Lehigh County Health & Medicine Fall/Winter 2020 - 9

L C M E D S O C .O R G

Unruptured brain aneurysms
may migrate or fail, though this is rare. Surgical
It is estimated that 3% of the population recovery may be longer than with endovascular
has an aneurysm, and about 20-30% of those treatment, and there is a higher risk of seizures
with aneurysms have multiple. Risk factors for and disability. Certain aneurysms are only able
developing brain aneurysms include high blood to be treated surgically.
pressure, smoking, connective tissue disease (such
as Ehlers-Danlos syndrome), family history of an- Endovascular treatment
eurysms, and female sex. They are most commonly
The alternative to surgery is endovascular
found in people age 40 to 60. As brain imaging coiling in which a catheter is introduced through
becomes more common and accessible, there is a peripheral artery and navigated to the brain
a higher rate of incidentally finding unruptured to find the aneurysm. Though it has not been
brain aneurysms.
available as long as surgical repair, it has quickly
become the choice of treatment when possible.
Treatment of unruptured aneurysms is typically First described in 1988, small detachable coils
limited to observation with repeated imaging. may be placed into the aneurysm to secure it and
Several factors play into the decision to electively prevent re-rupture. More recently, flow diversion
treat an aneurysm before it may rupture. In away from the aneurysm may be achieved with
general, the larger the aneurysm is, the more stenting. A combination of stenting and coiling
likely it is to rupture. Aneurysms less than 7mm may also be utilized based on the aneurysm. There
may be observed for many patients. However, if a is less immediate risk with endovascular repair,
patient has had a prior subarachnoid hemorrhage, but there is a higher rate of aneurysm recurrence.
hypertension, or the aneurysm is in a location Electively, this procedure can be performed in a day,
that is more prone to rupture, there is a higher and the patient is often discharged the next day.
likelihood of requiring preventive treatment. Repaired aneurysms usually require close follow
Guidelines recommend specific screening if a up and may require retreatment in the future.
person has two or more first-degree relatives with
aneurysms or subarachnoid hemorrhage. If an Conclusion
aneurysm is discovered incidentally, it is best to
Though subarachnoid hemorrhage due to
refer for evaluation by neurology, neurosurgery aneurysm rupture is a rare disease, it is important
or interventional neuroradiology.
to immediately recognize and treat it to prevent
complications and death. As with any brain
Aneurysm repair options
injury, time is brain and early treatment is better.
There are two possible approaches to repairing Recognizing a subarachnoid hemorrhage and
an aneurysm, both electively before rupture and transferring to a neuroscience intensive care unit is
immediately after a subarachnoid hemorrhage. vital to the survival of patients with this disease.
Both have associated risks and benefits, but ultimately the determination is based on the location References:
and imaging characteristics of the aneurysm itself. Diringer MN, Bleck TP, Hemphill C, et al. Critical care
Surgery
Aneurysm clipping was performed at Johns
Hopkins in 1937 and has evolved since. The
procedure requires general anesthesia and opening
the skull to physically treat the aneurysm. A surgical
clip is placed around the base of the aneurysm
to prevent it from rupturing. No treatment is
100% successful for life - there is still a risk of
aneurysm recurrence, though it is lower than the
endovascularly treated patients. Additionally, clips

management of patients following aneurysmal subarachnoid
hemorrhage: recommendations from the Neurocritical Care
Society's Multidisciplinary Consensus Conference. Neurocrit
Care. 2011;15(2):211-40.
Muehlschlegel S. Subarachnoid Hemorrhage. Continuum
(Minneap Minn). 2018;24(6):1623-1657.

Surgical and endovascular treatments for
cerebral aneurysm thrombosis.
(A) Endovascular coiling of the aneurysm sac.
(B) Surgical clipping of the aneurysm neck.
(C) Endovascular treatment combining
use of coils and a stent. (D) Endovascular
treatment with a flow diverter. Taken from
Perrone et al. (2015).

Ruigrok YM. Management of Unruptured Cerebral Aneurysms
and Arteriovenous Malformations. Continuum (Minneap
Minn). 2020;26(2):478-498.

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Lehigh County Health & Medicine Fall/Winter 2020

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