Treatment of Cerebral Aneurysms

16/9/22, 10:57 Treatment of cerebral aneurysms - UpToDate
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Treatment of cerebral aneurysms

Authors: Robert J Singer, MD, Christopher S Ogilvy, MD, Guy Rordorf, MD
Section Editor: José Biller, MD, FACP, FAAN, FAHA
Deputy Editor: Richard P Goddeau, Jr, DO, FAHA
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2022. | This topic last updated: Aug 12, 2022.
INTRODUCTION
Cerebral aneurysms are thin-walled protrusions in the intracranial arteries that may rupture
to cause a subarachnoid hemorrhage (SAH), often a devastating event with a high mortality
and morbidity. Unruptured cerebral aneurysms may also manifest clinically by their mass
effect on adjacent neurologic structures, or they may be discovered incidentally when a
patient has a neuroimaging study for another indication. Unruptured aneurysms have a
future risk of rupture and SAH that varies in part by size and location. Endovascular or
surgical repair is the only effective treatment for aneurysmal SAH to prevent rebleeding and
further morbidity and is also used for some patients with unruptured cerebral aneurysms to
prevent SAH.
The treatment of cerebral aneurysms is discussed in this topic. Other aspects of the clinical
features, diagnosis, and management of cerebral aneurysms and aneurysmal SAH are
discussed separately.
● (See "Screening for intracranial aneurysm".)

● (See "Unruptured intracranial aneurysms".)
● (See "Aneurysmal subarachnoid hemorrhage: Epidemiology, risk factors, and
pathogenesis".)
● (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis".)
● (See "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis".)
PATIENTS WITH SUBARACHNOID HEMORRHAGE
Early rebleeding — Rebleeding occurs in 8 to 23 percent of patients with aneurysmal

subarachnoid hemorrhage (SAH). Most studies have found that the risk of rebleeding is
https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 1/14
highest in the first 24 hours after SAH, particularly within six hours of the initial hemorrhage
[1-4]. (See "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis", section on
'Rebleeding'.)
Aneurysmal rebleeding is associated with a poor prognosis. In a prospective study involving

574 hospitalized patients admitted within 14 days of SAH, rebleeding was associated with a
12-fold reduction in the probability of survival with functional independence at three months
(odds ratio [OR] 0.08, 95% CI 0.02-0.34) after correction for admission Hunt and Hess grade
and aneurysm size [3]. Another prospective study found similar results [5]. In one case
series, half of hemorrhage expansions were related to rerupture of the aneurysm [6]. Other
mechanisms of hemorrhage expansion or rebleeding may be similar to those for
intracerebral hemorrhage. (See "Spontaneous intracerebral hemorrhage: Acute treatment
and prognosis", section on 'Managing hemorrhagic expansion'.)
Only aneurysm treatment is effective in preventing rebleeding. In one analysis of

neurosurgical aneurysm clipping, the authors estimated the absolute reduction in the risk of
a poor outcome was 10 percent (ie, 10 surgeries would prevent a poor outcome in one
patient) [7]. Patients in whom aneurysm treatment is not possible or is unavoidably delayed
may be candidates for antifibrinolytic therapy.
Timing and choice of therapy — Decisions regarding the timing and choice of therapy for a
rupture intracranial aneurysm are ideally made by a team of experienced clinicians.
● The timing of surgery following intracranial aneurysm rupture is an area of

controversy. The potential benefits of early surgery (within 24 to 72 hours of the
hemorrhage) include prevention of rebleeding and management of vasospasm. In
addition, the usual methods of treating vasospasm (hypervolemia, induced
hypertension, intraarterial vasodilators, and balloon angioplasty) are dangerous in the
presence of an untreated aneurysm. (See 'Early rebleeding' above and "Aneurysmal
subarachnoid hemorrhage: Treatment and prognosis", section on 'Vasospasm and
delayed cerebral ischemia'.)
● Decisions regarding the choice of therapy in the treatment of a ruptured intracranial

aneurysm are made by a team of experienced surgeons and endovascular
practitioners. Factors important to consider include the neurologic grade and clinical
status of the patient, the availability of expertise in surgical and endovascular
techniques, as well as the anatomic characteristics of the aneurysm, including the
location and the size of the aneurysm and its neck [8,9]. (See 'Anatomic considerations'
below.)
Good-grade SAH — Early aneurysm repair (within 24 to 72 hours) in patients with good-

grade aneurysmal SAH (Hunt and Hess grades I to III) ( table 1) is a generally accepted

treatment with a satisfactory outcome in the large majority of patients. Approximately 70 to

90 percent of patients have a good neurologic recovery, with a mortality rate of 1.7 percent
to 8 percent [10]. Limited clinical trial evidence suggests that early aneurysm surgery may be
associated with a lower risk of rebleeding and better outcome than later surgery, but the
results did not achieve statistical significance [11,12]. Observational studies, which are
limited by selection bias, suggest that early intervention is associated with better outcomes
[13].
A subset of patients with good-grade aneurysmal SAH may do as well, or even better, with
endovascular coiling [14,15]. In the largest of the randomized trials to examine this question,
the International Subarachnoid Aneurysm Trial (ISAT), 2143 patients with ruptured
intracranial aneurysms were randomly assigned to neurosurgical clipping or endovascular
coiling [16,17]. The patients in this study represented a selected subgroup in which 88
percent were of good clinical status, and aneurysms ≤3 mm were excluded; 90 percent of the
target aneurysms were smaller than 10 mm in diameter, and 95 percent of aneurysms were
in the anterior circulation [17]. Outcomes included:
● Lower rates of combined death and disability at one year in the endovascular group
(23.5 versus 30.9 percent), with an absolute risk reduction of 7.4 percent (95% CI 3.6-
11.2) [17]. At 10 years, the endovascular group continued to have somewhat lower
rates of both mortality and combined death and dependency (OR 1.35, 95% CI 1.06-
1.73, and OR 1.34, 95% CI 1.07-1.67, respectively) [18].
● Similar mortality at one year, 8.0 percent (95% CI 6.4-9.8) and 9.9 percent (95% CI 8.2-
11.9), in the endovascular and neurosurgical groups, respectively [17].
● Higher rates of post-treatment rebleeding from the target aneurysm in the

endovascular therapy group during the first year (2.6 versus 1.0 percent). Few
rebleeding events occurred in either treatment group after one year but again were
more common in the endovascular therapy group [19]. However, within eight years
rebleeding rates become similar [20]. (See "Late recurrence of subarachnoid
hemorrhage and intracranial aneurysms".)
● Lower rates of post-treatment seizures in the endovascular group (relative risk 0.52,
95% CI 0.37-0.74) [17]. At one year, the prevalence of epilepsy and cognitive
impairment were less common in patients treated by endovascular coiling than surgical
clipping [21].
These results can only be applied to patients who fit the characteristics of patients selected
to participate in the ISAT, which is a small percentage of patients presenting with SAH [16].
For such patients, endovascular coiling appears to have somewhat more favorable outcomes

and is probably the favored treatment for aneurysm repair if anatomic and morphologic
features of the aneurysm are deemed appropriate for endovascular treatment.
Poor-grade SAH — The prognosis for patients with aneurysmal SAH and with poor clinical
grade (Hunt and Hess IV and V) ( table 1) is poor, particularly in those patients with a
Glasgow Coma Scale motor score ( table 2) less than 4 [22]. Treatment decisions need to
be individualized with consultation with family members. Some data suggest that aneurysm
occlusion in such patients (particularly if associated with advanced age and medical
comorbidity) may not improve their overall prognosis [23]. Nonetheless, we favor early
treatment, with endovascular therapy when possible for patients with poor-grade SAH.
Early surgery may be more complicated than a procedure delayed for 10 to 14 days in
patients with poor clinical grade. The presence of cerebral edema (which may prevent brain
retraction and relaxation) and clot around the aneurysm increases the technical difficulty of
surgery. Early surgery may be associated with an increased risk of ischemic complications
[24]. However, early rebleeding is also more common in patients with poor clinical grade
[25]. One large retrospective study of 2106 patients found that delayed surgery was
associated with a small, nonsignificant reduction in delayed cerebral ischemia, but a
significant increase in poor outcomes [26].
Endovascular techniques also may offer a less invasive and often definitive mode of therapy
for this group [27]; the concerns regarding the increased difficulty of early surgery do not
apply to intraluminal therapy. In addition, although not substantiated by any large series,
the use of intravascular embolization of aneurysms in the acute setting may facilitate
aggressive medical management algorithms for proactive treatment of cerebral vasospasm.
A systematic review and meta-analysis that included the ISAT as well as other smaller
randomized trials and observational studies found that while outcomes at one-year were
more favorable in patient treated with endovascular coiling, the choice of treatment
modality did not seem to have a significant impact on outcome in patients with poor
preoperative grade [28]. In a subsequently performed randomized trial of 571 patients with
SAH that included patients with a broader spectrum of disease severity than were included
in ISAT, patients assigned to endovascular treatment were more likely to have a better
outcome at one year as measured by the modified Rankin Scale; the difference no longer
reached statistical significant at year 3 [29,30]. It is noteworthy that 38 percent of those
assigned to endovascular treatment crossed over to surgical clipping (usually because the
endovascular treatment was judged to be technically difficult); such patients had a worse
outcome than those who received the assigned endovascular treatment and was similar to
those who were assigned to and received clipping.
Post-treatment management — Patients are managed in the intensive care unit after

aneurysm therapy. Continuous cardiodynamic and neurologic monitoring is critical.
Postoperative angiography is used at the surgeons' discretion. Patients should have

monitoring and treatment for vasospasm. (See "Aneurysmal subarachnoid hemorrhage:
Treatment and prognosis", section on 'Vasospasm and delayed cerebral ischemia'.)
PATIENTS WITH UNRUPTURED ANEURYSMS
The management of unruptured intracranial aneurysms is controversial [31]. There are no

randomized trials on which to base recommendations. Decisions about therapy need to
weigh the natural history of the aneurysm, the risks of intervention, and patient preferences.
While these are discussed in detail separately, in general, asymptomatic aneurysms ≥7 to 10
mm in diameter warrant strong consideration for treatment, taking into account patient age,
existing medical and neurologic conditions, and relative risks for treatment [32]. (See
"Unruptured intracranial aneurysms", section on 'Risk factors for aneurysm rupture' and
"Unruptured intracranial aneurysms", section on 'Risk of intervention'.)
Surgical treatment of unruptured aneurysms has been the most common procedure used in
patients who undergo definitive therapy. In clinical studies, which are typically in centers
with high case volumes, endovascular techniques appear to be associated with lower
morbidity and mortality than surgical clipping and are playing an increasing role in the
treatment of unruptured aneurysms [33-40]. New technologies, such as flow diversion, may
advance the safety of endovascular treatment and allow aneurysms, previously considered
to be inaccessible or technologically difficult for such treatment [41]. (See 'Newer techniques'
below.)
TECHNIQUES
Surgical and endovascular techniques are available for aneurysm treatment. In many cases,
anatomic considerations, such as size and location, along with other morphological features,
determine which treatment is most appropriate for the patient.
Surgery — Surgical management of cerebral aneurysms, in which a clip is placed across the

neck of the aneurysm, is an effective and safe procedure with the evolution of microsurgical
techniques in the hands of an experienced surgeon ( image 1). This applies to patients
with unruptured cerebral aneurysms and those with subarachnoid hemorrhage (SAH) [7].
Treatment at specialized neurosurgical centers performing high volumes of cerebral

aneurysm procedures is associated with better outcome compared with treatment at lower-
volume centers [42]. Temporary clip occlusion may be achieved via traditional extraluminal
clip placement or with an intravascular balloon but does not clearly prevent complications
[43]. Intraoperative angiography is useful to facilitate accurate clip placement and to confirm

parent vessel patency after clip occlusion and occlusion of the aneurysm; this allows
immediate clip revision when necessary, which is estimated to occur in approximately 10
percent of patients [44-48]. Intraoperative hypothermia does not appear to improve
neurologic outcome after surgery for intracranial aneurysm clipping [49-51]. Prolonged
hypotension should be avoided during surgery [44].
Risks associated with surgical aneurysm treatment include new or worsened neurologic
deficits caused by brain retraction, temporary arterial occlusion, and intraoperative
hemorrhage [52-54]. Intraprocedural aneurysmal rupture occurred in 19 percent of 711
patients treated with surgical clipping in the Cerebral Aneurysm Rerupture After Treatment
(CARAT) study and was associated with periprocedural death and disability [55]. Procedure-
related surgical complications occurred in 29 (20 percent) of 143 patients in a retrospective
series [56], although functional outcome was good in 22 (76 percent) of those patients.
Endovascular therapy
Coil embolism — The Guglielmi electrolytically detachable coil system was introduced in

the early 1990s [57]. Platinum coils are inserted into the lumen of the aneurysm
( image 2). A local thrombus then forms around the coils, obliterating the aneurysmal sac
[58]. The procedure is often, but not invariably, performed under general anesthesia [44].
Complications of endovascular coiling include thromboembolism and intraprocedural

aneurysm rupture. Both of these complications are somewhat more common in the setting
of SAH than for unruptured aneurysms [59,60].
● Thromboembolism occurred in 12.5 percent of endovascularly treated aneurysms in

one series [61]. Aneurysm size >10 mm and neck size >4 mm were risk factors for this
complication.
● While of unproven benefit, some combination of heparin and/or antiplatelet therapy is

used in most centers to minimize sequelae [62]. In one large series, 9.3 percent of
patients experienced a thromboembolic event during coiling despite use of heparin
and aspirin [63]. In one series, GIIB/IIIa inhibitors appeared to be safer for this
indication than thrombolytic agents [64].
● Intraprocedural aneurysmal rupture occurred in 5 percent of 299 patients with

aneurysmal SAH treated with coil embolization in the CARAT study [55]. Periprocedural
death or disability was more likely in those with this complication compared with those
without rupture (34 versus 17 percent). Other studies have shown similar rates of
intraprocedural rupture during endovascular coiling of 4 to 5 percent [60,61,65].
Among different series, risk factors for this complication have been variably noted to
include small aneurysm size, middle cerebral artery location, ruptured versus

unruptured status, and hypertension [61,66,67]. Patients treated with anticoagulation

or antiplatelet therapy may require reversal of these therapies if intraprocedural
rupture occurs [44].
Coiled aneurysms also appear to be more likely than clipped aneurysms to recur and require
additional intervention. (See "Late recurrence of subarachnoid hemorrhage and intracranial
aneurysms", section on 'Recurrence of the treated aneurysm'.)
Newer techniques — Endovascular therapy for cerebral aneurysms is evolving. New

techniques under investigation including stent-assisted coiling, balloon-assisted coiling, flow
diverters and disruptors, and new embolic material including liquids offer promise that
aneurysms previously considered not amenable to therapy will be treatable in the future
[59,68].
Anatomic considerations — Aneurysms in distal arterial segments are often not amenable

to endovascular therapy [69]; surgical therapy may be preferred in these circumstances.
Endovascular treatment is often the preferred technique for proximal intracranial carotid
and posterior circulation aneurysms, which are accessible by angiogram but harder to get to
surgically [70]. In contrast, aneurysms at the middle cerebral artery trifurcation are difficult
to coil without complication, and surgery may be preferred for these lesions.
Combined endovascular and surgical techniques may be required with some very large or
complex aneurysms [71]. Some aneurysms remain challenging to treat by any technique;
these include giant aneurysms, fusiform aneurysms, and those with very broad necks and a
low fundus-to-neck ratio [59].
ANEURYSM RECURRENCE AND LATE REBLEEDING
Patients who survive aneurysmal subarachnoid hemorrhage (SAH) and those with
unruptured intracranial aneurysms have a small but enduring risk of subsequent SAH, which
can occur despite successful endovascular or surgical treatment of the aneurysm.
SAH may result from recurrence of the treated aneurysm, rupture of another pre-existing
aneurysm in a patient with multiple aneurysms, and de novo aneurysm formation. The risk
of these events and recommendations for monitoring and treatment are discussed
separately. (See "Late recurrence of subarachnoid hemorrhage and intracranial aneurysms".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Stroke in adults".)

SUMMARY AND RECOMMENDATIONS
● Patients with subarachnoid hemorrhage – Patients with ruptured cerebral

aneurysms present with aneurysmal subarachnoid hemorrhage (SAH). Decisions
regarding the timing and choice of therapy for ruptured intracranial aneurysms are
ideally made by a team of experienced clinicians who consider the neurologic grade
and clinical status of the patient, the availability of expertise in surgical and
endovascular techniques, as well as the anatomic characteristics of the aneurysm. (See
'Timing and choice of therapy' above.)
• For patients with good-grade aneurysmal SAH (Hunt and Hess grades I to III)
( table 1), we suggest early aneurysm repair (within 24 to 72 hours) (Grade 2C). In
centers with available expertise and in patients with endovascularly accessible
lesions, short-term outcomes appear to be improved with endovascular coiling
compared with surgical clipping. (See 'Good-grade SAH' above.)
• The optimal timing and choice of therapy in patients with more severe aneurysmal
SAH (Hunt and Hess grades IV and V) is uncertain. Their overall prognosis is poor,
particularly for older patients. Treatment decisions need to be individualized in
consultation with family members. (See 'Poor-grade SAH' above.)
● Patients with unruptured cerebral aneurysms – Asymptomatic aneurysms ≥7 to 10

mm in diameter warrant strong consideration for treatment, taking into account
patient age, existing medical and neurologic conditions, and relative risks for
treatment. (See "Unruptured intracranial aneurysms".)
● Treatment techniques – Surgical clipping and endovascular coiling are the most
commonly used techniques for aneurysm treatment. In many cases, anatomic
considerations, such as size, location, and other morphological features determine
which treatment is most appropriate for the patient. (See 'Techniques' above.)
• Surgical management of cerebral aneurysms involves placing a clip across the neck
of the aneurysm to secure the lesion ( image 1). Distal aneurysms and aneurysms
at the middle cerebral artery trifurcation can be difficult to treat with endovascular
techniques and are frequently treated with surgery. (See 'Surgery' above.)
• Endovascular techniques include placing coils into the lumen of the aneurysm
( image 2). A local thrombus then forms around the coils, obliterating the
aneurysmal sac. Other options include stent-assisted coiling, balloon-assisted
coiling, and flow diverters and disruptors. Endovascular treatment is often the
preferred technique for proximal intracranial carotid and posterior circulation

aneurysms, which are accessible by angiogram but can be difficult to access

surgically. (See 'Endovascular therapy' above.)
• Combined endovascular and surgical techniques may be required with some very
large or complex aneurysms. (See 'Newer techniques' above.)
● Management of late recurrence – Patients with aneurysmal SAH are at enduring risk
of recurrent SAH despite aneurysm treatment and may require follow-up evaluations.
(See "Late recurrence of subarachnoid hemorrhage and intracranial aneurysms".)
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Topic 90190 Version 13.0

GRAPHICS
Hunt and Hess grading system for patients with subarachnoid

hemorrhage
Grade Neurologic status
1 Asymptomatic or mild headache and slight nuchal rigidity
2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
3 Drowsy or confused, mild focal neurologic deficit
4 Stuporous, moderate or severe hemiparesis
5 Coma, decerebrate posturing
Based upon initial neurologic examination.
Adapted from: Hunt W, Hess R. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J
Neurosurg 1968; 28:14.
Graphic 69179 Version 5.0
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Glasgow Coma Scale (GCS)
Score
Eye opening
Spontaneous 4
Response to verbal command 3
Response to pain 2
No eye opening 1
Best verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Best motor response
Obeys commands 6
Localizing response to pain 5
Withdrawal response to pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1
Total
The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three
parameters: best eye response (E), best verbal response (V), and best motor response (M). The
components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS
score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates
with moderate injury, and a score of 8 or less represents severe brain injury.

Clip ligation of cerebral aneurysm
Left panel: Anteroposterior cerebral angiogram demonstrating a basilar

summit aneurysm.
Right panel: Postoperative cerebral angiogram demonstrating clip ligation of

the lesion with preserved parent vessel patency.
Courtesy of Guy Rordorf, MD.

Aneurysm before and after therapy
Towne projection of an aneurysm of the right posterior cerebral artery before

(left panel) and after (right panel) successful coil embolization.
Courtesy of Guy Rordorf, MD.


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16/9/22, 10:57 Treatment of cerebral aneurysms - UpToDate

Official reprint from UpToDate®

● (See "Screening for intracranial aneurysm".)

PATIENTS WITH SUBARACHNOID HEMORRHAGE

Early rebleeding — Rebleeding occurs in 8 to 23 percent of patients with aneurysmal

Aneurysmal rebleeding is associated with a poor prognosis. In a prospective study involving

Only aneurysm treatment is effective in preventing rebleeding. In one analysis of

● The timing of surgery following intracranial aneurysm rupture is an area of

● Decisions regarding the choice of therapy in the treatment of a ruptured intracranial

Good-grade SAH — Early aneurysm repair (within 24 to 72 hours) in patients with good-

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 2/14

treatment with a satisfactory outcome in the large majority of patients. Approximately 70 to

● Higher rates of post-treatment rebleeding from the target aneurysm in the

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 3/14

Post-treatment management — Patients are managed in the intensive care unit after

Postoperative angiography is used at the surgeons' discretion. Patients should have

PATIENTS WITH UNRUPTURED ANEURYSMS

The management of unruptured intracranial aneurysms is controversial [31]. There are no

Surgery — Surgical management of cerebral aneurysms, in which a clip is placed across the

Treatment at specialized neurosurgical centers performing high volumes of cerebral

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 5/14

Coil embolism — The Guglielmi electrolytically detachable coil system was introduced in

Complications of endovascular coiling include thromboembolism and intraprocedural

● Thromboembolism occurred in 12.5 percent of endovascularly treated aneurysms in

● While of unproven benefit, some combination of heparin and/or antiplatelet therapy is

● Intraprocedural aneurysmal rupture occurred in 5 percent of 299 patients with

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 6/14

unruptured status, and hypertension [61,66,67]. Patients treated with anticoagulation

Newer techniques — Endovascular therapy for cerebral aneurysms is evolving. New

Anatomic considerations — Aneurysms in distal arterial segments are often not amenable

ANEURYSM RECURRENCE AND LATE REBLEEDING

SOCIETY GUIDELINE LINKS

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 7/14

SUMMARY AND RECOMMENDATIONS

● Patients with subarachnoid hemorrhage – Patients with ruptured cerebral

● Patients with unruptured cerebral aneurysms – Asymptomatic aneurysms ≥7 to 10

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 8/14

aneurysms, which are accessible by angiogram but can be difficult to access

Use of UpToDate is subject to the Terms of Use.

Topic 90190 Version 13.0

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_re… 9/14

Hunt and Hess grading system for patients with subarachnoid

Grade Neurologic status

1 Asymptomatic or mild headache and slight nuchal rigidity

3 Drowsy or confused, mild focal neurologic deficit

4 Stuporous, moderate or severe hemiparesis

5 Coma, decerebrate posturing

Based upon initial neurologic examination.

Graphic 69179 Version 5.0

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_r… 10/14

Glasgow Coma Scale (GCS)

Response to verbal command 3

Best verbal response

Best motor response

Localizing response to pain 5

Withdrawal response to pain 4

Graphic 81854 Version 9.0

https://www.uptodate.com/contents/treatment-of-cerebral-aneurysms/print?search=hemorragia subaracnoidea aneurismática&source=search_r… 11/14

Clip ligation of cerebral aneurysm

Left panel: Anteroposterior cerebral angiogram demonstrating a basilar

Right panel: Postoperative cerebral angiogram demonstrating clip ligation of

Courtesy of Guy Rordorf, MD.

Graphic 68084 Version 3.0