A ruptured aneurysm (patient has already experienced a subarachnoid hemorrhage, SAH), generally requires treatment as soon as possible due to the high re-bleeding rate. Treatment options of the SAH patient are the same procedures (coiling and clipping) as for unruptured aneurysm, however, the decision is made by the attending physician as the patient is often unconscious or unable to participate in the decision-making. Treatment time and option decisions are made based on similar criteria: size, location and shape of the aneurysm and the added factors of the hemorrhage as well as the patient’s overall medical condition.

One caution the family of a ruptured aneurysm patient might want to take at this juncture is to ensure that both an interventional radiologist and a neurosurgeon consult over the case as time and the patient’s condition permit. In some cases either technique could be used, and the recommendation on how to proceed will be influenced by a number of considerations including, the age and condition of the patient and the experience and skills of the attending physicians.

• Clipping
• Occlusion and Bypass
• Endovascular Embolization or Coiling

Once a hemorrhage has occurred, several consequences might develop.

• Damage to the brain cells
• Fluid Build-up in the brain
• Narrowing of the Arteries
• Hydrocephalus
• Vasospasm

Clipping is still the most common surgical treatment for brain aneurysms. It is an effective, well researched surgical procedure with excellent results.

Microvascular clipping involves cutting off the flow of blood to the aneurysm. Under anesthesia, a section of the skull is removed and the aneurysm is located. The neurosurgeon uses a microscope to isolate the blood vessel that feeds the aneurysm and places a small, metal, clothespin-like clip on the aneurysm's neck, halting its blood supply. The clip remains in the patient and prevents the risk of future bleeding. The piece of the skull is then replaced and the scalp is closed. Clipping has been shown to be highly effective, depending on the location, shape, and size of the aneurysm. In general, aneurysms that are completely clipped surgically do not return.

In some cases, it may be best to stop blood flow through the artery leading to the brain aneurysm. This is known as an occlusion. Sometimes the aneurysm has caused severe damage to the artery, so the doctors go in and completely shut down that part of the artery and reroute the blood. This procedure is usually done as an open surgery, which requires similar surgical preparation as in a clipping procedure such as having your head shaved, and a section of the bone plate removed.

Sometimes an occlusion is combined with a bypass. A bypass reroutes blood flow around the occluded artery. Doctors take a small blood vessel from another part of your body, usually the leg, and graft it to a section of the brain artery where it makes most sense. This new artery (bypass) brings blood to the part of the brain that had been fed by the damaged artery.

Endovascular (meaning within the blood vessel) embolization, or coiling, uses the natural access to the brain through the bloodstream via arteries to diagnosis and treat brain aneurysms. The goal of the treatment is to safely seal off the aneurysm and stop further blood from entering into the aneurysm and increasing the risk of rupture or possibly rebleeding.

With the advent of this remarkable new treatment, some patients who were told they had inoperable aneurysms were now given hope and chance for survival. Other patients, because of advanced age, serious medical problems or other factors, could not undergo open brain surgery, so the GDC system became the alternative to their treatment.

	Once the patient has been anesthetized, the doctor inserts a hollow plastic tube (a catheter) into an artery (usually in the groin) and threads it, using angiography, through the body to the site of the aneurysm.
	Using a guide wire, detachable coils (spirals of platinum wire) or small latex balloons are passed through the catheter and released into the aneurysm. The coils or balloons fill the aneurysm, block it from circulation, and cause the blood to clot, which effectively destroys the aneurysm. The procedure may need to be performed more than once during the patient's lifetime.
	Patients who receive treatment for aneurysm must remain in bed until the bleeding stops. Underlying conditions, such as high blood pressure, should be treated. Other treatment for cerebral aneurysm is symptomatic and may include anticonvulsants to prevent seizures and analgesics to treat headache. Vasospasm can be treated with calcium channel-blocking drugs and sedatives may be ordered if the patient is restless. A shunt may be surgically inserted into a ventricle several months following rupture if the buildup of cerebrospinal fluid is causing harmful pressure on surrounding tissue. Patients who have suffered a subarachnoid hemorrhage often need rehabilitative, speech, and occupational therapy to regain lost function and learn to cope with any permanent disability.

In most cases, after a rupture the bleeding quickly stops. However, if leaked blood touches brain cells, these cells may become damaged. Blood in the cerebrospinal fluid (CSF) increases the pressure on the brain.

	Damage to Brain Cells Blood from an Aneurysm can leak into the CSF (cerebrospinal fluid) in the space around the brain (subarachnoid space). The pool of blood forms a clot. Blood can irritate, damage, or destroy nearby brain cells. This may cause problems with body functions or mental skills.
	Fluid Buildup in the Brain Blood from a torn aneurysm can block CSF circulation. This can lead to fluid buildup and increased pressure on the brain. The open spaces in the brain, called ventricles, may enlarge. This is known as hydrocephalus. It can make a patient lethargic, confused, or incontinent. Fluid may also build up in the brain after surgery. To stop fluid buildup, a drain may be placed in the ventricles. This removes leaked blood and trapped CSF.
	Narrowing of Nearby Arteries The blood sprayed around the base of the brain can also produce a problem called vasospasm. Vasospasm typically develops 5-8 days after the initial hemorrhage. Narrowing of the blood vessels can occur, and at times not enough blood is supplied to the brain and a stroke may result. To treat vasospasm, blood pressure is often elevated with medicines. Certain medications are also given to try to ease vasospasm. Finally, catheters can be introduced inside the artery in an attempt to use balloons or medications delivered to the vessel directly to open up these narrowed vessels. Vasospasm does relax over several days.
	Hydrocephalus When a brain aneurysm ruptures, the blood, which should be on the inside of blood vessels, now enters the subarachnoid space and eventually makes its way to the arachnoid granulations. Cells and debris in the blood can clog up and damage these granulations. This leads to obstruction of CSF absorption. This damage may be short term, or permanent. CSF now accumulates, like a dam effect, and results in hydrocephalus (water in the head), i.e., enlargement of the ventricles. This causes pressure to build up in the brain, and it manifests in one or more of the following: headache, nausea, vomiting, blurred or double vision, increasing drowsiness, even coma and death. The way to treat this is to divert the CSF, at first temporarily through a special drainage tube placed either into the ventricles (an “external ventricular drain”) or into the lumbar cistern (a “lumbar drain”). CSF will intermittently be drained via this tubing over several days and then an attempt made to gradually clamp off (wean”) the drain in order to see if the natural pathways for CSF absorption have recovered. If so, good, the drain will be removed. If a drain can't be weaned successfully (i.e., the patient gets symptomatic from hydrocephalus each time the drain is clamped), then a “shunt” usually needs to be placed by the neurosurgeon. Formal shunting requires a separate operation and carries its own short and long term risks. The literature reflects that one in three ruptured brain aneurysm patients will develop hydrocephalus, and many of these will require placement of a permanent shunt.
	Vasospasm The blood sprayed around the base of the brain can also produce a problem called vasospasm. The blood vessels narrow, and at times not enough blood can be supplied to the brain and a stroke may result. To treat vasospasm, blood pressure is often elevated with medicines. Certain medications are also given to try to ease vasospasm. This threat lessens over several days. Cerebral vasospasm can be classified into three types, namely, "subangiographic", "angiographic", and "clinical" vasospasm: Subangiographic vasospasm is the type that cannot be detected by the "gold standard" (i..e., best) imaging method for vasospasm detection known as cerebral angiography .This means that vasospasm is actually occurring at a physical level, but we just can't see it due to limitations of available imaging methods. Specifically, either the narrowing is too mild to detect, or the spasm is happening in a part of the arterial tree which is most difficult to look at using angiography - this part involves the smaller of the brain arteries. The patient may or may not be "clinically affected" by subangiographic vasospasm; that is, at the bedside, a physician may or may not be able to detect its presence. Surprisingly, some patients with subangiographic spasm still suffer symptoms that, to the exclusion of all other causes, are thought to be due to the vasospastic process taking place in their brain arteries, albeit beyond the level of angiographic detection. Angiographic vasospasm is the type that can be detected by cerebral angiography . Again, surprisingly, the patient may or may not be clinically affected by angiographic vasospasm. Generally, it is thought that if one can detect spasm angiographically, then the patient should be affected in such a way that it can be picked up by a physician at the patient's bedside. However, there are exceptions to this rule. The reasons for this are unknown, but may relate to differences between individuals in terms of the unique capacities of their brains to tolerate the same degree of arterial spasm ,or to differences in the "road-maps" of their brain circulation (e.g., presence of back-up routes of blood supply or "collateral circulation"). In general, in vasospasm due to aneurysmal bleeding, the vasospastic arteries (if detected) tend to be close to the site of the aneurysm rupture. However, more distant or remote arteries can also be affected in a "diffuse" or "generalized" manner. Clinical vasospasm is the type that, regardless of the angiographic findings, can be detected by a physician on physical examination of a patient.