Brain Aneurysm: When is Coiling and Neurointervention Needed at RSPJ?

By: dr. Andika Surya Atmadja, Sp.N, FINA, AIFO-K

Brain aneurysms are often described as ticking time bombs in the brain's blood vessels, small bulges in the blood vessel walls that could rupture and cause severe bleeding. The problem is, many aneurysms don't cause any symptoms until a sudden hemorrhage occurs. When an aneurysm is discovered, either incidentally during a brain exam or after severe symptoms develop, a doctor will assess its size, location, and risk of rupture.

What is a brain aneurysm? A “bulge” in a blood vessel in the brain.

A brain aneurysm is a widening or bulging of a blood vessel wall in the brain. It can be likened to a small bulging pouch on one side of a water hose. Aneurysms can be small and stable for years, grow slowly, or be discovered after a hemorrhage. Factors suspected to play a role include:

• Family history of aneurysms
• High blood pressure
• Smoking
• Some congenital connective tissue disorders

Not all aneurysms will rupture, but the risk of rupture increases if:

• The aneurysm is getting bigger
• Located in a specific blood vessel area
• Other uncontrolled risk factors

Symptoms of an aneurysm: often silent, sometimes only felt when it ruptures

Many brain aneurysms are asymptomatic and are only discovered when a CT or MRI scan is performed for another condition. However, an aneurysm can cause symptoms if:

1. Pressing the surrounding tissue

• Certain chronic headaches
• Optical nerve disorders (e.g., drooping eyelids, double vision)

2. Rupture and bleeding. This is an emergency condition that can cause:

• Sudden, severe headache
• Nausea and vomiting
• Stiff neck
• Sensitivity to light
• Decreased consciousness, including fainting
• Convulsions

In this condition, the patient must be immediately taken to the emergency room for assessment and emergency treatment.

Treatment options: observation, coiling, or open surgery

Not all aneurysms detected require immediate surgical treatment. Treatment decisions depend on the aneurysm's size, location, shape, whether it has ruptured, the patient's age and general health, and other risk factors. Broadly speaking, treatment options include:

1. Periodic Observation and Control

• For small aneurysms, specific locations, and those with a low risk of rupture,
• Periodic monitoring with CT/MR angio-imaging and risk factor monitoring is recommended.

2. Endovascular procedures

• Coiling
• Sometimes combined with a stent or other techniques
• Performed by an interventional neurosurgeon through a catheter inserted into a blood vessel, usually in the thigh or wrist.

3. Open surgery

• Performed by a neurosurgeon by opening the skull.
• The aneurysm is clamped with special clips from outside the blood vessel.

The medical team will explain the advantages and risks of each method, then recommend which one is most appropriate for your aneurysm condition.

What is endovascular coiling and how does it work?

Endovascular coiling is a neuro-interventional procedure to fill the aneurysm sac from within the blood vessels, without opening the skull. In simple terms:

1. Vascular access: A small catheter is inserted through a vein in the thigh or wrist and gently guided to the brain blood vessels at the site of the aneurysm under special X-ray guidance.
2. Entering the aneurysm: A smaller microcatheter is inserted into the aneurysm sac.
3. Filling the aneurysm: A coil is inserted into the aneurysm sac until it fills like a balloon. The goal is to reduce blood flow into the aneurysm and eventually clot it, thus reducing the risk of rupture.
4. Final evaluation with DSA: After coiling, repeat angiography is performed to ensure the aneurysm is adequately filled with coils and that flow in the main vessels remains good.

This procedure is performed in an angiography room under close monitoring and usually requires anesthesia (general or deep sedation, depending on the case).

Aneurysm neurointerventional surgery at Premier Jatinegara Hospital

1. Discussion with your doctor: Assessment of symptoms, medical history, and risk factors
2. Team discussion and treatment planning: Determining whether the aneurysm will be monitored only, treated with endovascular coiling, or surgical clipping is more appropriate, and explaining the benefits, risks, and alternatives to the procedure to the patient and family.
3. Preparation for the procedure: Blood tests, cardiac exams, anesthesia assessment, fasting instructions before the procedure, and medication management.
4. Day of the procedure: The patient is taken to the angiography room for a DSA to map the blood vessels and aneurysm in detail.
5. After the procedure: The patient is taken to the recovery room or intensive care unit and closely monitored for blood pressure, level of consciousness, pain, and signs of complications.

Aftercare and Long-Term Control

After an aneurysm, monitoring and control remain important:

• Immediate post-procedure care
• Risk factor control
• Re-check blood vessel imaging
• Rehabilitation if necessary

Each patient's journey can be different, and long-term plans will be tailored to each individual's condition.

When should you consult a neurologist/neuro intervention team?

You should consult a neurologist and neuro intervention team if:

• Sudah didiagnosis memiliki aneurisma otak pada CT/MRI/angiografi
• Mengalami sakit kepala sangat hebat mendadak, terutama bila disertai mual, muntah, kaku kuduk, atau penurunan kesadaran
• Ada riwayat aneurisma otak dalam keluarga, terutama bila disertai keluhan saraf tertentu
• Dokter sebelumnya menyarankan evaluasi lebih lanjut terkait kemungkinan kelainan pembuluh darah otak

Remember, not all aneurysms require immediate treatment. However, understanding the condition clearly and discussing it with an experienced team will help you and your family make a calmer and more informed decision.

FAQ:

1. Do all aneurysms require surgery or coiling?

No, the decision depends on the size, location, shape of the aneurysm, whether it has ruptured, and individual risk factors. Some aneurysms require regular monitoring, while others are recommended for coiling or surgery.

2. Isn't coiling "installing wires in the brain"? Is it safe, Doc?

Coiling is performed from within the blood vessels with a special tool, not "inserted into the brain" in a crude way. Every procedure has risks, but in the right patient and in the hands of an experienced team, coiling can help reduce the risk of future aneurysm rupture.

3. Do all cancer patients need a 3T MRI?

Aneurysms are filled with coils to reduce blood flow into the aneurysm sac. Functionally, this helps reduce the risk of rupture. However, follow-up checkups are still necessary as recommended by your doctor.

Have you recently been diagnosed with a brain aneurysm, or is your family member undergoing treatment for a brain hemorrhage caused by an aneurysm?

Don't hesitate to discuss your options with the neurology and neurointerventional teams at RSPJ.
Our team is ready to explain treatment options, including endovascular coiling, comprehensively and in easy-to-understand language.
 

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