Treatment of cerebral aneurysms
- Robert J Singer, MD
Robert J Singer, MD
- Associate Professor of Neurosurgery
- Neurovascular Therapeutics
- Geisel School of Medicine at Dartmouth
- Christopher S Ogilvy, MD
Christopher S Ogilvy, MD
- Professor of Surgery
- Harvard Medical School
- Guy Rordorf, MD
Guy Rordorf, MD
- Associate Professor of Neurology
- Harvard Medical School
Subarachnoid hemorrhage (SAH) is often a devastating event with a high mortality and morbidity. Most subarachnoid hemorrhages (SAH) are caused by ruptured intracranial saccular aneurysms. In most cases, the presence of the aneurysm is unsuspected until SAH occurs. After aneurysmal SAH, the patient is at substantial risk of rebleeding: 3 to 4 percent in the first 24 hours and 1 to 2 percent each day in the first month . Rerupture is associated with a mortality that is estimated to be 70 percent. Aneurysm repair is the only effective treatment to prevent this occurrence .
Unruptured cerebral aneurysms may manifest clinically by their mass effect on adjacent neurologic structures, or they may be discovered incidentally when a patient has a neuroimaging study for another indication. Such aneurysms have a future risk of rupture and SAH that depends in part on their size and location.
The treatment of cerebral aneurysms is discussed in this topic. Other aspects of the clinical features, diagnosis and management of cerebral aneurysms and aneurysmal SAH are discussed separately. (See "Unruptured intracranial aneurysms" and "Treatment of aneurysmal subarachnoid hemorrhage" and "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage".)
Surgical and endovascular techniques are available for aneurysm treatment. In many cases, anatomic considerations, such as size, location, along with other morphological features determine which treatment is most appropriate for the patient.
Surgery — Surgical management of cerebral aneurysms, in which a clip is placed across the neck of the aneurysm, is an effective and safe procedure with the evolution of microsurgical techniques in the hands of an experienced surgeon (image 1). This applies to patients with unruptured cerebral aneurysms and those with subarachnoid hemorrhage .
- Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40:994.
- Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711.
- Brilstra EH, Algra A, Rinkel GJ, et al. Effectiveness of neurosurgical clip application in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2002; 97:1036.
- Berman MF, Solomon RA, Mayer SA, et al. Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke 2003; 34:2200.
- Jabre A, Symon L. Temporary vascular occlusion during aneurysm surgery. Surg Neurol 1987; 27:47.
- Tang G, Cawley CM, Dion JE, Barrow DL. Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 2002; 96:993.
- Chiang VL, Gailloud P, Murphy KJ, et al. Routine intraoperative angiography during aneurysm surgery. J Neurosurg 2002; 96:988.
- Klopfenstein JD, Spetzler RF, Kim LJ, et al. Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment. J Neurosurg 2004; 100:230.
- Kumar R, Friedman JA. Intraoperative angiography during cerebral aneurysm surgery. Neurocrit Care 2009; 11:299.
- Todd MM, Hindman BJ, Clarke WR, et al. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005; 352:135.
- Zhao ZX, Wu C, He M. A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery. Clin Neurol Neurosurg 2012; 114:827.
- Li LR, You C, Chaudhary B. Intraoperative mild hypothermia for postoperative neurological deficits in intracranial aneurysm patients. Cochrane Database Syst Rev 2012; :CD008445.
- Andrews RJ, Bringas JR. A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 1993; 33:1052.
- Samson D, Batjer HH, Bowman G, et al. A clinical study of the parameters and effects of temporary arterial occlusion in the management of intracranial aneurysms. Neurosurgery 1994; 34:22.
- Fridriksson S, Säveland H, Jakobsson KE, et al. Intraoperative complications in aneurysm surgery: a prospective national study. J Neurosurg 2002; 96:515.
- Elijovich L, Higashida RT, Lawton MT, et al. Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study. Stroke 2008; 39:1501.
- McLaughlin N, Bojanowski MW. Early surgery-related complications after aneurysm clip placement: an analysis of causes and patient outcomes. J Neurosurg 2004; 101:600.
- Dovey Z, Misra M, Thornton J, et al. Guglielmi detachable coiling for intracranial aneurysms: the story so far. Arch Neurol 2001; 58:559.
- Guglielmi G, Viñuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. J Neurosurg 1991; 75:1.
- Pierot L, Wakhloo AK. Endovascular treatment of intracranial aneurysms: current status. Stroke 2013; 44:2046.
- Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular treatment of intracranial aneurysms in elderly patients: a systematic review and meta-analysis. Stroke 2013; 44:1897.
- Pierot L, Cognard C, Anxionnat R, et al. Ruptured intracranial aneurysms: factors affecting the rate and outcome of endovascular treatment complications in a series of 782 patients (CLARITY study). Radiology 2010; 256:916.
- van den Bergh WM, Kerr RS, Algra A, et al. Effect of antiplatelet therapy for endovascular coiling in aneurysmal subarachnoid hemorrhage. Stroke 2009; 40:1969.
- Ries T, Siemonsen S, Grzyska U, et al. Abciximab is a safe rescue therapy in thromboembolic events complicating cerebral aneurysm coil embolization: single center experience in 42 cases and review of the literature. Stroke 2009; 40:1750.
- Brinjikji W, McDonald JS, Kallmes DF, Cloft HJ. Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms. Stroke 2013; 44:1343.
- Renowden SA, Benes V, Bradley M, Molyneux AJ. Detachable coil embolisation of ruptured intracranial aneurysms: a single center study, a decade experience. Clin Neurol Neurosurg 2009; 111:179.
- Nguyen TN, Raymond J, Guilbert F, et al. Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture. J Neurosurg 2008; 108:1088.
- Chalouhi N, Penn DL, Tjoumakaris S, et al. Treatment of small ruptured intracranial aneurysms: comparison of surgical and endovascular options. J Am Heart Assoc 2012; 1:e002865.
- Fernandez Zubillaga A, Guglielmi G, Viñuela F, Duckwiler GR. Endovascular occlusion of intracranial aneurysms with electrically detachable coils: correlation of aneurysm neck size and treatment results. AJNR Am J Neuroradiol 1994; 15:815.
- Tateshima S, Murayama Y, Gobin YP, et al. Endovascular treatment of basilar tip aneurysms using Guglielmi detachable coils: anatomic and clinical outcomes in 73 patients from a single institution. Neurosurgery 2000; 47:1332.
- Suzuki S, Tateshima S, Jahan R, et al. Endovascular treatment of middle cerebral artery aneurysms with detachable coils: angiographic and clinical outcomes in 115 consecutive patients. Neurosurgery 2009; 64:876.
- Winn HR, Richardson AE, Jane JA. The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol 1977; 1:358.
- Inagawa T, Kamiya K, Ogasawara H, Yano T. Rebleeding of ruptured intracranial aneurysms in the acute stage. Surg Neurol 1987; 28:93.
- Naidech AM, Janjua N, Kreiter KT, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol 2005; 62:410.
- Larsen CC, Astrup J. Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review. World Neurosurg 2013; 79:307.
- Lord AS, Fernandez L, Schmidt JM, et al. Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. Neurology 2012; 78:31.
- van Asch CJ, Oudendijk JF, Rinkel GJ, Klijn CJ. Early intracerebral hematoma expansion after aneurysmal rupture. Stroke 2010; 41:2592.
- Sherif C, Gruber A, Dorfer C, et al. Ruptured carotid artery aneurysms of the ophthalmic (C6) segment: clinical and angiographic long term follow-up of a multidisciplinary management strategy. J Neurol Neurosurg Psychiatry 2009; 80:1261.
- Le Roux PD, Elliott JP, Downey L, et al. Improved outcome after rupture of anterior circulation aneurysms: a retrospective 10-year review of 224 good-grade patients. J Neurosurg 1995; 83:394.
- Whitfield PC, Kirkpatrick PJ. Timing of surgery for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2001; :CD001697.
- Ohman J, Heiskanen O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 1989; 70:55.
- Phillips TJ, Dowling RJ, Yan B, et al. Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke 2011; 42:1936.
- Koivisto T, Vanninen R, Hurskainen H, et al. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. Stroke 2000; 31:2369.
- van der Schaaf I, Algra A, Wermer M, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2005; :CD003085.
- Molyneux A, Kerr R, Stratton I, et al. 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.
- Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366:809.
- Nichols DA, Brown RD Jr, Meyer FB. Coils or clips in subarachnoid haemorrhage? Lancet 2002; 360:1262.
- Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009; 8:427.
- Schaafsma JD, Sprengers ME, van Rooij WJ, et al. Long-term recurrent subarachnoid hemorrhage after adequate coiling versus clipping of ruptured intracranial aneurysms. Stroke 2009; 40:1758.
- Scott RB, Eccles F, Molyneux AJ, et al. Improved cognitive outcomes with endovascular coiling of ruptured intracranial aneurysms: neuropsychological outcomes from the International Subarachnoid Aneurysm Trial (ISAT). Stroke 2010; 41:1743.
- van den Berg R, Foumani M, Schröder RD, et al. Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients. Crit Care Med 2011; 39:2722.
- Koffijberg H, Buskens E, Rinkel GJ. Aneurysm occlusion in elderly patients with aneurysmal subarachnoid haemorrhage: a cost-utility analysis. J Neurol Neurosurg Psychiatry 2011; 82:718.
- Brilstra EH, Rinkel GJ, Algra A, van Gijn J. Rebleeding, secondary ischemia, and timing of operation in patients with subarachnoid hemorrhage. Neurology 2000; 55:1656.
- Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg 2002; 97:250.
- Dorhout Mees SM, Molyneux AJ, Kerr RS, et al. Timing of aneurysm treatment after subarachnoid hemorrhage: relationship with delayed cerebral ischemia and poor outcome. Stroke 2012; 43:2126.
- Gonzalez NR, Dusick JR, Duckwiler G, et al. Endovascular coiling of intracranial aneurysms in elderly patients: report of 205 treated aneurysms. Neurosurgery 2010; 66:714.
- Li H, Pan R, Wang H, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke 2013; 44:29.
- McDougall CG, Spetzler RF, Zabramski JM, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg 2012; 116:135.
- Spetzler RF, McDougall CG, Albuquerque FC, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 2013; 119:146.
- Johnston SC, Wilson CB, Halbach VV, et al. Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol 2000; 48:11.
- Greving JP, Rinkel GJ, Buskens E, Algra A. Cost-effectiveness of preventive treatment of intracranial aneurysms: new data and uncertainties. Neurology 2009; 73:258.
- Pouratian N, Oskouian RJ Jr, Jensen ME, et al. Endovascular management of unruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 2006; 77:572.
- Qureshi AI, Janardhan V, Hanel RA, Lanzino G. Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review. Lancet Neurol 2007; 6:816.
- Johnston SC, Zhao S, Dudley RA, et al. Treatment of unruptured cerebral aneurysms in California. Stroke 2001; 32:597.
- Vallee JN, Aymard A, Vicaut E, et al. Endovascular treatment of basilar tip aneurysms with Guglielmi detachable coils: predictors of immediate and long-term results with multivariate analysis 6-year experience. Radiology 2003; 226:867.
- Raftopoulos C, Goffette P, Vaz G, et al. Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms. Neurosurgery 2003; 52:1280.
- Zacharia BE, Ducruet AF, Hickman ZL, et al. Technological advances in the management of unruptured intracranial aneurysms fail to improve outcome in New York state. Stroke 2011; 42:2844.
- McDonald JS, McDonald RJ, Fan J, et al. Comparative effectiveness of unruptured cerebral aneurysm therapies: propensity score analysis of clipping versus coiling. Stroke 2013; 44:988.
- Hwang JS, Hyun MK, Lee HJ, et al. Endovascular coiling versus neurosurgical clipping in patients with unruptured intracranial aneurysm: a systematic review. BMC Neurol 2012; 12:99.
- De Vries J, Boogaarts J, Van Norden A, Wakhloo AK. New generation of Flow Diverter (surpass) for unruptured intracranial aneurysms: a prospective single-center study in 37 patients. Stroke 2013; 44:1567.
- Endovascular therapy
- - Coil embolism
- - Newer techniques
- Anatomic considerations
- SUBARACHNOID HEMORRHAGE
- Early rebleeding
- Timing and choice of therapy
- - Good grade subarachnoid hemorrhage
- - Poor grade subarachnoid hemorrhage
- Posttreatment management
- UNRUPTURED ANEURYSMS
- ANEURYSM RECURRENCE AND LATE REBLEEDING
- SUMMARY AND RECOMMENDATIONS