Treatment

Aneurysm Treatment

There are currently two options for brain aneurysms – surgical clipping and endovascular coiling.

  • In surgical clipping, a craniotomy is done to expose the aneurysm the base is closed by a clip.
  • In endovascular coiling, a catheter is passed from the groin through the aorta to the brain arteries and the aneurysm is entered and platinum coils are introduced. They introduce a clotting reaction that fills the dome and prevents rupture.

One-third of brain aneurysms rupture. Size is not a significant risk factor.

The following measures help relieve symptoms and manage complications:

  • Painkillers for headaches
  • Calcium channel blockers – prevent calcium from entering cells of the blood vessels. They reduce the amount of narrowing and widening of the blood vessels, a complication of the ruptured aneurysm.
  • A vasopressor – rises the blood pressure and widens the narrowed blood vessels. The aim is to prevent a stroke.
  • Anti-seizure drugs – occur after rupturing of the aneurysm -phenytoin.
  • Ventricular catheter – prevents hydrocephalus by draining collected fluid in the brain spaces into an external bag. A shunt may be needed. This is a flexible rubber tube with a valve starting in the brain and ending in the abdominal cavity draining the excess fluid into the large abdominal cavity.
  • Rehabilitation therapy – there may be brain damage causing body and speech impairment. This therapy helps the patient relearn vital skills.
  • Treatment of unruptured cerebral artery aneurysm.

It may be sealed off by surgical clipping or endovascular coiling. The risks are almost equal and may be higher than the potential benefits. The decision making is helped by:

  • A site of the aneurysm
  • Size of the aneurysm
  • Patient’s age
  • Patients general condition
  • A family history of ruptured aneurysm
  • Other congenital conditions which increase the risk of aneurysm rupturing.

Aortic and peripheral aneurysms

The treatment is dependent on two choices:
1. Wait and watch
2. Surgery

How big is the aneurysm and how fast it is growing?

If the aneurysm is small (4cm or less) and asymptomatic. Wait and watch and perform ultrasound every 6 – 12 months. The patient is informed of the signs and symptoms of dissection or rupture.
Statins reduce the growth rate of small aneurysms.
Medium sized aneurysms (4 – 5.5 cm) are treated if the patient is willing.
Large aneurysms (5.5 and above) or expanding > 0.5 cm every 6 months.

In this case, the weakened section of the artery is replaced by a bypass graft. This can be sutured to the edges surgically or replaced by an endovascular graft. They need surgery where a synthetic graft replaces the diseased segment of the artery. However, the patient takes several months to recover. Endovascular insertion of the graft which is fixed to the neck with hooks. This strengthens the weakened section of the aorta. The recovery is much faster and fewer complications are seen

This should be done as soon as the aneurysm is 5.5 cm. Patient with Marfan’s syndrome or those with a family history of aortic dissection should undergo surgery much quicker. Beta-blockers have shown to reduce the growth rate of thoracic aneurysms in Marfan’s Syndrome.

Renal artery aneurysms

It is very rare and the treatment is the control of hypertension if the aneurysm is less than 3 cm in diameter. if it is symptomatic or enlarging rapidly then open surgical repair is considered or endovascular stenting is considered. There is an 80% risk of rupture in pregnant women and should be treated surgically.

Complications of ruptured aneurysms

AAA causes hypovolemic shock leading to death if not treated in time.
Cerebral artery aneurysm rupture may lead to severe headache followed by loss of consciousness. A piece of a clot may dislodge and give rise to blockage of the peripheral artery. This is a life-threatening emergency especially if the clot travels to the heart, lung or brain.

Can it be prevented?

This is mostly due to atherosclerosis and can be prevented by:

  • Quit smoking
  • Blood pressure under control.
  • Cholesterol under control.
  • Eat a healthy well-balanced diet rich in fruit and vegetables, unrefined carbohydrates, high fiber diet, good quality fats, lean proteins.
  • Control body weight.
  • 7 hours of good quality sleep each night.
  • Keep physically active.

Epidemiology

The incidence of brain aneurysms is 0.4% – 3.6% and commoner in females. The common age is 35 – 60 years. There are rarely warning signs.