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A brain aneurysm is a bubble or
blister that forms off a vessel in the brain.
And the reason we worry about it is that an aneurysm has
the possibility of bursting.
If it were to burst, the consequences are very serious.
Now, people are born with a defect in the vessel wall that,
with the passage of time and with the pounding of blood,
becomes an aneurysm.
We usually start to see them when patients are in their thirties or
forties, and they usually start causing problems, namely rupturing,
when patients are in their fifties, sixties and
recently in the early seventies.
Aneurysms can occur in any vessel in the body.
But the ones that occur in the brain are typically saccular aneurysms.
They're also called berry aneurysms.
But the ones that occur in the rest of the body are fusiform,
which are just a uniform dilatation.
But that's what an aneurysm is.
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It's typically very difficult to know whether you have a brain
aneurysm unless the aneurysm ruptures.
In very rare circumstances there are aneurysms that grow near a nerve
that controls movement of the eyes.
And patients can develop double vision or
they can develop a droopy eye.
But that is a very, very rare situation.
Some patients can have headaches associated with the growth of
aneurysms.
But, again, since so
many people have headaches, suffer from headaches,
it's very difficult to know that headache is caused by an aneurysm.
And, as a matter of fact, it's very rare for that to happen.
What turns out is that having an aneurysm is primarily a silent
condition.
People have the aneurysm that grows over time, but
they don't know that it's there.
These days in the United States, since MRIs and CT scans are so
widely available, essentially, patients are being unofficially
screened for aneurysms in the sense that when they report any headaches,
or any other symptoms that sound related to the brain, it's easy for
the doctors to obtain an MRI, MRA or CT.
And these patients are found to have the aneurysm, incidentally.
That means that the aneurysm hasn't caused any symptoms, but
then they're found.
So, essentially, aneurysms are typically silent unless
they rupture, and they're found incidentally.
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If you're diagnosed with a brain aneurysm,
typically these days, they're identified by MRI or MRA.
Now, MRI, MRA has a 60% false positive rate,
meaning that when an MRI or MRA indicates that you have an aneurysm,
there's a 60% chance that you may not have an aneurysm.
So that diagnosis usually has to be confirmed with a CTA,
which is a special form of CAT scan.
If the CTA confirm that you have an aneurysm,
then you should see a neurosurgeon.
It's very important to see a neurosurgeon as opposed
to a neurologist because neurosurgeons are the specialists
that focus their attention on this problem.
Now, the neurosurgeon will evaluate the studies, probably the MRI,
MRA and the CTA.
And if it's indicated, we'll obtain a catheter angiogram.
Now, it's an outpatient procedure, it's typically a safe procedure,
where patients are given a bit of sedation,
so they're sleepy, but not completely asleep.
And then a catheter is put into a femoral artery.
And through there, a dye is injected into the brain to find out
exactly what the aneurysm looks like, and
what are the vessels associated with the aneurysm.
It's very important to do this study because it's one of the few studies
that will give us an idea of what is the thickness of the wall
of the aneurysm.
So, typically, if someone is diagnosed with an aneurysm by MRI,
MRA, or CTA, thenthey see a neurosurgeon, and
then go on to have an angiogram, if indicated
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At this point, we have many options for treating aneurysms.
The big bifurcation is whether to treat the aneurysm with
open surgery or endovascular techniques.
Open surgery has the advantage that it is more permanent, that is,
the results are more lasting, but it's somewhat more invasive.
On the other hand, endovascular techniques are easier upfront, but
they require long-term follow-up.
So with open surgery, that involves doing a craniotomy.
And then the aneurysms can be treated by clipping,
which is putting little clamps at the base of the aneurysm.
They can be wrapped, the aneurysm can be trapped or
the patient can undergo a bypass.
In terms of endovascular options, at this point,
the leading endovascular option for
the treatment of aneurysms are the flow diversion devices.
The pipeline is the one that is widely approved,
was introduced in 2007, 2008, 2009,
but at this point, it's showing much promise.
Other options are using coils and stents or using coils alone.
Coiling was the first successful endovascular treatment for
aneurysms.
But we have found that it has a very high recurrence rate, and
at this point, coiling is being used less and less.
So, basically, the options for
treatment include open surgery, endovascular techniques,
and always there is the possibility of following the aneurysm.
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If you're diagnosed with an aneurysm, it's very important to
find someone who has tremendous experience with this problem.
So even though neurosurgeons are board certified, and
that allows them to treat any kind of problem, it's very important
to find what we call vascular or cerebrovascular neurosurgeons.
There are websites, for example,
the Joint Cerebrovascular Section,
that has a list of people who are members of that section.
And also in every department there is a cerebrovascular division, and
they are members of the cerebrovascular division.
Now, being a member of the Joint Section or
being a part of the cerebrovascular division, is not enough.
Basically, patients should not hesitate to ask the neurosurgeon,
or even their offices, what is their experience with aneurysms.
In general, in order to select a neurosurgeon specializing in this
problem, the neurosurgeon should have treated hundreds of aneurysms.
So it should be in the hundreds.
In addition to that,
the neurosurgeon should be working in a center of excellence,
preferably a hospital that has a stroke center status.
In that center,
they should be treating at least 200 aneurysm cases a year.
That is approximately four cases per week.
And that is, in our opinion, the minimum required to stay
up-to-date and just keep a highly efficient system.
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These days,
the outcomes of treatment of aneurysms are outstanding.
In good hands, that is, the hands of a surgeon who has
treated hundreds of these aneurysms, also working in
a center where at least 200 aneurysms are treated a year,
the mortality associated with either open surgery or
endovascular surgery for unruptured aneurysms is less than 1%.
And the complication rate from the procedures for
permanent morbidity is less than 5%.
And these are the standards that have to be met in order to treat.
Now, this shouldn't be confused with aneurysms that have ruptured.
If aneurysms have ruptured, and they have caused a hemorrhage,
then already, the patients come in with many problems.
In those cases, mortality can be higher, morbidity can be higher.
But for unruptured aneurysms, either with endovascular or open surgery,
the mortality rate should be less than 1%, and the morbidity,
that is, other complications, should be less than 5%.
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