Multiple Intracranial Aneurysms: A Case Report and Discussion

Rathika

Nursing In-charge, Kauvery Hospital, Hosur, Tamil Nadu

Introduction

Aneurysms are abnormal bulges or dilations in blood vessel walls, typically occurring in the arteries. They can form in various parts of the body, including the aorta, brain, and other arteries.

Aneurysms can be classified as true or false. A true aneurysm involves all three layers of the arterial wall (intima, media, and adventitia). In contrast, a false aneurysm (also called a pseudo aneurysm) affects only the outer layers of the artery (adventitia).

Key points about aneurysms

Structure: True aneurysms involve all three layers of the arterial wall (intima, media, adventitia).

Causes: They result from weakening of vessel walls due to factors like:

Destruction of extracellular matrix proteins, especially elastin
Imbalance between proteolytic and anti-proteolytic activities

Complications: Aneurysms can grow large before causing symptoms and may rupture, leading to dangerous bleed or even death. Risk increases with size, most occurring at diameters >2cm.

Size: Defined as a dilation at least twice the normal vessel diameter.

Early Detection and Treatment are Crucial for Preventing Rupture

Based on their shape, aneurysms can be classified as saccular or fusiform. Cerebral aneurysms are predominantly saccular (also known as Berry aneurysms), constituting approximately 90% of the cases. In contrast, aortic aneurysms are more commonly fusiform (94%). Aneurysms are further categorized based on their location in the body.

This review focuses on saccular cerebral aneurysms. Saccular cerebral aneurysms are classified by size as follows:

Small: 5 mm or less
Medium: 6 mm to 14 mm
Large: 15 mm to 25 mm
Giant: Greater than 25 mm

Case Presentation

A 68-year-old male presented to the Emergency Room (ER) with complaints of giddiness followed by a brief loss of consciousness (5–10 min) and a history of a single episode of vomiting.

On Examination

Patient was conscious and oriented
Blood Pressure (BP): 100/70 mmHg (Right arm), 90/60 mmHg (Left arm)
Cardiovascular System (CVS): S1 S2 (+)
Respiratory System (RS): Bilateral air entry present (BAE+), soft abdomen, non-tender
Glasgow Coma Scale (GCS): E4V5M6, Bilateral pupils reactive (3 mm RTL)

Vital Signs

Blood Pressure: 100/70 mmHg; Pulse Rate (PR): 80 bpm; SpO2: 100%

Random Blood Sugar (GRBS):120 mg/dL

Investigations

Laboratory Investigations

Parameter	Patient Value
Hemoglobin (Hb)	12.4 g/dL
Total Leukocyte Count	7,820 cells/cu mm
Urea	29.3 mg/dL
Creatinine	0.6 mg/dL
Platelet Count	190,000/cu mm
Sodium	136 mmol/L
INR	1.01
PTT	11.3 sec
Troponin	270.6 g/L
Bilirubin	0.6 mg/dL
SGOT	39 U/L
SGPT	21 U/L
Serum Osmolality	293 mOsm/L

CT Brain

Right frontotemporal (FTP) acute subdural hemorrhage (SDH) present, Grade III subarachnoid hemorrhage (SAH), midline shift absent, cisterns open.

Clinical Course and Management

The patient subsequently developed respiratory arrest and was intubated with mechanical ventilation support. A repeat CT brain confirmed right FTP acute SDH, Grade III SAH, and a saccular aneurysm arising from the supraclinoid part of the right internal carotid artery (ICA). No evidence of thrombosis was noted.

He was diagnosed with a ruptured right C6 segment saccular aneurysm with right FTP acute SDH/Grade III SAH. Digital Subtraction Angiography (DSA) revealed multiple intracranial aneurysms, including a left supraclinoid segment blister aneurysm.

The patient’s family was counselled regarding treatment options. With informed consent, endovascular coiling of the right supraclinoid segment aneurysm was performed successfully. The postoperative period was uneventful. The patient was later extubated, demonstrating improved neurological status (GCS E4V6M6, pupils 3 mm RTL bilaterally).

A repeat CT brain showed persistent right temporoparietal intracerebral hemorrhage (ICH) with lateral ventricle compression. Conservative management was initiated with anti-edema measures, serial neuroimaging, and electrolyte monitoring. Despite stabilization, the patient developed irrelevant speech, hallucinations, and sleep disturbances, necessitating psychiatric evaluation and supportive therapy.

Medications

Drug	Dosage	Frequency
Levetiracetam (Levipil)	500 mg	BD
Nimodipine	60 mg	Q6H
Domperidone (Xenodom)	500 mg	BD
Pantoprazole (Sompraz D)	40 mg	OD
Tramadol (Trapex)	2 mg	OD
Amniotic Growth Factor (Amniorich)	-	OD
Dexamethasone (Dexa)	4 mg	BD
Sodium Bicarbonate (Nodosis)	500 mg	TID

Nursing management

The patient was managed with antibiotics, antiepileptics, and antidepressants, along with symptomatic treatment. Ventilator support was provided as needed. Continuous psychological support was extended to both the patient and family. The patient gradually improved and was discharged in stable condition.

Exercise-nutrition-psychology oriented nursing
- Improves self-management ability by 10.7% (P<0.05)
- Reduces postoperative complications (3.1% vs 10.7%, P<0.05)
Comfort nursing
- Shortens time to resume normal diet and exercise
- Improves Glasgow Outcome Scale scores
- Reduces anxiety and pain
- Increases patient satisfaction

Nutrition support

For patients with saccular aneurysm, a heart-healthy diet is recommended, emphasizing:

Enteral nutrition (EN) initiated ~3 days’ post-admission
8% calorie adequacy (mean 10.0 kcal/kg/day)
Consider small bowel feeding (10% of intolerant patients) and motility agents (76.7%) for GI intolerance
Diet prescribed: Fruits, vegetables, whole grains, lean proteins, healthy fats, and antioxidants
Limited intake of: Saturated fats and sodium to manage blood pressure and reduce inflammation.

Conclusion

This case highlights the importance of early detection, rapid intervention, and multidisciplinary management in ruptured intracranial aneurysms. Endovascular coiling remains an effective, minimally invasive treatment, reducing morbidity and improving patient outcomes in appropriately selected cases.

Multiple Intracranial Aneurysms: A Case Report and Discussion

Multiple Intracranial Aneurysms: A Case Report and Discussion

Rathika

Nightingale Journals