What are the surgical treatments available in India for Cerebral Aneurysms?

Cerebral Aneurysm Surgery in India

What is a Cerebral Aneurysm?

A cerebral (brain or intracranial) aneurysm is an area where a blood vessel in the brain weakens, resulting in a bulging or ballooning out of part of the vessel wall. Usually, aneurysms develop at the point where a blood vessel branches, because the “fork” is structurally more vulnerable. The disorder may result from congenital defects or from other conditions such as high blood pressure, atherosclerosis (the build-up of fatty deposits in the arteries), and less commonly, head trauma or infection.

Aneurysms are usually found at the base of the brain just inside the skull, in an area called the subarachnoid space. In fact, 90 percent of subarachnoid hemorrhages (SAHs) are attributed to ruptured cerebral aneurysms and the two terms are often used synonymously.

Aneurysms range in size, from quite small – about 1/8 inch – to nearly one inch. Aneurysms larger than one inch are called giant aneurysms, pose a particularly high risk, and are difficult to treat.

• Saccular or "berry" aneurysms, which are shaped like a small sac, are the most common type and often require intervention.
• Fusiform aneurysms are diffuse bulges of the vessel wall involving most of the entire circumference of the blood vessel itself. They may rupture or cause stroke-like symptoms when they compress the surrounding brain.
• Mycotic aneurysms are rare and result from an infection. The infection damages and weakens the blood vessel, thereby increasing the associated risk of rupture. This infection occurs most commonly as a complication of subacute bacterial endocarditis (a heart infection). Traumatic aneurysms occur when a cerebral blood vessel incurs trauma from a head injury. The damaged blood vessel weakens at the site of injury which may cause it to rupture.

Signs/Symptoms

People who suffer a ruptured brain aneurysm may have warning signs, including:

• Localized migraine-like headache
• Nausea and vomiting
• Stiff neck
• Blurred or double vision
• Sensitivity to light (photophobia)
• Loss of sensation

Many people with unruptured brain aneurysms have no symptoms. Others might experience some or all of the following symptoms, which may be possible signs of an aneurysm:

• Cranial nerve palsy
• Dilated pupils
• Double vision
• Pain above and behind eye
• Localized headache
• Progressive weakness or numbness

What are the treatment options available in India for Cerebral Aneurysm?

There are two main types of treatment for a brain aneurysm:

• Preventative Treatment: where an aneurysm is treated to prevent it from rupturing
• Emergency Treatment: where an aneurysm is repaired after it ruptures

What are the surgical treatments available in India for Cerebral Aneurysms?

• Neurosurgical Clipping: Neurosurgical clipping is a procedure carried out under general anaesthetic (you're asleep throughout). A cut is made in your scalp and a small flap of bone is removed to reveal your brain underneath.When the aneurysm is located, the neurosurgeon (an expert in surgery of the brain and nervous system) will seal it shut using a tiny metal clip. After the bone flap has been replaced, the scalp is stitched together.
• Endovascular Coiling: Endovascular coiling involves inserting a catheter into an artery in your leg or groin. The tube is guided through the network of blood vessels into your head and finally into the aneurysm. Tiny platinum coils are then passed through the tube into the aneurysm. The coils block the flow of blood into the aneurysm. Over time this should seal the aneurysm off from the main artery to prevent it from rupturing

Treatment Options

The treatment of an aneurysm, like all medical decisions, should be agreed upon by both the physician and the patient. If the case is a medical emergency, in which the ruptured aneurysm has caused the patient to lose consciousness, this discussion may take place with the patient’s nearest relative or medical decision maker. The treating physician will discuss the risks and benefits of each available treatment option. He or she will usually recommend one treatment over another, based on the patient’s individual circumstances.

While the best method of securing the aneurysm should be made on an individual basis, in general, patients with a ruptured cerebral aneurysm should be treated as soon as possible. Surgical risks and outcomes depend on whether or not the aneurysm has ruptured, the size and location of the aneurysm, and the patient's age and overall health.

The following factors should be considered:

• Risk of hemorrhage — what is the chance of the aneurysm rupturing?
• Size, shape and location
• Age and health of patient
• Family history
• Risks of treatment

Nonsurgical Treatment

Observation is considered a reasonable option if the aneurysm is very small or in a location which is felt to present a low risk of growth or rupture. Repeated testing over time may be recommended and the risks of aneurysmal hemorrhage remain. In such cases, the risks are often considered to be lower than the risks associated with treatment. Because aneurysm rupture is fundamentally unpredictable, however, and because rupture of the very smallest aneurysms is well documented, the role of serial imaging remains undefined, and may provide a false sense of security.

Medical therapy is an option reserved for the treatment of unruptured aneurysms in patients with significant risk factors for surgery and general anesthesia. Patients with unruptured aneurysms who have high blood pressure may be prescribed an antihypertensive (blood pressure lowering) medication, and encouraged to follow a diet and exercise program in addition to smoking cessation. These are important factors that have been shown to have a significant effect on aneurysm formation, growth, and/or rupture.

Advantages

• Durability
• Direct visualization of the aneurysm (which may have very complex dimensions)
• Ability to decompress or deflate the aneurysm after clipping
• Ability to inspect other blood vessels in the area for smaller aneurysms
• In cases of SAH, the advantage of enabling evacuation of some of the clotted blood surrounding the aneurysm and the base of the brain
• Better option for convoluted arterial systems
• Better option for wide-neck aneurysms or those without defined openings

Post Treatment

For a patient with a ruptured cerebral aneurysm, surgical elimination of the aneurysm is only the beginning. Intensive care recovery for the next 10 to 14 days is the rule . At some time during that period (often immediately upon completion of surgery), cerebral angiography or a substitute study is done to document that the aneurysm has been eliminated. Patients who have been treated for an unruptured aneurysm usually have no complications related to vasospasm, swelling or hydrocephalus, and stay in intensive care for 1 to 2 days. Patients treated by coiling are often discharged from the hospital after 1 day, and those undergoing clipping, 3 to 5 days.

Outcome

Outcome and recovery after aneurysm rupture is variable. In general, those patients who presented in good neurological condition tend to have better recoveries. 

 

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