After testing is finished and a definitive diagnosis made, the physician will discuss treatment options with you. The decision to proceed with aneurysm surgery or aneurysm coiling depends on several factors such as the size, the shape, and the location of the aneurysm. Another factor taken into consideration is your overall health status.
- Medical Management
- Surgery- Opening the skull and clipping the Aneurysm
- Occlusion and Bypass
- Endovascular Procedure
Small, unruptured aneurysms that are not creating any symptoms may not require treatment unless they grow, symptoms appear, or they rupture. If aneurysms go untreated it is very important to have annual check-ups to monitor blood pressure, cholesterol, and any other medical problems. Small aneurysms require regular testing to monitor the aneurysm to make sure that it is not growing or changing in any way.
Surgery- Clipping the Aneurysm
The surgeon must remove a section of the skull, a procedure called a craniotomy. The covering of the brain is peeled back. Trapped blood and Cerebral spinal fluid may be removed. The brain tissue is spread apart and a tiny metal clip is placed across the neck of the aneurysm to stop blood flow into the aneurysm. After clipping of the aneurysm, the bone is secured in its original place, and the wound is closed.
Occlusion and Bypass
Occlusion is stopping the blood flow through the artery leading to the aneurysm. It is most often done as open surgery. Often occlusion is combined with bypass. Bypass reroutes blood around the occlusion. It takes blood to the part of the brain that had been fed by the damaged artery. A small blood vessel is used for the bypass.
You will wake up in the recovery room and then move to the Intensive Care Unit (ICU) or to the Neuroscience Specialty Unit (NSU). You will have:
- You will not be allowed to eat or drink
- You may receive medication to help you relax
- You may be allowed to take heart and blood pressure medications with a sip of water
- Your groin will be shaved
- A catheter may be placed in your bladder, because you will not be allowed out of bed for a while
- An IV (intravenous line) will be placed to provide fluids and medications
- An arterial line may be in place to monitor blood pressure continuously
During the procedure:
- The procedure begins as if an angiogram is being performed.
- A special tube (sheath) is inserted into the femoral artery in your groin.
- A catheter is then inserted and navigated, by X-ray guidance, through the vascular system, into the base of the aneurysm.
- The endovascular surgeon carefully places tiny platinum coils through the catheter and release them into the aneurysm.
- The coils stay in the aneurysm and act as a mechanical barrier. The mass of coils attracts blood-clotting factors inside the aneurysm. This will form a blood clot and seal the aneurysm off from the blood vessel.
- The coils are made of platinum so they can be easily seen via X-ray and they are flexible to conform to the shape of the aneurysm.
- Within 24 hours a new blood vessel wall covers the opening of the aneurysm.
- The number of coils used depends on the size of the aneurysm. (The larger the aneurysm the more coils will be needed).
- During the procedure you will be given a blood thinner called Heparin to prevent clots from forming in the wrong places. Heparin may be continued after the procedure.
After the procedure:
- After the procedure you will be transferred to the NSU or the ICU.
- The sheath in the groin may be left in place until the next day. The sheath will be removed with the physician’s order.
- Neurological checks and vital signs such as blood pressure, heart rate, and oxygen saturation will be taken frequently.
- You will be connected to a heart monitor, until after the sheath is out.
- While the sheath is in you will be on complete bed rest, the leg (with the sheath in) must be kept straight.
- You may be allowed to have the head of bed raised 30 to 45 degrees.
- After you are fully awake and able to swallow, you may be allowed to have clear liquids.
- You will continue to have IV fluids until the following morning, or until eating and drinking adequately.
- A Foley catheter may be left place until you begin getting out of bed.
- The arterial line will be left in place until after the sheath is removed.
When the sheath is removed:
- A nurse will hold pressure on the artery until the bleeding stops this takes approximately 20 to 30 minutes.
- You will remain on bed rest with the leg kept straight for approximately 4 to 8 hours.
- You will continue to be monitored frequently. After a period of time and if there are no neurological problems, no bleeding or problems at the procedure site, and vital signs remain stable you will be allowed to get out of bed.
- A dressing will be in place for 24 hours. After 24 hours, it will be removed and a band-aid placed. The area must be kept dry for 48 hours.
- Do not lift heavy objects.
Major complications of Coiling or Surgery
- Stroke- weakness, paralysis- or loss of sensation, including vision, confusion, loss of speech, or loss of memory.
- Some of the aneurysm remains
- Rupture of the aneurysm
- Hydrocephalus (an abnormal accumulation of cerebral spinal fluid within cavities called ventricles inside the brain)
- Swelling or bleeding in the brain
Minor complications of Coiling or Surgery
- Bruising or bleeding at the puncture site
- A lump or hematoma (collection of blood in the tissue) at the puncture site
The doctor will determine when you are ready for discharge. You may be on medications that you will continue to take at home. Often follow-up appointments are made prior to discharge. The doctor may occasionally order outpatient CT scan or MRI to evaluate the treatment of the aneurysm. After aneurysm coiling is performed, a routine follow-up angiogram may be performed 6 to 12 months after the procedure to make sure the aneurysm remains blocked off. In some cases, further coil treatments may be needed to make sure that the aneurysm is no longer a risk.
When to Call the Doctor
- New onset of seizures
- Severe headache
- Any loss of function
- High or long-lasting fever
- Drainage, redness or pain at incision/puncture site
- Fainting or falling
- If any other changes occur
REFERENCES and RESOURCES
Brain Aneurysm Resources: Information for Patients and Physicians.
ASITN (American Society of Interventional and Therapeutic Neuroradiology.
The Brain Aneurysm Foundation www.bafound.org
“Treatment of Brain Aneurysms.” Queen Elizabeth II Health Sciences Centre. Halifax, Novia Scotia. 1994.
Mangiard, John R. “Brain and Neuro Surgery Information Center, Aneurysm Surgery.”
Molyneux, Andrew, et.al., "International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial." THE LANCET Saturday 26, October 2002 Vol. 360 No. 9342 Pages 1267-1274
Prolo, Donald J. “Brain Aneurysm: Understanding Care and Recovery.” San Bruno, CA: the Staywell company, 2000.
“What you should know about Cerebral Aneurysms.” UCSF Center for Cerebrovascular Research. April, 2003. American Society of Neuroradiology.