An aneurysm generally refers to a bulge in the vessel wall. This means that individual layers of the wall or all layers of a blood vessel expand outwards.
The causes of such a defect are manifold. Common risk factors are
Aneurysms in the brain can also be caused by congenital weakness of the arterial walls. If a vessel in the brain is affected, this is referred to as a brain aneurysm. Brain aneurysms are usually located at the bifurcation of blood vessels.
Brain aneurysm surgery is the neurosurgical treatment to remove or close this bulge in the brain.
A brain aneurysm can lead to life-threatening cerebral bleeding if it bursts © rob3000 | AdobeStock
There are various procedures from which the doctor can choose together with the patient. The procedure chosen depends on the individual
- risk factors,
- family history and
- severity
and severity.
A brain aneurysm usually does not cause any symptoms and is often an incidental finding during an examination. Sometimes
may indicate an aneurysm.
However, the risk of the aneurysm bursting increases with its size. This can lead to a dangerous cerebral hemorrhage, a so-called subarachnoid hemorrhage, which must be avoided at all costs. The rupture of an aneurysm can be triggered by physical exertion or occur spontaneously at rest.
Bleeding must be treated as quickly as possible, as it can cause numerous consequential damages. In 30 percent of cases, it leads to death. Possible complications include
The aneurysm should be surgically removed if the surgical risk is lower than the risk of rupture. The risk of rupture is determined on the basis of several factors. These include
- the size of the aneurysm,
- high blood pressure,
- localization,
- shape,
- familial accumulation,
- alcohol consumption,
- previous bleeding and
- other genetic factors.
There are two different procedures in neurosurgery for the surgical treatment of brain aneurysms:
- microsurgical clipping
- coiling
Microsurgical clipping
In microsurgical clipping, the surgeon closes the bulge with a clip. The clip is precisely adapted to the size and shape of the aneurysm and separates the outpouching in the vessel from the blood flow. The clip is made of titanium or other metals.
For this brain aneurysm operation, the surgeon makes a small incision in the skin and opens the bony skull. This provides a gentle access route to the aneurysm. In the case of larger aneurysms, a bypass may need to be placed to bypass the aneurysm. The advantages of this technique are
- Safe closure of the aneurysm with a low risk of rupture,
- the effectiveness against aneurysms with a wide neck,
- good intraoperative complication management and
- the possibility of treating concomitant cerebral hemorrhages.
Significant disadvantages of this brain aneurysm surgery are
- the invasiveness, which increases the general surgical risk,
- the increased risk of intraoperative ruptures and
- the inaccessibility of some localizations.
Coiling
The second treatment option is coiling. This brain aneurysm operation is performed via an endovascular approach, i.e. via the blood. In contrast to clipping, this is a neuroradiological procedure under constant X-ray monitoring.
An artery in the thigh is punctured by a specialist. Through this opening, he pushes a thin catheter upwards along the vessels to the aneurysm. Another thin catheter is then advanced through the first and guided into the aneurysm.
The surgeon inserts thin platinum coils into the aneurysm through this catheter. They cause a thrombosis within the aneurysm and thus block it. If the neck of the aneurysm is too wide, a balloon or stent may need to be inserted to widen the adjacent vessel. This also prevents the balloon or stent from being floated out of the aneurysm.
The advantages of this technique are that it is minimally invasive and, according to studies, has better long-term results.
The disadvantages are the slightly higher risk of rupture and incomplete closure, which occurs in 15 percent of cases.
Which procedure is the right one?
The choice depends on individual factors. If the suitability is equivalent, the surgeon generally prefers coiling as it has a lower surgical risk.
Clipping is more suitable
- for younger patients,
- for patients without relevant concomitant diseases,
- for aneurysms that are more centrally located,
- for complex-shaped aneurysms and
- for concomitant bleeding.
Coiling is to be preferred
- in older patients with comorbidities,
- for aneurysms of the posterior stromal region,
- for simple forms with a thin neck and
- in the absence of bleeding.
The experience of the treating neurosurgeons and neuroradiologists is also decisive in the choice of procedure.
The hospital stay lasts around three to four days. After a post-operative follow-up MRI and completion of all examinations, the patient is discharged.
Further follow-up appointments are arranged on site. It will also be clarified whether these appointments will be held at the radiologist 's practice or at the hospital. It is important that you attend these appointments to ensure optimal follow-up of the operated aneurysm.
An aneurysm can no longer cause complications if it is completely occluded. For this reason , check-ups are rarely necessary after clipping .
After endovascular therapy, a follow-up MRI scan must be performed after six months and after two years. This procedure often leads to re-bleeding and therefore to the need for follow-up treatment.
If the occlusion is insufficient, the doctors may change the treatment strategy. After treatment by coiling in combination with a stent, treatment with two different drugs to thin the blood should be carried out for four weeks, followed by subsequent monotherapy.
Untreated brain aneurysms should be monitored annually by MRI, even if they are stable in size. Patients with acquired aneurysms should reduce the risk factors as much as possible:
- Make sure you eat a balanced diet,
- keep blood lipids low,
- control your blood pressure,
- avoid nicotine and alcohol consumption.
In general, serious complications are very rare when operating on unruptured aneurysms of less than ten millimeters. For more complicated aneurysms, such as giant aneurysms or more complicated forms, the risk of treatment is higher.
Treatment by clipping can lead to
- Wound infections,
- secondary bleeding,
- epileptic seizures or
- vascular occlusion with stroke
may occur. Coiling could lead to
- perforation (rupture) of the aneurysm with subsequent bleeding,
- an allergic reaction to the contrast medium, and
- vascular occlusion
may occur.
However, the probability of vessel occlusion is less than two percent for both procedures. The prognosis for both procedures is very good overall. With coiling, however, more frequent follow-up checks are necessary.