Assessment

HISTORY. Prior to rupture, cerebral aneurysms are usually asymptomatic. The patient is usually seen initially after subarachnoid hemorrhage (SAH). Ask about one or more incidences of sudden headache with vomiting in the weeks preceding major SAH. Other relevant symptoms are a stiff neck, back or leg pain, or photophobia, as well as hearing noises or throbbing (bruits) in the head. "Warning leaks" of the aneurysm in which small amounts of blood ooze from the aneurysm into the subarachnoid space can cause such symptoms. These small "warning leaks" are rarely detected because the condition is not severe enough for the patient to seek medical attention.

Identify risk factors such as familial predisposition, hypertension, cigarette smoking, or use of over-the-counter medications (e.g., nasal sprays or antihistamines) that have vasoconstrictive properties. Ask about the patient's occupation, because if the patient's job involves strenuous activity, there may be a significant delay in going back to work or the need to change occupations entirely.

PHYSICAL EXAMINATION. In most patients, the neurological examination does not point to the exact site of the aneurysm, but in many instances, it can provide clues to the localization. Signs and symptoms can be divided into two phases: those presenting before rupture or bleeding and those presenting after rupture or bleeding. In the phase before rupture or bleeding, observe for oculomotor nerve (cranial nerve III) palsy—dilated pupil (loss of light reflex), possible drooping eyelids (ptosis), extraocular movement deficits with possible double vision—as well as pain above and behind the eye, localized headache, or extraocular movement deficits of the trochlear (IV) or abducens (VI) cranial nerves. Small, intermittent, aneurysmal leakage of blood may result in generalized headache, neck pain, upper back pain, nausea, and vomiting. Note if the patient appears confused or drowsy.

PSYCHOSOCIAL. The patient has to cope not only with an unexpected, sudden illness but also with the fear that the aneurysm may rupture at any time. Assess the patient's ability to cope with a sudden illness and the change in roles that a sudden illness demands. In addition, assess the patient's degree of anxiety about the illness and potential complications.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Cerebral

Symmetrical, intact

Pooling of contract medium,

Radiographic views of

angiogram

pattern of cerebral

indicating bleeding or

cerebral circulation show

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