Brain Aneurysm Rupture Treatment: Surgical Clipping vs. Endovascular Coiling

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• Case Presentation: A 45-Year-Old Male with Ruptured Brain Aneurysm
• Diagnostic Process for a Suspected Ruptured Brain Aneurysm
• Treatment Decision: Factors Influencing Clipping or Coiling
• Surgical Approach for Middle Cerebral Artery Aneurysms
• Endovascular Alternative and Its Limitations
• Long-Term Management and Lifestyle Changes After Treatment
• Full Transcript

Case Presentation: A 45-Year-Old Male with Ruptured Brain Aneurysm

Dr. Mika Niemela, MD, presents a classic clinical case of a brain aneurysm rupture. The patient is a 45-year-old man with a history of smoking and hypertension. He experiences a sudden collapse on the street, a common presentation for a subarachnoid hemorrhage. This emergency scenario immediately triggers a specific diagnostic and treatment pathway in the hospital.

Diagnostic Process for a Suspected Ruptured Brain Aneurysm

The initial diagnostic step is a non-contrast head CT scan. This imaging test can reveal bleeding in the brain, suggesting a ruptured aneurysm. Dr. Mika Niemela, MD, explains that if physicians suspect an aneurysm, the patient then undergoes further vascular imaging. This is typically a CT angiography or an MR angiography scan. These advanced imaging techniques are crucial for confirming the presence of an aneurysm and mapping its precise size and location.

Treatment Decision: Factors Influencing Clipping or Coiling

Once a brain aneurysm is confirmed, a multidisciplinary team, including neurosurgeons, must decide on treatment. Dr. Mika Niemela, MD, outlines the critical factors in this decision. Patient age is a primary consideration; a younger patient has a longer life expectancy, making durable treatment paramount. Other key factors include the aneurysm's size—in this case, 10 millimeters—and its specific location within the brain's vascular architecture. The patient's risk factors, like smoking and hypertension, also inform the long-term prognosis and treatment strategy.

Surgical Approach for Middle Cerebral Artery Aneurysms

For the presented case, Dr. Mika Niemela, MD, strongly advocates for surgical clipping. The aneurysm is located on the middle cerebral artery (MCA). Surgical clipping involves a craniotomy, where a neurosurgeon places a tiny metal clip across the aneurysm's neck. This prevents blood from entering it, effectively eliminating the risk of re-rupture. This open surgical approach is often the preferred treatment for MCA aneurysms in younger, healthier patients due to its proven long-term durability.

Endovascular Alternative and Its Limitations

Endovascular coiling is a minimally invasive alternative to open surgery. A catheter is threaded through the arteries to the aneurysm site. Platinum coils are then deployed into the aneurysm sac to promote clotting. However, Dr. Mika Niemela, MD, notes a significant limitation for MCA aneurysms: a high recanalization risk. Recanalization means the aneurysm can reopen over time, necessitating further treatment. He states that approximately 50% of all brain aneurysm cases today are treated using endovascular techniques, but they are more commonly used for aneurysms in the posterior circulation of the brain.

Long-Term Management and Lifestyle Changes After Treatment

Successful treatment is only one part of the patient's journey. Dr. Mika Niemela, MD, emphasizes the importance of aggressive risk factor management. Quitting smoking is non-negotiable for improving long-term vascular health. Controlling hypertension with medication is equally critical. For elderly patients with very small aneurysms, conservative management with risk factor control may sometimes be recommended over intervention. Dr. Anton Titov, MD, and Dr. Mika Niemela, MD, confirm that after treatment, patients can typically return to a normal life, including exercise, provided they maintain these healthy lifestyle changes.

Full Transcript

Dr. Anton Titov, MD: A middle-aged man collapses on a street. Ruptured brain aneurysm is found on a CT scan. Neurosurgeons face a decision whether to do open brain surgery, “clipping” of aneurysm, or an endovascular treatment, “coiling”. What brain aneurysm treatment method would lead to best results?

Is there a clinical case that would illustrate the topics that we discussed today?

Dr. Mika Niemela, MD: I can tell you about some brain aneurysm patients. Many of the brain aneurysm patients have sudden aneurysm rupture. Maybe somebody falls on a street.

Let's say a 45 year-old man who is a smoker. Smoking happens less and less nowadays. But let's say this patient is a smoker with hypertension. He falls on the street. He is brought to a hospital. He gets a head CT scan.

Physicians suspect that there may be a brain aneurysm that ruptured. These patients go to CT angiography or MR angiography. A brain aneurysm is found. Then they consult neurosurgeons about the patient.

There's a 10 millimeter aneurysm in the MCA (middle cerebral artery). Should we operate or should we treat this brain aneurysm endovascularly?

The patient comes to a neurosurgery service. We talk with the patient. We think about the risk factors for brain aneurysm. Risk factors are gender, smoking status, whether the patient is hypertensive. Maybe there is other ruptured brain aneurysm cases in the family.

Dr. Anton Titov, MD: What is the size of the brain aneurysm? In this case, a 45 year old man in Finland has almost 40 more years of life expectancy.

Dr. Mika Niemela, MD: This patient is smoking. So we ask a patient to quit smoking. Usually we recommend surgery in a 10-millimeter brain aneurysm in the MCA [Middle Cerebral Artery] at that age.

We do not typically suggest endovascular coiling of this brain aneurysm. Because there is a high recanalization risk in MCA aneurysms after endovascular treatment.

Sometimes this patient would be 75 years old. We would just treat this patient conservatively.

Dr. Anton Titov, MD: It means that his hypertension should be treated well. The patient with treated brain aneurysm can live a normal life. We don't give any restrictions. Patients can exercise. But they must quit smoking and take care of hypertension. It depends on the age of the patient.

For a 45 year old patient you choose surgical treatment of brain aneurysm?

Dr. Mika Niemela, MD: Yes. Surgical clipping of middle cerebral artery brain aneurysm. Yes.

Then you would proceed with observing clinical situation in this patient. We follow elderly patients [we observe brain aneurysm]. In younger age groups, best clinical course of action depends on the location of the aneurysm.

We can advocate surgery or endovascular brain aneurysm treatment. We treat endovascularly mostly aneurysms in the posterior brain circulation.

We do endovascular aneurysm coiling in about 50% of all brain aneurysm cases today.

Dr. Anton Titov, MD: Professor Niemela, thank you very much for this very interesting conversation!

Dr. Mika Niemela, MD: My pleasure! Thank you very much!

Dr. Anton Titov, MD: We're looking forward to seeing you again in the future! Thank you very much!