**3.8 Medical management after flow diverter placement**

All the patients that can be good candidates for PED placement based on their UIA characteristics needs also to be eligible for prolonged DAPT. Acetylsalicylic acid (ASA) plus clopidogrel is the DAPT of reference used for preventing thrombosis in such procedures [69]. The laboratory tests pre and post-procedure are yet to be standardized; due to the risk of clopidogrel resistant (28–68%) [70], is has been considered necessary to assess platelet reactivity. High platelet reactivity (HPR) is related with thromboembolic evens after stenting arteries [71]. Depending on institutional protocols, some neuro-interventional teams use the VerifyNow P2Y12 assay which has been widely studied however, the results of this tests may not be completely reliable [72] due to the fact that P2Y12 response units (PRU) cannot differentiate aspirin-induced platelet inhibition in patients administered clopidogrel. Other studies recommend the use of the Thromboelastography (TEG), which is dynamic and real time tool to measure clot formation. The advantages of VerifyNow assay is that can be done very fast with instant results, however in patients with programed procedures for UIA stenting this concerning may not be transcendental.

**Figure 3.** *Web Endoluminal bridge placement in left ICA bifurcation.*

**Figure 4.** *Flowchart of management after incidental UIA diagnosis.*

VerifyNow can overestimate the rate of clopidogrel resistance when compared to TEG. However, there is currently no randomized trials that have assessed the utility of this tests. Moreover, there's no strong evidence to support that the assessment of platelet reactivity improves clinical and imaging outcomes after stent placement. Nevertheless, the neuro-interventional teams at these days usually starts the DAPT with 325 mg of ASA and 75 mg of clopidogrel 7 days prior and maintain for 3–6 months after PED placement.

#### **4. Ruptured intracranial aneurysms**

A 50-year-old female was preparing her children for school when she experienced a headache severe enough to make her lie down on the sofa. She managed to get the children off to school, but the headache did not abate. She was used to headaches, as she had migraines periodically that were controlled with over-thecounter medications, but this one was different and much more intense. She took a couple of acetaminophen, and when the pain was not relieved, she brought herself to the emergency department (ED) [73].

Headache is seen in up to 2% of patients, presenting to the emergency department (ED). Most are benign, but it is imperative to understand and discern the life-threatening causes of headache when they present. Headache caused by a subarachnoid hematoma (SAH) from a ruptured aneurysm is one of the deadliest, but fortunately, also rare, comprising only 1% of all headaches presenting to the ED [74].

Rupture is the most serious consequence of intracranial aneurysms. Subarachnoid hemorrhage (SAH) from a leaking aneurysm is a neurological emergency. While SAH is typical of aneurysmal rupture, it is also associated with intraventricular hemorrhage, intracerebral hemorrhage, and subdural hematoma. The force of rupture and location of an aneurysm determine the presence of the other types of hemorrhage. Although the prevalence of aneurysms is high, the

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*Endovascular Treatment of Brain Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88964*

**4.1 Presentation**

worst headache of my life."

consciousness

3.Epileptic seizures

mortality [78]

**4.2 Scoring system**

vasospasm [80, 81].

**4.3 Initial imaging**

actual rupture itself (**Tables 1**–**3**).

onset or rapidly escalating headache (**Figure 5**).

4.Focal neurological deficits

5.Intraocular hemorrhage [76, 77]

• Subhyaloid (pre-retinal) hemorrhage [79].

that will rupture and the ones that never will.

global annual incidence of subarachnoid hemorrhage is 10/100,000person years, so the best possible treatment plan would be to determine exactly those aneurysms

The presenting symptom of SAH is acute headache, generally described as "the

Some cohort studies mention it as "thunderclap" headache that peaks at head-

2.Signs of intracranial hypertension-nausea, vomiting, diminished level of

• Terson syndrome: hemorrhage in vitreous humor, associated with high

Several scoring systems have been developed to predict patient outcomes for those with aneurysm related sub-arachnoid hemorrhage (a-SAH). The Hunt and Hess score and World Federation of Neurological Surgeons grading system are both used to predict patient outcome, and the Fisher grade helps to predict

The severity of neurologic impairment and the amount of subarachnoid bleeding on admission are the strongest predictors of neurologic complications and outcome [82]. Therefore, it is essential that patients with SAH be scored promptly after arrival and stabilization. The World Federation of Neurological Surgeons Scale (WFNSS) and the modified Fisher Scale are the most reliable and simple to perform [74, 75]. Higher WFNSS and modified Fisher Scale scores are associated with worse clinical outcome and a higher proportion of neurologic complications. The modified Fisher scale is designed to predict the development of delayed cerebral ischemia (DCI) which is the most common cause of disability secondary to rupture next the

With such a large number of patients presenting to the ED with a chief complaint of headache [79–84], the description of headache can help differentiating those with a benign cause from those with an emergent etiology such as SAH. The diagnosis of SAH should be considered in any patient with a severe and sudden

ache onset or reaches severity within minutes to an hour of onset [75].

1.Signs of meningeal irritation-meningismus, photophobia

global annual incidence of subarachnoid hemorrhage is 10/100,000person years, so the best possible treatment plan would be to determine exactly those aneurysms that will rupture and the ones that never will.
