Treatment of Brain Aneurysms

Not all aneurysms need to be treated and your physician may elect to closely observe your aneurysm.  There are two main treatment options for patients who need to have their aneurysm treated.

• Open surgical clipping
• Endovascular therapy: coiling

You physician will discuss these options with you.

Open surgical "clipping":

The "open surgical clipping" is performed by a neurosurgeon who will make an incision in the skin over the head, make an opening in the bone and dissect through the spaces of the brain to place a clip accross the aneurysm where it arises from the blood vessel.  This prevents the blood flow from entering the aneurysm.  Most elective patients spend 2-3 nights in the hospital and then will go home on light restricted activity for 1-2 months after surgery.

There have been considerable advances in open surgery techniques.  Many neurosurgeons can now perform mini craniotomies, or eye brow incisions to clip an aneurysm.  In select patients a small incision is made over the eyebrow.  A small two inch window is then made in the bone over the eye and through this incision a small clip is placed across the opening of the aneurysm.  These patients usually spend 1-2 days in the hospital after surgery and then go home.  Patients are usually on light restricted activity for 1-2 months after surgery.  However, it is still an invasive procedure and takes longer to recover from than a coiling procedure.

Endovascular "coiling":http://www.brainaneurysm.com/Upload_Module/upload/Internal/20111207003108pic-3coils.jpg

Endovascular treatment is performed by a neurointerventional surgeon who may be a neuroradiologist, neurosurgeon, or neurologist that has completed additional training.  Studies have shown that patients with a ruptured aneurysm tend to do better in the long term after a coiling procedure.  A coiling procedure is performed as an extension of the angiogram.  A catheter is inserted into a vessel over the hip and other catheters are navigated through the blood vessels to the vessels of the brain and into the aneurysm.  Coils are then packed into the aneurysm up to the point where it arises from the blood vessel, preventing blood flow from entering the aneurysm.  Most elective patients will go home the next day after surgery and are back to normal activities the following day.  More than 125,000 patients worldwide have been treated with detachable platinum coils. Learn more about the development of detachable platinum coil technology.

Additional devices, such as a stent or a balloon, may be needed to help keep the coils in place inside the aneurysm.  Stent assisted coiling involves permanently placing a stent in the vessel adjacent to the aneurysm to provide a scaffolding of support that keeps the coils within the aneurysm sac.  Balloon remodeling involves temporarily placing a removable balloon adjacent to the aneurysm while coils are positioned in the aneurysm.

There have been considerable advances in endovascular techniques over the last few years and the field continues to evolve.  Most notable is the use of new flow diverting embolization devices.  These devices are similar to a stent in that they are placed into the main vessel adjacent to an aneurysm.  These devices divert flow away from the aneurysm and provide a scaffolding for healing of the vessel wall to occur.  Over time, the aneurysm disappears.  This technology allows your doctor to treat many aneurysms that were previously considered untreatable or that were considered to be high risk by other methods.  There are many other new devices that are becoming available as well, such as newer that are easier and safer to deliver, as well as stents that can bridge two vessels.

Which procedure should I have?

Both open surgery and endovascular methods are effective.  The best treatment for you depends on a number of factors: whether your aneurysm has ruptured, it's size, shape and location.  Like all medical decisions, the best treatment option should be made with your physician.

Treatment of Ruptured Aneurysms
Until recently, most studies on the surgical clipping and endovascular treatment of brain aneurysms were either small-scale studies or were retrospective studies that relied on analyzing historical case records. The only multi-center prospective randomized clinical trial - considered the gold-standard in study design - comparing surgical clipping and endovascular coiling of ruptured aneurysm is the International Subarachnoid Aneurysm Trial (ISAT)¹ .

http://www.brainaneurysm.com/Upload_Module/upload/Internal/20111207003217pq-treatment.gifThe study found that, in patients equally suited for both treatment options, endovascular coiling treatment produces substantially better patient outcomes than surgery in terms of survival free of disability at one year. The relative risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than in surgically-treated patients.

The study results were so compelling that the trial was halted early after enrolling 2,143 of the planned 2,500 patients because the trial steering committee determined it was no longer ethical to randomize patients to neurosurgical clipping. Long-term follow-up will be essential to assess the durability of the substantial early advantage of endovascular coiling over conventional neurosurgical clipping for the treatment of brain aneurysms.

It is important to note that patients enrolled in the ISAT were evaluated by both a neurosurgeon and an endovascular coiling specialist, and both physicians had to agree that the aneurysm was treatable by either technique. This study provides compelling evidence that, if medically possible, all patients with ruptured brain aneurysms should receive an endovascular consultation as part of the protocol for the treatment of brain aneurysms.

Treatment of Unruptured Aneurysms
Although no multi-center randomized clinical trial comparing endovascular coiling and surgical treatment of unruptured aneurysms has yet been conducted, retrospective analyses have found that endovascular coiling is associated with less risk of bad outcomes, shorter hospital stays and shorter recovery times compared with surgery. Studies have shown that:

• Average hospital stays are more than twice as long with surgery as compared to endovascular coiling treatment²
• Four times as many surgical patients report new symptoms or disability after treatment as compared to coiled patients³
• There can be a dramatic difference in recovery times. One study showed that surgically-treated patients had an average recovery time of one year compared to coiled patients who recovered in 27 days³

To find more information about clinical studies about the surgical and endovascular coiling treatment of brain aneurysms, see the clinical research section.

¹Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002: 360: 1267-74. 

²Johnston SC, et. al. Surgical and Endovascular Treatment of Unruptured Cerebral Aneurysms at University Hospitals. Neurology. 1999; 52:1799-1805 

³Johnston SC, et.al. Endovascular and Surgical Treatment of Unruptured Cerebral Aneurysms: Comparison of Risks. Ann Neurology. 2000; 48:11-19