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__NOTOC__
__NOTOC__
'''For patient information, click [[Cerebral aneurysm (patient information)|here]]'''
{{Infobox_Disease
{{Infobox_Disease
  | Name          = Cerebral aneurysm
  | Name          = Cerebral aneurysm
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{{Cerebral aneurysm}}
{{Cerebral aneurysm}}
'''For patient information, click [[Cerebral aneurysm (patient information)|here]]'''


{{CMG}}; {{AE}} {{CZ}}; {{KD}}  
{{CMG}}; {{AE}} {{CZ}}; {{KD}}  


{{SK}} Berry aneurysm
==[[Cerebral aneurysm overview|Overview]]==
==[[Cerebral aneurysm historical perspective|Historical Perspective]]==
==[[Cerebral aneurysm classification|Classification]]==
==[[Cerebral aneurysm pathophysiology |Pathophysiology]]==
==[[Cerebral aneurysm causes |Causes]]==
==[[Cerebral aneurysm differential diagnosis|Differentiating Cerebral aneurysm from other Diseases]]==
 
==[[Cerebral aneurysm epidemiology and demographics|Epidemiology and Demographics]]==
==[[Cerebral aneurysm risk factors|Risk Factors]]==
==[[Cerebral aneurysm screening|Screening]]==


==[[Cerebral aneurysm natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
==Diagnosis==
==Diagnosis==
===Physical Examination===
[[Cerebral aneurysm diagnostic criteria|Diagnostic Criteria]] | [[Cerebral aneurysm history and symptoms|History and Symptoms]] | [[Cerebral aneurysm physical examination|Physical Examination]] | [[Cerebral aneurysm laboratory findings|Laboratory Findings]] | [[Cerebral aneurysm CT|CT]] | [[Cerebral aneurysm MRI|MRI]] |[[Cerebral aneurysm other imaging findings|Other Imaging Findings]] | [[Cerebral aneurysm other diagnostic studies|Other Diagnostic Studies]]
===General===
Confusion, lethargy or stupor may be present.
===Neurologic Examination===
* Motor weakness may be present.
* Sensory abnormalities may be present.
* Neck stiffness may be present.
 
In outlining symptoms of ruptured cerebral aneurysm, it is useful to make use of the [[Hunt and Hess scale]] of subarachnoid [[hemorrhage]] severity:
 
* Grade 1: Asymptomatic; or minimal [[headache]] and slight [[nuchal rigidity]]. Approximate survival rate 70%.
* Grade 2: Moderate to severe headache; nuchal rigidity; no [[neurology|neurologic]] deficit except [[cranial nerve]] [[palsy]]. 60%.
* Grade 3: Drowsy; minimal neurologic deficit. 50%.
* Grade 4: Stuporous; moderate to severe [[hemiparesis]]; possibly early [[decerebrate rigidity]] and vegetative disturbances. 20%.
* Grade 5: Deep [[coma]]; decerebrate rigidity; [[wiktionary:moribund|moribund]]. 10%.
===Multi Sliced CT===
The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan:
 
* Grade 1: No hemorrhage evident.
* Grade 2: Subarachnoid hemorrhage less than 1mm thick.
* Grade 3: Subarachnoid hemorrhage more than 1mm thick.
* Grade 4: Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension.
 
The Fisher Grade is most useful in communicating the description of SAH.  It is less useful prognostically than the Hunt-Hess scale.
 
Images shown below are courtesy of RadsWiki and copylefted.
 
<div align="left">
<gallery heights="175" widths="175">
Image:Basilar-artery-aneurysm-01.jpg|MSCT: A large basilar artery aneurysm
Image:Basilar-artery-aneurysm-02.jpg|MSCT: A large basilar artery aneurysm
</gallery>
</div>
 
 
 
<div align="left">
<gallery heights="175" widths="175">
Image:Basilar-artery-aneurysm-03.jpg|MSCT: A large basilar artery aneurysm
Image:Basilar-artery-aneurysm-04.jpg|MSCT: A large basilar artery aneurysm
</gallery>
</div>
 
===MRI===
Images shown below are courtesy of RadsWiki and copylefted.
 
<div align="left">
<gallery heights="175" widths="175">
Image:Cavernous-sinus-aneurysm-001.jpg|MRI: A large cavernous sinus aneurysm
Image:Cavernous-sinus-aneurysm-002.jpg|MRI: A large cavernous sinus aneurysm
</gallery>
</div>
 
 
<div align="left">
<gallery heights="175" widths="175">
Image:Cavernous-sinus-aneurysm-003.jpg|MRI: A large cavernous sinus aneurysm
Image:Cavernous-sinus-aneurysm-004.jpg|MRI: A large cavernous sinus aneurysm
</gallery>
</div>
 
 
<div align="left">
<gallery heights="175" widths="175">
Image:Cavernous-sinus-aneurysm-005.jpg|MRI: A large cavernous sinus aneurysm
Image:Cavernous-sinus-aneurysm-006.jpg|MRI: A large cavernous sinus aneurysm
</gallery>
</div>
 
 
<div align="left">
<gallery heights="175" widths="175">
Image:Cavernous-sinus-aneurysm-007.jpg|MRI: A large cavernous sinus aneurysm
Image:Cavernous-sinus-aneurysm-008.jpg|MRI: A large cavernous sinus aneurysm
Image:Cavernous-sinus-aneurysm-009.jpg|MRI: A large cavernous sinus aneurysm
</gallery>
</div>
 
===Angiography===
 
Images shown below are courtesy of RadsWiki and copylefted.
 
<div align="left">
<gallery heights="175" widths="175">
Image:Basilar-artery-aneurysm-05.jpg|Cranial Angiography: Same case as in MSCT images. A large basilar artery aneurysm
Image:Basilar-artery-aneurysm-06.jpg|Cranial Angiography: Same case as in MSCT images. A large basilar artery aneurysm
</gallery>
</div>


==Treatment==
==Treatment==
[[Cerebral aneurysm medical therapy|Medical Therapy]] | [[Cerebral aneurysm surgery|Surgery]] | [[Cerebral aneurysm primary prevention|Primary Prevention]] | [[Cerebral aneurysm secondary prevention|Secondary Prevention]] | [[Cerebral aneurysm cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cerebral aneurysm future or investigational therapies|Future or Investigational Therapies]]


[[Emergency medicine|Emergency treatment]] for individuals with a ruptured cerebral aneurysm generally includes restoring deteriorating [[Respiration (physiology)|respiration]] and reducing [[intracranial pressure]]. Currently there are two treatment options for brain aneurysms.  Either surgical clipping or endovascular coiling is usually performed within the first three days to occlude the ruptured aneurysm and reduce the risk of rebleeding.
==Case Studies==
[[Cerebral aneurysm case study one|Case #1]]


'''Surgical clipping''':  Surgical clipping was introduced by [[Walter Dandy]] of the [[Johns Hopkins Hospital]] in 1937. It consists of performing a craniotomy, exposing the aneurysm, and closing the base of the aneurysm with a clip. The surgical technique has been modified and improved over the years. Surgical clipping has a lower rate of aneurysm recurrence after treatment. Either surgical clipping or endovascular coiling is usually performed within the first three days to occlude the ruptured aneurysm and reduce the risk of rebleeding.
== Related Chapters ==
 
'''Endovascular coiling''': This was introduced by Guido Guglielmi at UCLA in 1991. It consists of passing a catheter into the femoral artery in the groin, through the aorta, into the brain arteries, and finally into the aneurysm itself. Once the catheter is in the aneurysm, platinum coils are pushed into the aneurysm and released. These coils initiate a clotting or thrombotic reaction within the aneurysm that, if successful, will eliminate the aneurysm. In the case of broad-based aneurysms, a stent is passed first into the parent artery to serve as a scaffold for the coils ("stent-assisted coiling").Either surgical clipping or endovascular coiling is usually performed within the first three days to occlude the ruptured aneurysm and reduce the risk of rebleeding.
 
At this point it appears that the risks associated with surgical clipping and endovascular coiling, in terms of stroke or death from the procedure, are the same. The major problem associated with endovascular coiling, however, is a higher aneurysm recurrence rate. For instance, the most recent study by Jacques Moret and colleagues from Paris, France, (a group with one of the largest experiences in endovascular coiling) indicates that 28.6% of aneurysms recurred within one year of coiling, and that the recurrence rate increased with time. <ref name="Piotin et al 2007">{{cite journal |last=Piotin |first=M |coauthors=Spelle, L, Mounayer, C, Salles-Rezende, MT, Giansante-Abud, D, Vanzin-Santos, R, Moret, J  |year=2007 |month=May |title=Intracranial aneurysms: treatment with bare platinum coils--aneurysm packing, complex coils, and angiographic recurrence. |journal=Radiology |volume=243 |issue=2 |pages=500-8 |id=PMID 17293572 }}</ref> These results are similar to those previously reported by other endovascular groups. For instance Jean Raymond and colleagues from Montreal, Canada, (another group with a large experience in endovascular coiling) reported that 33.6% of aneurysms recurred within one year of coiling. <ref name="Raymond et al 2003">{{cite journal |last=Raymond |first=J |coauthors=Guilbert, F, Weill, A, Georganos, SA, Juravsky, L, Lambert, A, Lamoureux, J, Chagnon, M, Roy, D  |year=2003 |month=Jun |title= Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. |journal=Stroke |volume=34 |issue=6 |pages=1398-1403 |id=PMID 12775880 }}</ref> The long-term coiling results of one of the two prospective, randomized studies comparing surgical clipping versus endovascular coiling, namely the International Subarachnoid Aneurysm Trial (ISAT) are turning out to be similarly worrisome. In ISAT, the need for late retreatment of aneurysms was 6.9 times more likely for endovascular coiling as compared to surgical clipping.  <ref name="Campi et al 2007">{{cite journal |last=Campi  |first=A |coauthors=Ramzi N, Molyneaux AJ, Summers, PE, Kerr, RS, Sneade, M, Yarnold, JA, Rischmiller, J, Byrne, JV  |year=2007  |month=May  |title= Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or
clipping in the International Subarachnoid Aneurysm Trial (ISAT).  |journal=Stroke |volume=38 |issue=5 |pages=1538-1544 |id=PMID 17395870 }}</ref>
 
Therefore it appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher recurrence rate after treatment. It is unclear, however, whether the higher recurrence rate translates into a higher ''rebleeding'' rate, as the data thus far do not show a difference in the rate of recurrent hemorrhage in patients who had aneurysms clipped vs. coiled after rupture. <ref name="Campi et al 2007"/> The long-term data for ''unruptured'' aneurysms are still being gathered.
 
Patients who undergo endovascular coiling need to have annual studies (such as MRI/MRA, CTA, or angiography) indefinitely to detect early recurrences. If a recurrence is identified, the aneurysm needs to be retreated with either surgery or further coiling. The risks associated with surgical clipping of previously-coiled aneurysms are very high. Ultimately, the decision to treat with surgical clipping versus endovascular coiling should be made by a cerebrovascular team with extensive experience in both modalities.
 
==References==
{{reflist|2}}
 
== See also ==
*[[Charcot-Bouchard aneurysm]]
*[[Charcot-Bouchard aneurysm]]
*[[Intracranial berry aneurysm]]
*[[Intracranial berry aneurysm]]
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[[Category:Radiology]]
[[Category:Radiology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
 
[[Category:Emergency medicine]]
[[ca:Aneurisma cerebral]]
[[Category:Disease]]
[[de:Aneurysma#Hirn-Aneurysmata]]
[[es:Aneurisma]]
[[fr:Anévrisme intra-crânien]]
[[ja:脳動脈瘤]]
[[pt:Aneurisma cerebral]]
[[fi:Aivoaneurysma]]


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Revision as of 16:46, 7 March 2013

Cerebral aneurysm
Brain: Berry Aneurysm: Gross, natural color, close-up, an excellent view of typical berry aneurysm located on anterior cerebral artery
Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Kalsang Dolma, M.B.B.S.[3]

Overview

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Case #1

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