SURGICAL TREATMENT OF THE BRAIN ANEURYSMS
Why do we have to treat cerebral aneurysms?
Aneurysms have a tendency to bleed because its walls are thinner than that of a normal artery. This leads to a cerebral haemorrhage of varying severity, but which threatens the life of the patient, if not in the first bleeding, in successive bleeding. Therefore, as soon as brain aneurysm is diagnosed, it should be treated as soon as possible.
Wall of a brain aneurysm
How are brain aneurysms treated?
The traditional treatment of aneurysms is excluding it from the circulation by surgical clipping, but now there is another treatment modality that is the “endovascular”. In selected cases, endovascular treatment provides results as good as surgery but without its risks. Unfortunately, it cannot always be applied.
What should you tell us BEFORE the surgery?
- If you have any clotting problems.
- If you underwent lately any medical problem.
- If you are taking anticoagulanting agents (e.g. warfarin, aspirin, anti-inflammatory agents).
- If you take any medications or herbal remedies.
- If you have any allergies.
What is surgical treatment?
As part of the preparation before the operation, it is necessary to shave a section of the head. To address the aneurysm, the surgeon should first open a window in the skull, which is known as a craniotomy. Most brain aneurysms can be repaired with microsurgery. The most common surgical procedure consists in closing the neck of the aneurysm with a titanium clip. To do this, the aneurysm is carefully separated from the brain and the titanium clip placed around the neck (or base) of it. Once the clip is in place, the aneurysm is obliterated and closed so that no more blood can enter inside it. This prevents further haemorrhages from it. The bone flap is replaced and the wound closed by layers.
What is the risk of surgery?
The risks of the operation are determined by the general condition of the patient, the size and location of the aneurysm, and other factors. In general, the risk of death from surgery after a ruptured aneurysm is relatively small (less than five percent), but exists. The risks may be somewhat higher in the case of large aneurysms, particularly those located in deep area. The surgical risk is less if the surgical procedure is performed before the aneurysm rupture. After surgical treatment the patient may have vasospasm (contraction of the arteries of the brain) which in extreme cases can seriously reduce the blood supply to the brain and even cause a stroke.
Patients who undergo surgery for an aneurysm may need a blood transfusion. Blood from the blood bank is tested to rule out infectious diseases. In the case of surgical procedures for aneurysms the patient’s own blood is not a good option because it involves that the surgical procedure is delayed some weeks to allow blood collection, and that, in principle, is not recommended. Ideally, aneurysm must be treated without unnecessary delays. We have techniques to avoid blood transfusions, but, in the case of aneurysms, is not always enough.
Titanium clips are used which are compatible with MRI and do not trigger alarms or metal detectors at airports.
The most common risks are as follows:
- Impossibility to clip the aneurysm (depends on the shape, location and if some small arterial branches come out of the aneurysm itself).
- Partial clipage of the aneurysm, so that some portions of it remain without being isolated from the bloodstream and may bleed again.
- Infection (can be treated with antibiotics).
- Bleeding in the postoperative period, which may or not require drainage.
- Stroke, especially in case of severe vasospasm.
- Blood clot in the legs that can be released and migrate to the lungs (rare).
- Death (rare).
What happens after surgery?
In most cases, the patient remains, at least, one night in the Intensive Care Unit. The ICU stay is higher if the aneurysm has ruptured, to monitor the onset and then to treat vasospasm. Once transferred to the ward, most patients remain there for from a few days to a week. Most patients leave the hospital within a few days in the case of an unruptured aneurysm, and generally in one or two weeks after bleeding. If complications arise, the process can take much longer. While in the ward, let the nurses know any physical limitation or pain you might have. If all goes according to plan, the recovery at home usually takes about a month.
Hopefully you feel sleepy during the day for about six weeks after the operation. Some patients complain of exhaustion until more than a year after surgery.
Is there a risk of re-bleeding after clipping the aneurysm?
Yes. Depends on whether the aneurysm can be isolated or not completely. Sometimes, small parts of the aneurysm are not obliterated and they grow bigger and bleed over time. In any case it is very rare. When the aneurysm neck cannot be defined we place around it a piece of muscle from the patient or a piece of gauze. This causes a scar around the aneurysm and partially reinforces the wall.
Can I develop new aneurysms in the future?
Yes, it happens but it is rare.