Brain aneurysms
A weak point in the wall of an artery in the brain that balloons out. Most never cause trouble. A small proportion rupture, causing bleeding around the brain, which is a medical emergency.
Greenslopes Private Hospital, Brisbane
Watkins Medical Centre, Spring Hill, or telehealth
A current GP or specialist referral is needed
At a glance
Often by chance on a scan done for another reason.
Around 2 to 3 in every 100 adults have one.
Depends on size, position, shape, family history, smoking and blood pressure.
Assessed for each aneurysm individually.
Monitoring, clipping, or coiling and stenting.
Chosen with an interventional neuroradiology colleague.
A sudden, worst-ever headache: call 000.
A ruptured aneurysm needs emergency treatment.
What an aneurysm is
Arteries carry blood under pressure. Where the wall is weak, usually at a branching point, it can bulge into a sac. The sac is the aneurysm; the question is whether it will ever leak.
Most brain aneurysms are small and silent. They are found when a scan is done for headache, dizziness, a head injury or something unrelated. The annual chance of rupture for any one aneurysm is low, but it adds up over a lifetime, and it is higher for larger aneurysms, for those in certain positions, for irregular shapes, and in people who smoke, have high blood pressure or a family history of aneurysms.
A ruptured aneurysm causes a subarachnoid haemorrhage: bleeding into the fluid-filled space around the brain. It is a life-threatening emergency treated in hospital, usually by securing the aneurysm within a day or two so that it cannot bleed again, followed by a period in intensive care.
For an unruptured aneurysm the decision is a comparison of two risks: the risk of leaving it alone over the years ahead against the risk of the procedure to treat it. Neither is zero, and the balance is different for each person. That comparison is the substance of the consultation.
Symptoms
An unruptured aneurysm usually causes nothing at all. A ruptured one is unmistakable.
- No symptoms: most unruptured aneurysms are found by chance
- A large aneurysm can press on nearby nerves: double vision, a drooping eyelid, an enlarged pupil, or pain behind the eye
- Rupture: a sudden, severe headache unlike any before, often described as the worst of a lifetime
- With rupture: neck stiffness, vomiting, sensitivity to light, confusion, collapse or loss of consciousness
A sudden, severe headache that peaks within seconds needs an emergency department immediately, even if it eases. Call 000.
How it is diagnosed
CT angiography or MR angiography shows the aneurysm’s size, shape and position and is enough to plan monitoring. A catheter angiogram, done through the groin by an interventional neuroradiologist, gives the most detailed picture and is used when treatment is being planned. Blood pressure and smoking are addressed whatever else is decided.
The scan is on the screen, the options are set out on equal terms, and nothing is booked until you have had time to think.
Treatment options
Whether to treat, and how, is decided together with an interventional neuroradiology colleague. The shape and position of the aneurysm decide which technique suits it.
- MonitoringInterval imaging for small aneurysms where the risk of treatment is higher than the risk of rupture, together with blood pressure control and stopping smoking.
- ClippingA craniotomy in which a small titanium clip is placed across the neck of the aneurysm under the operating microscope, sealing it off permanently. The most durable treatment; it involves an operation on the brain.
- CoilingPlatinum coils are packed into the aneurysm through a catheter passed from the groin, by an interventional neuroradiologist, causing it to clot off. No incision in the head; follow-up imaging is needed and some aneurysms need further treatment later.
- Stents and flow divertersFor wide-necked or awkward aneurysms, a stent in the parent artery holds coils in place or diverts flow away from the sac. Blood-thinning tablets are needed for a period afterwards.
- After a ruptureEmergency treatment by clipping or coiling, followed by intensive care to manage the effects of the bleed on the brain and its blood vessels.
Not every option applies to every person. Which ones apply to you, and in what order, is explained at the consultation and confirmed in writing before anything is booked.
Recovery and follow-up
Recovery depends on whether the aneurysm had bled and on which treatment was used. Follow-up imaging continues for years.
After clipping of an unruptured aneurysm, a stay of several days in hospital and a few weeks of tiredness and headache are usual. After coiling, most people go home within a day or two. Recovery after a rupture is a different matter and depends on the effects of the bleed; rehabilitation is often part of it.
Follow-up imaging, by MR angiography or catheter angiogram, checks that the aneurysm has stayed sealed. Where other small aneurysms are being watched, they are imaged at the same time.
Deciding about an unruptured aneurysm
There is rarely urgency, and there is no wrong question. The consultation sets out the estimated risk of rupture, the risks of each treatment, and what monitoring would involve, so that the decision is yours and made with the facts in front of you.
Dr Gert TollessonNeurosurgeon, Brisbane
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