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CEREBRAL ANEURYSMS: Treating the worst headache of your life.

November 19, 2009

Venu Vadlamudi, MD



This article serves as a follow up on the topic of subarachnoid hemorrhage discussed by my colleague, Matthew Flaherty, MD, and more specifically focuses on cerebral aneurysms and endovascular (meaning from within the blood vessel) treatment of these lesions and I refer you to his article (Click to Read: The worst headache of your life .) for background information.

Cerebral aneurysms are more common than people may think and can be found in about one in twenty people. Risk factors for cerebral aneurysm formation include high blood pressure, smoking (remember, smoking is always bad and many diseases have an association with it), personal or family history of a cerebral aneurysm, and many of the congenital and connective tissue disorders outlined by Dr. Flaherty. There is increased incidence of cerebral aneurysms with age, peaking around 50 years of age. Overall, cerebral aneurysms are slightly more common in women, however, in persons younger than 40 years, cerebral aneurysms are more common in men.

The danger with cerebral aneurysms is that they have a risk of rupture (bleeding) that leads to subarachnoid hemorrhage causing that worst headache of your life (link to Matt's article). The annual risk for rupture of a cerebral aneurysm is about 2% but if it does rupture, it is associated with serious complications including death. As many as 10-15% of people won't make it to the hospital. Of those who do make it to a hospital, the mortality (risk of death) from subarachnoid hemorrhage due to a ruptured cerebral aneurysm has been reported to be as high as 30-50%. The thirty-day mortality rate approaches 50-60% and those who survive often suffer major neurological morbidity. Only about 30% of patients survive without major neurological disability. Another disturbing statistic is that once an aneurysm ruptures, it can bleed a second time which typically happens in the first 5-7 days following the initial bleed and is associated with up to 80% mortality, meaning that over those who survived the first bleed, only about 20% will survive a second bleed. These grim statistics demonstrate the seriousness of this disease. In the past, once an aneurysm was diagnosed, the only way to treat it was open brain surgery to place a clip across the base of the aneurysm. Since the last fifteen years, there has been advancement in technology that allows for the treatment of cerebral aneurysms without the need for open surgery - endovascular coiling.

Endovascular coiling of cerebral aneurysms is performed by an interventional neuroradiologist, a specialist in the treatment of certain neurological disorders through minimally invasive techniques. For the treatment of cerebral aneurysms, the patient is placed under general anesthesia and the interventional neuroradiologist makes a tiny skin nick in the groin and, through the artery and using x-ray guidance, threads special plastic tubes (catheters and microcatheters) through the system of arteries into the artery from which the aneurysm arises. At this point, pictures are taken using x-ray dye that fully outlines the characteristics of the aneurysm (Figure 1). Following this, the microcatheter is inserted into the aneurysm and tiny platinum coils, so-called because they are engineered to coil in a predetermined shape once out of the catheter, are placed within the aneurysm. These coils fill up the volume within the aneurysm precluding blood from filling it and making the aneurysm "invisible" to the passing blood (Figures 2 and 3). Once the aneurysm is filled, the catheters are removed and the patient is left with only a small nick in the groin - no stitches necessary. The patient typically stays in the hospital for a several days to ensure they are stable and recovering well and can usually be sent home afterwards with careful follow up - remember that one of the risk factors is a personal history of cerebral aneurysm. This endovascular technique for treating cerebral aneurysms has been very effective and is now the preferred way for treating most cases of this disease. In our own facility, we are now treating nearly 80% of cases with endovascular coiling and literature has shown that for patients with subarachnoid hemorrhage due to cerebral aneurysm rupture, in-hospital mortality is lower at facilities with interventional neuroradiology services.

In summary, cerebral aneurysms are a common disease that is very serious because of their risk of rupture. In the event that they are discovered, most commonly because they have already ruptured, treatment is necessary and can now be performed using endovascular coiling, a minimally-invasive technique with excellent results and now the preferred way for treating most cases. Although this disease may not be completely preventable, you can decrease your risk by maintaining a healthy weight (overweight/obesity typically increases your blood pressure), cessation of smoking (remember, smoking is always bad!), and making sure you see your physician regularly for check-ups.



Figure 1: Angiogram (x-ray dye picture) demonstrating an aneurysm.


Figures 2 and 3: Following coiling of the aneurysm (the black material within are the platinum coils), the aneurysm becomes "invisible" to the passing blood on the follow-up angiogram.


REFERENCES:
1. Rasmussen PA, Mayberg MR. Defining the natural history of unruptured aneurysms. Stroke. 2004; 35:232-233.
2. Smith WS, Johnston SC, Easton JD. Cerebrovascular diseases. In: Kasper DL, editor. Harrison's principles of Internal Medicine. 16th Ed. New York: McGraw-Hill; 2005: 2372-93.
3. Tofteland ND and Salyers WJ. Subarachnoid Hemorrhage. Hosp Physician. May 2007; 31-41.
4. White PM et al on behalf of the HELPS Trial Collaboration. HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS Trial): Procedural Safety and Operator-Assessed Efficacy Results. Am J Neuroradiol 2008; 29:217-23.
5. Molyneux A et al for the International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured aneurysms: a randomised trial. Lancet 2002; 360:1267-74.
6. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354:387-396.
7. Molyneux A et al for the International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366:809-17.
8. Deshaies EM et al. Determination of Filling Volumes in HydroCoil-treated Aneurysms by using Three-Dimensional Computerized Tomography Angiography. Neurosurg Focus 2005; 18:E5:1-5.
9. Raymond J et al. Long-Term Angiographic Recurrences After Selective Endovascular Treatment of Aneurysms With Detachable Coils. Stroke 2003; 34:1398-1403.

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