Ruptured brain aneurysm

I am a Neurosurgeon with advanced training in Interventional vascular Neurosurgery(FINR) from Zurich, Switzerland, and FMINS-Fellowship in minimally invasive and Endoscopic Neurosurgery from Germany.
I am presently working in Columbia asia hospitals, Bangalore.
My areas of interest are Vascular Neurosurgery, Stroke specialist, interventional neuroradiology.

1. Ruptured brain aneurysm
Dr. Avinash KM
MS, MRCS Ed(UK), Mch (KEM, Mumbai), FINR(Switzerland), FMINS(Germany),
• Interventional & Neurovascular surgeon and Stroke specialist,
• Endoscopic Neuro and Spine surgeon,
• Minimally invasive Neuro and Spine surgeon (FMINS).
mob: [phone], E mail: [email protected]
Consultant Neurosurgeon and Neurointerventionist
Columbia Asia Hospital, Bangalore.

2. What is brain Aneurysm?
A brain aneurysm, also referred to as a cerebral aneurysm or intracranial
aneurysm (IA), is a weak bulging spot on the wall of a brain artery very much
like a thin balloon or weak spot on an inner tube. Over time, the blood flow
within the artery pounds against the thinned portion of the wall and
aneurysms form silently from wear and tear on the arteries. As the artery wall
becomes gradually thinner from the dilation, the blood flow causes the
weakened wall to swell outward. This pressure may cause the aneurysm to
rupture and allow blood to escape into the space around the brain. A
ruptured brain aneurysm commonly requires advanced surgical treatment

3. What are the symptoms of aneurysms?
1. Asymptomatic incidentally detected aneurysms
2. Symptomatic unruptured aneurysms
3. Ruptured aneurysms
Most brain aneurysms cause no symptoms and may only be discovered during tests for
another, usually unrelated, condition(Asymptomatic incidentally detected
aneurysms).
In other cases, an unruptured aneurysm will cause problems by pressing on areas in
the brain. When this happens, the person may suffer from severe headaches, blurred
vision, changes in speech, and neck pain, depending on what areas of the brain are
affected and how bad the aneurysm is.
Symptoms of a ruptured brain aneurysm often come on suddenly. A sudden, severe
headache that is different from past headaches.(worst headache of life)
Neck pain.
Nausea and vomiting.
Sensitivity to light.
Fainting or loss of consciousness.
Seizures.

4. Watch videos about aneurysms and what is ruptured
aneurysm
About general Aneurysms:
http://www.youtube.com/watch?v=Km_rYhtvOYI
http://www.youtube.com/watch?v=mf8KOTn-R0o&feature=channel&list=UL
About SAH ( Ruptured aneurysm):
http://www.youtube.com/watch?v=fUVejm_T0nY

5. What are the risk factors for formation of aneurysm?
Modifiable risk factorsNon modifiable risk
factors
Smoking
Hypertension
Heavy drinking
OCP
Atherosclerosis
Coffee use
Age
Female sex
Genetics/familial
Collagen vascular diseases
AVMs

6. Why aneurysmal rupture is dangerous?
•Death before reaching the hospital is 15%.
•Mortality rate (epidemiological study) of
patients who reach hospital is 32% in USA, 43
to 44% in EUROPE and 27% in JAPAN.
•Significant lifestyle modifications among
survivors is 12% (ISAT data)
•Dependents (MRS 4 and 5) is about 6.5%
(ISAT data)

7. Why ruptured aneurysms(SAH) should be treated on
urgent emergency basis?
Rebleeding prior to treatment:
•The peak rate of rehemorrhage occurs in the first 24 h – the
“spike of death” – and ranges as high as 17–19%.

The rebleed rate appears to be approximately
20% within the first 2 weeks of the ictus, and
40% at 1 month.
•The rate of rebleeding is roughly 2–3% per day.
•Death after rebleed is approximately 73%.

8. What are the Treatment options for treating
aneurysmal rupture?
•Surgical clipping :
•Endovascular coiling
•Parent artery sacrifice with or with out bypass
surgery

9. Which one of the two modalities is better?
Coiling or Clipping?
Morbidity and Mortality:
•ISAT TRIAL (for ruptured aneurysms): this is
one of the largest study to date done for ruptured intracranial
aneurysms.
The study results are as below
Dead or dependent at one year
(after surgery or endovascular treatment)-
•Surgical group: 30.6% patients were dead
or dependent at one year
•Endovascular group: 23.7% of patients
were dead or dependent at one year

10. Long-term ISAT Results :
Long-term Recurrence or Rebleeding Requiring after primary coiling or
clipping of brain aneurysm:
Clipping coiling
Total number of patients
retreated for recurrance
0.9% 8.6%
Total rebleeds after
treatment
3 patients 7 patients
Over all risk of
rebleeding
0.3% 0.6%

11. Final comments
Clearly, as per studies, Endovascular coiling
is the treatment of choice for aneurysmal
rupture with risks as shown above.
How ever not all aneurysms can be coiled.
For the aneurysms which cannot be coiled
clipping is the option.

12. What international guidelines say about ruptured
aneurysm treatment?
Recommendations
1. Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early
as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Class I; Level
of Evidence B).
2. Complete obliteration of the aneurysm is recommended whenever possible (Class I; Level of
Evidence B).
3. Determination of aneurysm treatment, as judged by both experienced cerebrovascular surgeons
and endovascular specialists, should be a multidisciplinary decision based on characteristics of
the patient and the aneurysm (Class I; Level of Evidence C)
4. For patients with ruptured aneurysms judged to be technically amenable to both endovascular
coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of
Evidence B).
5. In the absence of a compelling contraindication, patients who undergo coiling or clipping of a
ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to
be individualized), and strong consideration should be given to retreatment, either by repeat
coiling or microsurgical clipping, if there is a clinically significant (eg, growing) remnant (Class
I; Level of Evidence B).
6. Microsurgical clipping may receive increased consideration in patients presenting with large (>50
mL) intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling
may receive increased consideration in the elderly (70 years of age), in those presenting with
poor-grade (World Federation of Neurological Surgeons classification IV/V) aSAH, and in
those with aneurysms of the basilar apex (Class IIb; Level of Evidence C).
7. Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and
should only be considered when less risky options have been excluded (Class III; Level of
Evidence C).