General Principles for the Management of Ruptured and Unruptured Intracranial Aneurysms

Intracranial aneurysms pose a challenge in decision making and management. The majority of intracranial aneurysms arise at branching points of large arteries, and hemodynamic stress contributes to the initial development and subsequent growth. The incidence of intracranial aneurysms is variable ranging from 1% to 6%. Estimated rupture rates are approximately 1% to 2% per year but may vary significantly by patient and aneurysm characteristics. The question remains for every unruptured aneurysm whether the benefit of aneurysm occlusion outweighs the risk of a possible subarachnoid hemorrhage. As technology advances and new techniques become available for aneurysm obliteration, further questions arise regarding the optimal treatment choice. Once the aneurysm has ruptured, one-third die and two-thirds survive, with 50% of survivors leading independent lives. The risk of rebleeding after SAH is greatest on the first day, but continues to be significant over time in untreated ruptured aneurysms. The treatment goal of intracranial aneurysms is to exclude them from the parent circulation, and the options include endovascular occlusion, microsurgical clipping, or a combination of approaches. Once a ruptured aneurysm is secured, the most significant cause of morbidity and death is cerebral vasospasm. Aneurysm patients should ideally be treated at centers of excellence that employ expertise in all areas of neurovascular care, including endovascular, microvascular, neurocritical care, and neuroanesthesia.