Intracranial (Cerebral) Aneurysm Nursing Care Management and Study Guide

An intracranial aneurysm is a dilation of a cerebral artery wall caused by weakness in that wall. When it ruptures it bleeds into the subarachnoid space, and that is a hemorrhagic stroke. Your job on the floor is to recognize neurologic deterioration early, keep blood pressure controlled, prevent rebleeding and vasospasm, and protect a patient who needs absolute rest and minimal stimulation.

What Is an Intracranial Aneurysm?

Hemorrhagic strokes bleed into brain tissue, the ventricles, or the subarachnoid space, and a ruptured intracranial aneurysm is one cause. The aneurysm is a dilation of a cerebral artery wall from arterial weakness; subarachnoid hemorrhage is what happens when it ruptures.

Pathophysiology

Blood entering the subarachnoid space disrupts normal brain metabolism. The sudden entry of blood raises ICP, and the surrounding brain tissue is compressed and injured.

Statistics and Incidences

Intracranial aneurysm accounts for half of hemorrhagic strokes. The mortality rate has been reported as high as 48% at 30 days after an intracranial hemorrhage. Hemorrhagic strokes account for 15% to 20% of cerebrovascular disorders and are primarily caused by intracranial hemorrhage. Primary intracerebral hemorrhage from spontaneous rupture of small vessels accounts for roughly 80% of hemorrhagic strokes.

Causes

The cause is unknown, though atherosclerotic fatty plaques lining cerebral vessels, a congenital defect in the vessel wall present at birth, and uncontrolled hypertensive vascular disease that ruptures small cerebral vessels are all implicated.

Clinical Manifestations

Symptoms appear when the aneurysm presses on nearby cranial nerves or brain tissue. The conscious patient most often reports a severe headache. Increased ICP can cause vomiting and a sudden, early change in level of consciousness. Focal seizures can occur with brain stem involvement. Expect nuchal rigidity (pain and stiffness of the neck and spine from irritation), and visual loss, diplopia, or ptosis if the aneurysm sits next to the oculomotor nerve.

Prevention

Primary prevention is the best approach. Control hypertension, especially in people older than 55 years, to reduce risk. Stroke risk screenings identify high-risk individuals and groups, and patient and community education on recognition and prevention lowers risk further.

Complications

Hematoma expansion (rebleeding) is a fatal complication. Cerebral vasospasm causes cerebral ischemia. Acute hydrocephalus develops when free blood obstructs CSF reabsorption by the arachnoid villi. Seizures may occur from extreme nerve irritation.

Assessment and Diagnostic Findings

Any patient with a suspected stroke should get a CT scan or MRI to determine stroke type, hematoma size and location, and the presence of ventricular blood or hydrocephalus. Cerebral angiography confirms the diagnosis of intracranial aneurysm. Lumbar puncture is performed only if there is no evidence of increased ICP, the CT is negative, and subarachnoid hemorrhage still must be confirmed.

Medical Management

The goals are to let the brain recover from the initial insult, prevent or minimize rebleeding, and prevent or treat complications. Bed rest with sedation prevents agitation and stress. If bleeding is caused by warfarin anticoagulation, correct the INR with fresh frozen plasma and vitamin K. Antiseizure agents are often given prophylactically for a brief period because seizures can follow intracerebral hemorrhage. Analgesics may be prescribed for head and neck pain. Sequential compression devices or anti-embolism stockings prevent deep vein thrombosis.

Surgical Management

Surgery prevents bleeding in an unruptured aneurysm or further bleeding in a ruptured one. Surgical evacuation is most often done via craniotomy. Endovascular treatment occludes the parent artery. Aneurysm coiling obstructs the aneurysm site with a coil.

Nursing Management

All patients are monitored in the intensive care unit after an intracerebral aneurysm.

Nursing Assessment

Perform a complete neurologic assessment initially, evaluating level of consciousness, pupillary reaction (watch for sluggish response), motor and sensory function, cranial nerve deficits (extraocular movements, facial droop, ptosis), speech difficulty and visual disturbance, and headache or nuchal rigidity.

Nursing Diagnosis

Major diagnoses may include ineffective tissue perfusion related to bleeding or vasospasm, disturbed sensory perception related to medically imposed restrictions, and anxiety related to illness or aneurysm precautions.

Nursing Care Planning and Goals

Goals are to improve cerebral tissue perfusion, relieve sensory and perceptual deprivation, relieve anxiety, and prevent complications.

Nursing Interventions

Improve cerebral tissue perfusion. Monitor closely for neurologic deterioration and keep a neurologic flow record. Check blood pressure, pulse, level of consciousness, pupillary responses, and motor function hourly, and report respiratory changes immediately. Implement aneurysm precautions: immediate and absolute bed rest in a quiet, nonstressful setting with visitors restricted to family. Elevate the head of the bed 15 to 30 degrees or as ordered. Avoid anything that suddenly raises blood pressure or obstructs venous return (Valsalva maneuver, straining); have the patient exhale during voiding or defecation, eliminate caffeine, give all personal care, and minimize external stimuli. Apply anti-embolism stockings or sequential compression devices and watch the legs for DVT signs (tenderness, redness, swelling, warmth, edema).

Relieve sensory deprivation by keeping stimulation to a minimum and explaining restrictions so the patient feels less isolated. Relieve anxiety by informing the patient of the plan of care and providing support and reassurance to patient and family.

Monitor and manage complications. Assess for and immediately report signs of vasospasm, which may occur several days after surgery or at the start of treatment (intensified headache, decreased responsiveness, aphasia, partial paralysis); give calcium channel blockers or fluid volume expanders as prescribed. Maintain seizure precautions, protect the airway, and prevent injury if a seizure occurs; phenytoin (Dilantin) is the antiseizure agent of choice. Watch for hydrocephalus, which may be acute (first 24 hours after hemorrhage, sudden stupor or coma), subacute (days later), or delayed (several weeks later, with gradual drowsiness, behavioral changes, and ataxic gait); report it immediately. Watch for rebleeding, which occurs most often in the first 2 weeks and presents with sudden severe headache, nausea, vomiting, decreased consciousness, and neurologic deficit. Monitor laboratory data often, because hyponatremia (serum sodium under 135 mEq/L) affects up to 30% of patients; report low levels persisting for 24 hours, since SIADH or cerebral salt wasting syndrome may develop.

Teach self care. Give the patient and family the information they need to cooperate with care and activity restrictions and to prepare for discharge: the causes of intracranial hemorrhage, its possible consequences, the medical or surgical treatments used, and the importance of aneurysm precautions and close monitoring. Facilitate transfer to rehabilitation as indicated.

Evaluation

Expected outcomes are improved cerebral tissue perfusion, relief of sensory and perceptual deprivation, relief of anxiety, and absence of complications.

Discharge and Home Care Guidelines

Teach the patient and family about the causes of intracranial aneurysm and its possible consequences, the medical and surgical treatments used and why interventions to protect cerebral perfusion matter, and the use of assistive devices or home modifications to help the patient live with any disability. Stress the importance of keeping followup appointments for monitoring of risk factors.

Documentation Guidelines

Document the extent, nature, and duration of the problem; effects on independence and lifestyle; pulses and BP; assistive device needs; plan of care and teaching plan; response to interventions and teaching; progress toward outcomes; modifications to the plan of care; and long-term needs.