MICHAEL ENGLISH, M.D. -...

As they left the hospital,Emma Jamison’s familygave each nurse a hug.

Three weeks ago, Ms. Jamisonhad developed a sudden, severeheadache. Within minutes, shecouldn’t speak clearly. Her familycalled 911, and she was rushedto the hospital, where she wasdiagnosed with a subarachnoidhemorrhage (SAH) from a rupturedcerebral aneurysm.

Ms. Jamison’s hospitalization was long and eventful, but itended well because the nurses who cared for her were wellinformed about her condition. Read on to find out what youshould know about caring for a patient with a cerebralaneurysm rupture.

Subtle, growing troubleThe signs and symptoms of a growing aneurysm are subtle.(For more on causes and locations of cerebral aneurysms, seeAll about aneurysms.) Often the first signs and symptoms area minor headache, intermittent blurred vision, cranial nervepalsy, or dilated pupils.1 These signs and symptoms may beunnoticed, ignored, or misdiagnosed until the aneurysmruptures and the patient is diagnosed with an SAH.

In some cases, an aneurysm is discovered during the diag-nostic workup for other medical conditions. How to treatthese “incidental aneurysms” is somewhat controversial and

22 l Nursing2008CriticalCare l Volume 3, Number 6 www.nursing2008criticalcare.com

Find out how torecognize andrespond to thispotentiallydevastatingcondition.By DaiWai Olson, RN, CCRN,and Noreen Halley, RN

Cerebral aneu Are you

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www.nursing2008criticalcare.com November l Nursing2008CriticalCare l 23

u rysm rupture

is based primarily on the sizeand location of the aneurysm.1

Although exact numbers areunknown, an estimated 10% to40% of patients who experiencean aneurysm rupture don’t sur-vive the emergency phase (thefirst 24 hours).2 For those who dosurvive, treatment is aimed atpreventing secondary brain injury.

Ms. Jamison’s “worst headacheof her life” is the classic presenta-tion of a ruptured aneurysm.1 Theheadache is caused by the suddenincrease in intracranial pressure(ICP). Nausea, vomiting, slurredspeech, and loss of consciousnessmay occur within moments of the

first headache. When an aneurysmruptures, the sudden release ofblood into the subarachnoid spacecauses increased ICP, which if leftuntreated may result in cerebralhypoxia and necrosis of braintissue. The area of the brain sur-rounding the necrotic tissue isat greatest risk for secondarybrain injury.

When a patient with a suspect-ed SAH arrives at the emergencydepartment, follow advancedcardiac life support guidelines toassess and support the ABCs (air-way, breathing, circulation).Provide supplemental oxygen ifindicated, establish intravenous

(I.V.) access, and take blood sam-ples. Check the patient’s bloodglucose level and treat abnormal-ities as indicated. Perform a neu-rologic screening assessmentand activate the stroke team.

Take a detailed history fromthe patient or family member (ifthe patient isn’t responsive),including time of symptom onsetand a comprehensive medicationhistory. Find out whether thepatient has any allergies.

Diagnostic testingAneurysms are definitively diag-nosed using radiographic imag-ing.3 A computed tomography(CT) scan of the brain is thefastest way to rule in an SAH.On a brain CT scan withoutcontrast, blood from a rupturedaneurysm shows up as a whiteimage. A cerebral arteriogramlets the radiology team see theaneurysm better. Newer com-puterized techniques now letneurosurgeons see three-dimen-sional reconstructions of theseimages, which helps them maketreatment decisions.

If the CT scan is negativebut the physician still suspectsaneurysm rupture, he may per-form a lumbar puncture. Thecerebrospinal fluid is assessed forxanthrochromia, a pale yellowsubstance resulting from bloodbreakdown and an indicator ofaneurysm rupture.

Magnetic resonance imaging(MRI), another imaging option, isa less-sensitive method of detect-ing subarachnoid blood than theCT scan. However, magnetic res-onance angiography (MRA) canproduce high-quality images ofthe cerebral arteries, similar tothose in a three-dimensional CTscan. Because MRI and MRA


Cerebral aneurysm rupture

All about aneurysmsAn aneurysm is an outpouching of an artery resulting from progressiveweakening of the vessel wall. Causes include hypertension, infections,trauma, and smoking. Once the aneurysm is formed, the pressure exertedfrom arterial flow causes the aneurysm to expand.

Although aneurysms may form anywhere, most are found at thebifurcations—where arteries divide. Most cerebral aneurysms developat the circle of Willis, shown above.

Aneurysms are named for their shape, size, and location. • Shapes are berry (saccular) or fusiform. • Sizes are described as either small (less than 10 mm), medium (10 to 15

mm), large (15 to 25 mm), giant (25 to 50 mm), or super-giant (> 50 mm).• Location is described in two parts: first by the side of the brain, then by

the cerebral artery affected. For example, an aneurysm can be describedas a berry-shaped large left middle cerebral artery aneurysm.

Anterior communicating artery

Anterior cerebral artery

Middle cerebral artery

Posteriorcommunicating artery

Circle of Willis

Posteriorcerebral artery

Basilar artery

Aneurysm

scans require more time to com-plete and are more expensive,they’re not routinely ordered forall patients.

Treatment optionsCerebral aneurysms can bemanaged in two ways. A nonin-terventional approach is pre-ferred when the aneurysm issmall and hasn’t ruptured andthe dangers of definitive treat-ment outweigh the dangers ofleaving the aneurysm untreated.More than simply a “wait andsee” approach, the noninterven-tional approach is directed atcontrolling risk factors such astobacco use and hypertension.4

If the risk of aneurysm ruptureoutweighs the benefits of moni-toring, however, the patient will

need an invasive procedure toeither clip or coil the aneurysm.

Clipping a cerebral aneurysmrequires opening the skull whilethe patient is under general anes-thesia. The risks, which areextensive and serious, includebleeding, infection, stroke, andanesthesia complications.

To clip an aneurysm, the sur-geon retracts layers of the brainuntil he can see the aneurysm. Hethen secures a metal surgical clipacross the neck of the aneurysm(between the aneurysm and thenatural contour of the arterywall), reestablishing the naturalshape of the artery wall and cut-ting the aneurysm off from the


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Clipping a cerebralaneurysm requires

opening the skull whilethe patient is undergeneral anesthesia.

blood vessel. More than one clipmay be needed; clips typically aremade of titanium because thissubstance doesn’t interfere withdiagnostic tests such as MRIs.

Endovascular coiling involvesembolizing the aneurysm to pre-vent it from rupturing. Althoughless invasive than surgery, thisprocedure also carries substantialrisks, including vessel perforation,bleeding, infection, distal throm-boembolism, and incompleteembolization.5

For a coiling procedure, thepatient is placed supine and acatheter is threaded into the cere-bral vasculature via the femoralartery. Contrast media is injectedthrough the catheter to outlinethe cerebral vasculature andaneurysm on radiographic imag-ing. This picture is the road mapthat guides the interventionalist,who guides smaller catheters tothe neck of the aneurysm anddeposits one or more titaniumcoils into the aneurysm. Thecoils fill the aneurysm and trig-ger clot formation (thrombosis).Large aneurysms may requirenumerous coils.

Handling complicationsThe greatest complication fromany cerebral aneurysm is arupture that leaks blood intothe cranial vault.1 This is whathappened in Ms. Jamison’scase, causing the changes herfamily observed (headache fol-lowed by signs and symptomsof stroke). Monitoring for neuro-logic changes, especially in levelof consciousness (LOC), is keyafter aneurysm rupture. Evensubtle changes are significant.Expect to monitor the patient’sneurologic status at least every2 hours.

Make sure each shift reportincludes documentation of thepatient’s LOC; pupillary size,shape, and reaction to light; andmotor function, as these pieces ofthe neurologic exam are thoughtto be most sensitive to changes.

One cause for deterioration ina patient’s neurologic function isarterial vasospasm, which typi-cally occurs 3 to 14 days aftercerebral aneurysm rupture.Vasospasm can be life-threaten-ing if it results in acute ischemicstroke. Vasospasm is presumedto be a response to the toxinsreleased when blood from thecerebral hemorrhage breaks down.A CT scan can rule out other possi-ble causes of change in LOC, suchas hydrocephalus or rebleeding.

Preventing secondarybrain injuryThe 2 weeks after aneurysmrupture are critical. Medical andnursing care focuses on prevent-ing secondary brain injury byoptimizing blood flow to thebrain. The conventional treat-ment to optimize blood flow isreferred to as “triple-H therapy,”consisting of induced hyperten-

sion, hypervolemia, and hemodi-lution.1 Various interventions maybe used to maintain triple-H ther-apy, but the primary tool is thecontinuous infusion of I.V. fluidto maintain adequate cerebralperfusion pressure. This is intend-ed to keep cerebral arteries filledwith blood during vasospasms.

Monitoring the effectiveness oftriple-H therapy includes hemo-dynamic monitoring and compre-hensive serial neurologic exams.Compare the patient’s currentneurologic assessment with pre-vious findings to determine howyour patient is doing. Report anychange in the neurologic examto the medical team. Thoroughdocumentation and an accuratechange-of-shift report help thecaregivers identify trends in thepatient’s clinical picture.

To manage vasospasm, a patientwith SAH may be prescribednimodipine, a calcium channelblocker, which causes vasodila-tion and improves cerebral bloodflow. Monitor the patient closelyfor hypotension, a commonadverse reaction to nimodipine;decreased blood pressure willcompromise cerebral blood flow.Because a patient who’s sufferedan SAH is at an increased riskfor seizure, she may also be pre-scribed an anticonvulsant such asphenytoin. If she has no seizureactivity over time, the medicationis discontinued.

Make sure your patient receivesoptimal nutritional support andprotect her from infections. Skincare, turning, and deep-breathingexercises promote physical stabil-ity and independence. Supportyour patient and her family emo-tionally and, before discharge,refer them to support groupsas appropriate.


Cerebral aneurysm rupture

Monitoring forneurologic changes,especially in levelof consciousness,

is key afteraneurysm rupture.

Recovery for a patient withSAH can last from a few weeksto several years. Ms. Jamisonprogressed quickly through herrecovery period. She spent2 weeks in an inpatient rehabili-tation unit, where she receivedphysical therapy and occupation-al therapy twice daily. Becauseshe’d lost a portion of her abilityto name objects (anomia), shewas enrolled in an extensivespeech therapy program. Afterdischarge, Ms. Jamison contin-ued to have some difficulty walk-ing and she may always need afour-prong cane for assistance.Her daughter has moved in withher and takes her to physicaltherapy three times each week.

Ms. Jamison was fortunate.Her family quickly recognizedthe need for treatment and acti-vated the emergency responsesystem. The nurses who caredfor her were vigilant with theirassessments, and she receivedappropriate treatment. By under-standing cerebral aneurysmrupture and SAH, you can helppatients like Ms. Jamison surviveand recover from these potentiallydevastating disorders. ❖

REFERENCES

1. Greenberg MS. Handbook of Neurosurgery,6th edition. Lakeland, Fla., Thieme MedicalPublishers, 2005.

2. Cerebral aneurysm fact sheet. NationalInstitute of Neurological Disorders and

Stroke, 2006. http://www.ninds.nih.gov/disorders/cerebral_aneurysm/detail_cerebral_aneurysm.htm. Accessed August 15, 2006.

3. Littlejohns L, Bader MK. Prevention ofsecondary brain injury: Targeting technol-ogy. AACN Clinical Issues. 16(4):501-514,October-December 2005.

4. Wang DZ, et al. Treatment options forunruptured cerebral aneurysm. CurrentTreatment Options in Neurology. 6(6):451-458,November 2004.

5. Molyneux A, et al. InternationalSubarachnoid Aneurysm Trial (ISAT) ofneurosurgical clipping versus endovascularcoiling in 2,143 patients with rupturedintracranial aneurysms: A randomised trial.Lancet. 360(9342):1267-1274, October 26,2002.

DaiWai Olson is a doctoral candidate at theUniversity of North Carolina at Chapel Hill and astaff nurse in the neurocritical care unit at DukeUniversity Medical Center in Durham, N.C. NoreenHalley is a staff nurse in the neurocritical care unitat Duke University Medical Center.

Adapted from: Olson D. Cerebral aneurysmrupture—are you prepared? Nursing. 2007;37(3):64cc1-64cc4.


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