Cerebral Aneurysm Surgical Repair
A cerebral aneurysm is the ballooning of an artery at a region of weakness or thinning of the blood vessel walls, from the pressure created by the blood within the artery. This bulging of the vessel may compress and damage surrounding brain tissue or rupture, causing blood to collect in the surrounding tissues . Cerebral aneurysms can lead to complications such as stroke , subarachnoid hemorrhage and death in severe cases.
Small aneurysms with minimal symptoms are usually monitored closely. Treatment depends on the size and location of the aneurysm. Surgery is indicated to treat ruptured or large aneurysms and involves two techniques.
Microvascular clipping is a technique that involves identifying the area of the artery that forms the neck of the aneurysm and clipping it with a metal clip to block blood flow into the aneurysm and prevent bleeding. If the artery is significantly damaged by the aneurysm, the entire artery may be clamped and the area of the aneurysm bypassed with a vessel graft. This involves cutting through the skull to access the aneurysm.
Microsurgical Clipping And Endovascular Coiling For Brain Aneurysm
A diagnosis of a brain aneurysm is scary. If a brain aneurysm ruptures or bleeds, it can have life-changing consequences. However, if you’re diagnosed early and treated successfully, the outcome and the chances of making a full recovery are quite good.
One of the most effective ways neurosurgeon Judy Huang, M.D., of the Johns Hopkins Department of Neurosurgery, treats brain aneurysms today is with microsurgical clipping. Endovascular approaches, such as coiling and stent embolization, are also widely used. Here’s what you should know about each.
Surgery For A Brain Aneurysm: Hospital Recovery
After surgery for a brain aneurysm, you may spend 1 to 4 weeks in the hospital. The stay depends on the amount of damage caused by the aneurysm, your health, and your response to treatment and therapy. Your healthcare team will monitor how well treatment has worked. Then they will decide whether you need rehabilitation.
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What Are The Treatment Options
Options for treatment vary depending on the patients age and condition and the aneurysms size, type, and location. Aneurysms that rupture and cause bleeding and aneurysms that are larger than 7 mm require treatment. Smaller aneurysms, especially if they are found incidentally and cause no symptoms, can be monitored over time.
If an aneurysm has not ruptured, the risk of bleeding is estimated at 0.05% per year for aneurysms smaller than 7 mm and at about 1% per year for aneurysms larger than 7 mm. Aneurysms can be treated with surgery or an endovascular procedure that does not require opening of the skull.
After A Prophylactic Surgery
If your surgery was done to prevent an aneurysm rupture, you may need physical therapy. You should not develop substantial new neurological deficits from surgical repair of an unruptured brain aneurysm unless you have had surgical complications.
Any neurological problems that you had prior to your prophylactic surgery may improve after repair of an unruptured brain aneurysm, but your symptoms can persist if brain damage has already occurred.
If you have persistent symptoms, you may need to participate in rehabilitation and/or physical therapy to optimize your recovery after surgery. It is not usually possible to predict whether the symptoms of an unruptured brain aneurysm will improve after the aneurysm is repaired.
The purpose of surgery for an unruptured brain aneurysm is to prevent additional brain damage and to reduce the risk of death.
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What Happens After Surgery
After surgery you’ll be taken to the recovery room, where vital signs are monitored as you awake from anesthesia. Then you’ll be transferred to the intensive care unit for observation and monitoring. Pain medication will be given as needed. You may experience nausea and headache after surgery. Medication can control these symptoms.
Ruptured aneurysm patients stay in the NSICU for 14 to 21 days and are monitored for signs of vasospasm, which is a narrowing of an artery that may occur 3-14 days following a SAH. Signs of vasospasm include arm or leg weakness, confusion, sleepiness, or restlessness .
After 24 to 48 hours, unruptured aneurysm patients are usually transferred to a regular room. Monitoring will continue as you increase your activity level. In a few days you’ll be released from the hospital and given discharge instructions.
Be sure to have someone at home to help you for the first 24 to 48 hours. Follow the surgeonâs home care instructions for 2 weeks after surgery or until your follow-up appointment. In general, you can expect:
- Donât lift anything heavier than 5 pounds.
- No strenuous activity including yard work, housework, and sex.
- Donât drink alcohol. It thins the blood and increases the risk of bleeding. Also, donât mix alcohol with pain medicines.
- Donât smoke or use nicotine products: vape, dip, or chew. It may delay healing.
- Donât drive, return to work, or fly air travel until your surgeon says itâs OK.
What Is Endovascular Coiling
Endovascular coiling is a procedure performed to block blood flow into an aneurysm . Endovascular coiling is a more recent treatment for brain aneurysms it has been used in patients since 1991.
Endovascular coiling is a minimally invasive technique, which means an incision in the skull is not required to treat the brain aneurysm. Rather, a catheter is used to reach the aneurysm in the brain.
During endovascular coiling, a catheter is passed through the groin up into the artery containing the aneurysm. Platinum coils are then released. The coils induce clotting of the aneurysm and, in this way, prevent blood from getting into it.
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What Are The Endovascular Approaches To Brain Aneurysm Treatment
Through recent advances in technology, neurosurgeons can now perform minimally invasive endovascular approaches to treat some brain aneurysms. Endovascular coiling and stent embolization use specialized technology to treat an aneurysm from inside the blood vessel.
Here are highlights of endovascular approaches:
- What happens: Using specialized techniques, neurosurgeons place a stent inside the blood vessel to divert the flow of blood away from the aneurysm. Alternatively, a coil can be placed inside the aneurysm to prevent blood from filling the aneurysm. With these approaches, neurosurgeons reach the aneurysm from the inside of the blood vessels through a puncture site in the leg with a catheter, which means no skull incision.
- What it does: The aneurysm no longer fills with blood, meaning it won’t rupture.
- Benefits: While still complex surgeries, endovascular procedures are shorter procedures. That means a shorter recovery only one week, in most situations. This procedure has shown promising results because it can get rid of an aneurysm entirely.
- Disadvantage: There is a higher risk of aneurysm recurrence with these approaches. To identify any regrowth of aneurysms early, your neurosurgeon may recommend you get routine angiograms .
What Is A Brain Aneurysm
A brain aneurysm is an area of weakness in a brain blood vessel that over time can grow larger and thinner. Aneurysms are dangerous because they can grow and eventually rupture allowing blood to leak out of the vessel. When aneurysms bleed, the blood accumulates in the fluid space under the brain and this is called a subarachnoid hemorrhage. Aneurysms that bleed are life-threatening and should be treated urgently as it is a life-threatening emergency. Brain aneurysms that are discovered before they have bled are often treated to prevent rupture.
Brain aneurysms are relatively common. Approximately 1012 million people in the U.S. have brain aneurysms and about 27,000 new aneurysms are discovered each year . However, not all aneurysms are high risk to rupture and it is important to speak with a cerebrovascular neurosurgeon about your particular aneurysm.
The cerebrovascular neurosurgeons at Baylor Medicine and Baylor St. Lukes Medical Center in Houston, Texas, specialize in the diagnosis and treatment of brain aneurysms and other brain blood vessel disorders. Our doctors have national reputations as leaders in the field of aneurysm treatment. Each brain aneurysm is different and our doctors provide great expertise managing these potentially dangerous lesions.
Figure 1a: Saccular aneurysm. Figure 1b: Fusiform Aneurysm
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Who Performs The Procedure
Surgical clipping of a cerebral aneurysm is always performed by a neurosurgeon, often one with expertise in cerebrovascular disease. Most cerebrovascular neurosurgeons have had five to seven years of general neurosurgery training and an additional one to two years of specialized cerebrovascular training.
Endovascular coiling is done either by a neurosurgeon or by an interventional neuroradiologist. An interventional radiologist has undergone extensive training in both radiology and interventional procedures involving the brain and spinal cord. All neurosurgeons that perform endovascular coiling have undergone additional training in endovascular techniques in addition to full neurosurgery training .
What Are The Risks
No surgery is without risk. General complications related to brain surgery include infection, allergic reactions to anesthesia, stroke, seizure, and swelling of the brain. Complications specifically related to aneurysm clipping include vasospasm, stroke, seizure, bleeding, and an imperfectly placed clip, which may not completely block off the aneurysm or blocks a normal artery unintentionally.
Several studies have suggested that memory loss and cognitive disability is more common after craniotomy for aneurysm clipping than after endovascular coiling, especially in patients over 50.
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S Of Cerebral Aneurysms
Treatment of a Brain Aneurysm with Detachable Platinum Coils
Tiny platinum coils are threaded through a microcatheter and pushed into the aneurysm. The coils are flexible enough to conform to the aneurysm shape.
The aneurysm is filled in with coils, obstructing the flow of blood into the aneurysm. Each coil is attached to a delivery wire, allowing the physician to reposition or withdraw the coil to ensure ideal placement. Once properly positioned within the aneurysm, the coil is detached from the delivery wire using an electrolytic detachment process .
Preoperative Preparation And Simulation
Important preoperative informations by imaging are the following : first the length of M1 segment, second the curvature of M1 segment, third the direction of aneurysm, fourth the location of rupture point, fifth the length between aneurysm and sylvian vein and/or skull base, sixth the relationship between aneurysm and sphenoidal ridge, and seventh the shape and the number of superficial sylvian vein. The preoperative simulation by 3D CTA is more useful because of the information not only of the artery but also of the vein and skull bone. We can decide the dissection point of sylvian fissure and the length between aneurysm and sylvian vein or skull base preoperatively.
In few straightforward cases, no need to routinely expose the entire M1 prior to aneurysm dissection. To translate the imaging information to the surgical planning is very important. The surgeon needs to address few thinking such as: how does he want to start the sylvian fissure dissection? How he should avoid premature rupture either by his retractor placement of his surgical maneuver? And where approximately the aneurysm located and where he will prepare for the proximal control?
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Symptoms And Causes Of Aneurysms
Causes of Aneurysms:
The precise cause of aneurysms is not yet clear, and a lot more research needs to be done to determine that. However, there are several factors that contribute to the development of an aneurysm. These include:
High Blood Pressure:Hypertension or high BP can weaken the arterial wall over time and cause it to bulge or balloon out.
Atherosclerosis: This is a condition where a deposit called plaque builds up inside the artery walls over time. Plaque is a combination of cholesterol, calcium, fat, and other substances present in your blood. Plaque slowly hardens and narrows the artery. This causes the walls to weaken and results in high BP and aneurysms.
Trauma and Tumours: Physical trauma and injuries, like those caused in a vehicular accident, can damage your arterial walls, resulting in aortic aneurysms. Tumours can also weaken arterial walls by exerting pressure on them and cause the formation of aneurysms.
Heredity: Some kinds of aneurysms are hereditary and run in the family. For example, abdominal aneurysms are hereditary, and research has shown that it occurs in two or more closely-related family members.
Abnormal Blood flow at Arterial Junctions: Arterial junctions or bifurcations are especially vulnerable to aneurysms, as the junctions are exposed to the highest stress from blood flow. They can weaken after a while, resulting in aneurysms.
Symptoms of Aneurysms:
- Internal bleeding
Why Are Brain Aneurysms Dangerous
Size and location are the most important factors that determine the likelihood that an aneurysm will rupture. Small aneurysms are unlikely to rupture and are often not treated at all unless they begin to grow. The larger an aneurysm is, the higher the chance it will bleed and the more likely it will need treatment. However, certain aneurysms with abnormal shapes or certain vessel locations may need treatment at small sizes.
The location of an aneurysm is also important. Aneurysms on blood vessels located in the back half of the brain are at higher risk of bleeding than aneurysms found on blood vessels in the front half of the brain . Other factors that are thought to increase the likelihood of a rupture include aneurysm growth, multiple aneurysms, prior aneurysm rupture, symptoms of aneurysm leak or nerve compression, irregular aneurysm wall outpouchings, and aneurysm ruptures in multiple family members.
Table 1. The chance of rupture for a given aneurysm depends on its size and location on brain blood vessels. Larger aneurysms are higher risk for bleeding. Aneurysms on the vessels at the front of the brain are less dangerous than aneurysms on the back part of the brain .
Five-Year Aneurysm Rupture Risk: Size and Location
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Risk Factors: Health Conditions And Lifestyle
Some health problems may make you more likely to have an aneurysm, including certain conditions youâre born with, like polycystic kidney disease, or tissue disorders, like Ehlers-Danlos syndrome. Your chances are also higher if you have hardened arteries, high blood pressure, or a serious head injury. Some lifestyle choices can raise your risk, too, like heavy drinking, smoking, or using illegal drugs, especially cocaine.
What Is The Cost Of Brain Aneurysm Surgery
When you are approaching the doctor for brain aneurysm surgery, it is also important to know the cost. Well, the cost of brain aneurysm surgery in India is between 4 and 6 lakhs. Rest depends on the procedure you have adopted and your stay at the hospital. The doctor will help you to know about everything in the beginning so that you can make things up for it and start the treatment without having any second thoughts.
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After An Aneurysm Rupture
Your recovery would take months and will require intensive therapy if you have had brain aneurysm surgery after an aneurysm rupture. You will likely be taking medication to reduce swelling for several weeks. And you might need to return for another surgery to place the portion of your skull that was removed after the edema diminishes if you had a craniectomy.
How Do I Decide What Procedure To Have If I Have A Cerebral Aneurysm
The treatment of choice for an intracranial aneurysm, like all medical decisions, should be agreed upon by both the physician and the patient. In the case of either ruptured or un-ruptured intracranial aneurysms, the treating physician should discuss the risks and benefits of each available treatment option. The physician will usually make recommendations for one treatment over another, depending on the facts of each individual case. Seeking a second opinion, when possible, is usually advisable.
Although unresolved controversies remain as to what the best treatment option is for an individual patient, both surgical clipping and endovascular coiling/stenting are considered to be viable treatment options in the management of cerebral aneurysms today.
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Purpose Of Brain Aneurysm Surgery
Brain aneurysm surgery can be done to minimize brain damage if an aneurysm has already bled. And it is done to reduce the risk of brain damage if a non-bleeding brain aneurysm is likely to bleed.
Often, unruptured brain aneurysms do not cause symptoms. Sometimes, however, they can cause vague effects, such as:
- A droopy eyelid
These effects can be constant or intermittent, and they can worsen as the aneurysm enlarges.
A bleeding brain aneurysm may cause a buildup of blood in the brain, which can irritate the brain and produce pressure on the brain. Bleeding and edema could result in severe brain damage. The symptoms of a ruptured brain aneurysm can include:
- Intense headaches
- Paralysis on one side of the body
These effects can begin suddenly and may worsen rapidly, and a ruptured brain aneurysm may even lead to death.
You might not be scheduled for brain aneurysm repair right away after your diagnosis, but your healthcare provider would monitor your aneurysm with regularly scheduled surveillance brain imaging to see if it is getting bigger. And any new or changing neurological symptoms could signal that you are at risk of experiencing a rupture of your brain aneurysm.
It can be difficult to predict with certainty whether a brain aneurysm will rupture. Aneurysms that are large, that are increasing in size, or that have started to leak are more likely to rupture than small brain aneurysms that are not changing in size.
Dissection Of The Aneurysm And Neck Clipping
After the proximal and distal vessels have been exposed, dissection of the aneurysm can begin. During this stage of the operation, we usually employ temporary clipping of the proximal vessel, with keeping normotension over 100 mmHg of systolic blood pressure, normothermia under 36.5 °C, and brain protective drugs. The aneurysm must be dissected in its neck, with no perforating vessels remaining adherent to the posterior surface of the aneurysm. It is sometimes useful to place a tentative clip across the dome of the aneurysm and then to dissect it from around the structure further before placing the final clip. MCA aneurysms often have a wide-based neck that involves 180° or more of the circumference of the bifurcation point. Optimal occlusion of such aneurysms requires the use of the application of multiple clips . In some of these cases, it may also be necessary to use wrapping with some material to reinforce any unclipped areas of the neck. Perforators arising from the MCA must be handled with care. Most lenticulostriate vessels arise from the posteromedial surface of the M1 segment and enter the anterior perforated substance to supply the internal capsule and the basal ganglia.
Multiple clipping method for broad neck MCA aneurysm. Broad neck MCA aneurysm. Multiple clipping methods for MCA aneurysm using ring clip
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