Brain Aneurysm & Subarachnoid Hemorrhage Case Review Coordination

• Date and reason the aneurysm was discovered.
• Whether there has been previous subarachnoid haemorrhage, sentinel-type acute headache, cranial-nerve palsy, visual loss, thromboembolic symptoms or mass effect.
• Neurological and functional baseline.
• Headache phenotype and whether another headache diagnosis has been assessed.
• Hypertension, smoking and major vascular or medical conditions.
• Family history of intracranial aneurysm or subarachnoid haemorrhage.
• Current patient concerns, risk tolerance and treatment goals.

• Original DICOM files and formal reports.
• Thin-slice CTA or MRA suitable for aneurysm characterization.
• Non-contrast CT and haemorrhage imaging where rupture is suspected or confirmed.
• MRI sequences showing thrombus, mass effect, infarction or associated brain findings where relevant.
• All earlier studies required for growth assessment.
• Modality, acquisition date, slice thickness and contrast information.

Measurements from different modalities or techniques may not be directly interchangeable. Apparent growth should be reviewed on technically comparable studies whenever possible.

• Complete digital subtraction angiography series where performed.
• Three-dimensional rotational angiography and working projections.
• Formal angiography report.
• Parent artery, branches, perforators, neck and dome configuration.
• Collateral circulation and vessel-access limitations.
• Vasospasm, dissection, stenosis or other associated vascular pathology.

Catheter angiography is invasive. The treating team determines whether its additional diagnostic or planning value justifies the risk.

• Exact arterial location and side.
• Maximum dimensions and neck width.
• Regular, irregular, lobulated or daughter-sac morphology.
• Saccular, fusiform, dissecting, blister-like, partially thrombosed or giant configuration.
• Relationship to branch and perforator vessels.
• Documented measurement change and the time interval between studies.
• Map of all additional aneurysms.

• Operative report and surgical approach.
• Clip manufacturer, model and MRI-safety documentation where available.
• Temporary clipping, bypass or parent-vessel reconstruction details.
• Intraoperative vascular imaging or monitoring.
• Early postoperative CT, CTA or DSA.
• Residual neck, recurrence, branch compromise, infarction or cranial-nerve outcome.
• Wound, seizure and rehabilitation history.

• Procedure report and date.
• Primary or balloon-assisted coiling details.
• Coil or intrasaccular device type where documented.
• Immediate occlusion grade and branch preservation.
• Intraprocedural rupture, thromboembolism or access complication.
• Follow-up CTA, MRA or DSA.
• Coil compaction, residual neck, residual sac or recanalization.

• Device manufacturer, model, number, size and deployment location.
• Parent-vessel and covered-branch anatomy.
• Antiplatelet loading and maintenance plan.
• Medication adherence, previous intolerance and platelet-function testing where used.
• Ischaemic, haemorrhagic or access complications.
• Follow-up imaging showing aneurysm filling, device patency, stenosis or branch status.
• Planned duration and review of antiplatelet therapy by the treating team.

• Initial CT and CTA/DSA identifying the rupture source.
• Clinical severity and neurological examination.
• Date and method of aneurysm securing.
• External ventricular drainage, hydrocephalus and later shunt history.
• Delayed cerebral ischaemia, vasospasm, infarction and seizure records.
• Respiratory, cardiac, electrolyte, infectious and other intensive-care complications.
• Discharge neurological, cognitive and functional status.

• Antiplatelet and anticoagulant medication.
• Hypertension treatment and recent blood-pressure profile.
• Kidney function relevant to contrast exposure.
• Contrast, medication and latex allergies.
• Bleeding or clotting disorders.
• Previous anaesthetic complications.
• Upcoming operations, pregnancy or planned pregnancy requiring coordinated advice.

• Physical, occupational, speech and neuropsychological rehabilitation reports.
• Current cognition, fatigue, mood, vision, balance and return-to-work status.
• Access to local neurosurgery, neurointervention, stroke neurology and emergency care.
• Ability to complete CTA, MRA or DSA surveillance.
• Medication supply and adherence support.
• Family or caregiver support and travel fitness.
• Insurance or funding requirements for staged treatment.

Most unruptured aneurysms do not rupture during an individual patient’s lifetime. Preventive occlusion may be considered when the estimated future rupture risk is judged to exceed the risk and burden of the proposed treatment. The comparison includes aneurysm anatomy, patient age and health, life expectancy, centre experience, treatment durability and patient preference. The supporting evidence remains limited, so shared multidisciplinary decision-making is essential.

Aneurysm size contributes to rupture-risk assessment, but location, morphology, documented growth, previous SAH, smoking, hypertension, age and other factors can alter the decision. Small aneurysms are not risk-free, and large aneurysms are not automatically suitable for treatment. Measurements should be interpreted with modality and technical variability in mind.

Tools such as PHASES or UIATS can structure discussion, but they have population, variable-selection and calibration limitations and may not capture every morphological or treatment-related factor. A score should not be presented as a personalized prediction or used alone to select observation, clipping or an endovascular device.

Documented growth or new irregularity generally triggers renewed risk assessment because it may indicate a changing lesion. True growth should be distinguished from differences in scanner, reconstruction, slice thickness, projection or measurement technique. The next step is individualized; growth does not automatically identify the safest procedure.

An unruptured aneurysm may cause cranial-nerve palsy, visual dysfunction, thromboembolism or mass effect, especially in selected locations or larger lesions. Common headache disorders frequently coexist and are not automatically caused by the aneurysm. Treatment aimed at a symptom cannot guarantee recovery, particularly when nerve compression has been prolonged.

Multiple aneurysms require a complete vascular map and separate assessment of each lesion. Family history and selected inherited conditions may influence screening and follow-up, but broad screening is not automatically appropriate for every relative or every connective-tissue diagnosis. Previous SAH and the number of affected first-degree relatives are important contextual factors.

Observation is an active pathway that may include serial CTA or MRA, blood-pressure treatment, smoking cessation and defined triggers for renewed review. Follow-up timing depends on aneurysm and patient characteristics, previous stability and image quality. Surveillance cannot guarantee that rupture will not occur between studies and should continue only while preventive treatment would remain a meaningful option.

Clipping directly excludes the aneurysm at its neck while preserving the parent and branch vessels. It may be favourable for selected accessible aneurysms, complex branch anatomy, associated haematoma or cases where long-term durability is a major consideration. Risks include haemorrhage, infarction, perforator or branch compromise, cranial-nerve injury, seizure, infection and anaesthetic complications.

Post-treatment imaging may still be required to confirm occlusion and evaluate additional or future aneurysms. Clipping should not be described as universally more durable or appropriate without reference to the specific anatomy and patient.

Coiling fills the aneurysm sac while preserving the parent artery. Balloon assistance can temporarily support coil placement in selected wide-neck configurations without leaving a permanent implant. Risks include thromboembolism, intraprocedural rupture, coil protrusion and access complications. Residual filling, coil compaction or recanalization may require surveillance or retreatment.

An intracranial stent can support coil retention across a wide neck, but it introduces device-related thrombosis and antiplatelet considerations. The plan must address medication loading, adherence, bleeding risk, future procedures and follow-up of stent patency. Emergency ruptured and elective unruptured cases have different constraints and should not be discussed as equivalent.

Intrasaccular devices may be considered for selected wide-neck bifurcation aneurysms. Because the device is mainly within the aneurysm sac, parent-vessel implantation and antiplatelet requirements can differ from stent or flow-diverter pathways. Suitability depends on sac geometry, neck, branch configuration, rupture status and centre experience. Follow-up is still required.

A flow diverter is placed in the parent artery to redirect flow and promote gradual aneurysm thrombosis and vessel reconstruction. Occlusion is delayed rather than immediate. The pathway commonly requires antiplatelet therapy and surveillance of device patency, aneurysm filling and covered branches. Risks include thromboembolic stroke, intracranial haemorrhage, in-device stenosis, branch or perforator compromise and rare delayed rupture.

Flow diversion is not a universal first choice. It is most appropriate when anatomy and expected benefit justify the implant and medication burden and when lower-risk alternatives are not preferable.

Medication strategy depends on the device, urgency, bleeding risk and coexisting indications for antithrombotic treatment. Platelet-function testing may inform local protocols, but practices and thresholds vary and no universal prospectively validated therapeutic range applies to every patient and device. Patients should not start, stop or alter antiplatelet or anticoagulant medication without the treating team.

Parent-vessel sacrifice, sometimes with bypass, may be considered for selected giant, fusiform, dissecting or otherwise unreconstructable aneurysms. Collateral and perfusion testing can support planning but cannot guarantee that sacrifice will be free of ischaemic risk. Bypass adds its own patency, infarction, haemorrhage and surgical risks.

Residual neck or sac filling after clipping or endovascular treatment does not have a single management rule. Review considers the original rupture status, size and pattern of the residual, growth, device or clip anatomy, previous complications and the risk of retreatment. Technical completion of a procedure is not equivalent to durable complete occlusion.

Aneurysmal subarachnoid haemorrhage is a medical emergency. Timely transfer to a centre with neurocritical, endovascular and microsurgical expertise is important. The ruptured aneurysm should be identified and secured promptly—preferably within 24 hours when feasible—to reduce rebleeding risk. The choice between clipping and endovascular treatment depends on patient condition and aneurysm anatomy.

Recovery may be complicated by hydrocephalus, delayed cerebral ischaemia, vasospasm, infarction, seizures, electrolyte disturbance, cardiac or pulmonary dysfunction, infection and prolonged critical illness. New deterioration requires renewed assessment even after technically successful aneurysm treatment. Some patients later require permanent CSF diversion.

A patient may appear physically recovered while experiencing fatigue, slowed processing, memory or executive difficulty, anxiety, depression, sleep problems or reduced work capacity. Follow-up should include cognition, mood, communication, mobility, return to driving or work and caregiver burden. A favourable basic disability score may not capture the full recovery burden.