When you hear the term “cerebral aneurysm” you probably think of a weakened blood vessel bursting in the brain, an event that requires immediate emergency surgery.
However, only 20% of cerebral aneurysms are identified at the time of hemorrhage. For 80% of patients, the aneurysm is found incidentally at the time of a brain scan, often for another reason.
For incidental aneurysms, patients and physicians have many questions about next steps in evaluation and treatment. For some patients, treatment may be warranted. For others, however, the risk of surgery to treat an unruptured aneurysm may be greater than the risk of observation, such as waiting and watching the aneurysm for signs of growth or change.
An “intracranial aneurysm” means part of a blood vessel in the brain is bulging outward, like a balloon. This part of the blood vessel becomes thinner and weaker, sometimes weak enough to burst. Unruptured aneurysms may or may not cause symptoms. Most do not, but either way, doctors are finding them more often thanks to techniques like MRI (magnetic resonance imaging) and CTA (computed tomographic angiography).
Figuring out which aneurysms are more likely to burst, which patients will benefit from treatment, and which form of treatment is appropriate is challenging, but there is a large body of information that provides some direction.
Dr. Philip M. Meyers has co-written a set of guidelines for the American Heart Association/American Stroke Association on how to assess and treat patients with unruptured intracranial aneurysms. Evaluating best scientific evidence from around the world, the guidelines update a previous set published in 2002. These new guidelines give recommendations to help surgeons weigh the many factors involved in each individual case.
If an aneurysm ruptures it becomes an emergency medical situation. Now that doctors are finding these unruptured aneurysms more often it might seem that treating them all before they can present more danger is a good idea. This is an over-simplification; there are treatment risks and substantial costs, Dr. Meyers and his co-authors conclude. For aneurysms at very low risk of rupture, the best course of action may be watch and wait.
The guidelines call for doctors to take each patient’s individual circumstances into account when deciding whether and how to repair an aneurysm. Surgeons should consider a number of things such as the location and size of the aneurysm, whether it’s growing or causing symptoms, the age of the patient, and whether the patient has other illnesses. Then, the risks of surgery must be taken into account, as well as which kind of surgery will have the most benefit.
Dr. Meyers and his co-authors found that in general, surgery is most likely to benefit a patient who has an aneurysm at certain locations, that is growing or causing symptoms, or who has a history of prior bleeding in the brain. They also found that assessment and surgery have the best outcome when performed at a high-volume center of excellence for cerebrovascular diseases, such as Columbia University Medical Center/NewYork-Presbyterian Hospital.
You can read the complete set of guidelines here.
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