult
- Keep systolic blood pressure under about 160 with nicardipine or labetalol
- Secure the aneurysm early by endovascular coiling or surgical clipping
- Oral nimodipine for 21 days to reduce injury from vasospasm
- Treat hydrocephalus with an external ventricular drain
Red flags
- Sudden thunderclap headache
- Falling level of consciousness
- New deficit days later (vasospasm) or a dilated pupil
Practice it in Making Synapses
Making Synapses cases
Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.