The cerebral aneurysm is a dilation of a cerebral artery, non-broken cerebral aneurysms are often encountered occasionally during other investigations. These injuries can be treated or kept under observation.
What are unruptured cerebral aneurysms?
The aneurysm is a dilation of a cerebral artery. The dimensions can vary from a few millimeters to lesions giants with diameters greater than 2.5 cm. The aneurysm can affect any cerebral artery. aneurysms, as well as the size and location, can be divided into two large families: ruptured brain aneurysms and cerebral aneurysms which are intact.
Untreated aneurysms are lesions often encountered occasionally during other investigations. At the very moment it is diagnosed, this aneurysm becomes a problem, first of all for the patient, then for the neurosurgeon who must decide whether the lesion needs treatment or just observation.
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What are the causes of unruptured cerebral aneurysms?
The aneurysm is often localized in the bifurcation of cerebral vessels, a sign that the cause is often embryological. Hypertension is an essential cofactor in the growth and rupture of aneurysms. The same goes for smoking, multiple aneurysms, and connective tissue pathology.
What are the unruptured cerebral aneurysms symptoms?
Sometimes it remains silent all his life. It rarely increases progressively in size until it shows symptoms of headache, compression of cranial nerves with disturbances of ocular motility, seizures, etc.
A small percentage undergoes a break. The size of the lesion is directly related to the risk of breakage. An aneurysm less than 6-7 mm has a low bleeding risk; if more than 7 mm it is generally to be treated.
Everything must also be related to the age of the patient in consideration of the assessment of bleeding risk.
- Often brain CT can lead to suspicion, but much more frequently it is occasional findings in MRI performed for other reasons.
- Angio MRI
- Cerebral angiography (catheterization is performed through the femoral artery until it reaches the intracranial vessels and contrast is injected obtaining a complete visualization of the cerebral flow) to be carried out in doubtful cases or where it is necessary to know the brain blood flow and anatomical changes.
It is up to the neurosurgeon to assess whether the lesion needs treatment or just observation. Currently, the medical literature does not provide reliable guidelines.
The right approach is on a case-by-case assessment, taking into account the age, location of the injury, and the patient’s psychological status in relation to the new pathology.
The neurosurgical treatment of non-broken aneurysms is elective and presents limited risks in relation to the size of the pouch, the location of the lesion, and the age of the patient.
If the neurosurgeon has opted for operation, there are two possibilities:
- Microsurgical treatment
- Endovascular treatment
Endovascular treatment is not an alternative to microsurgical therapy, but an actual intervention choice. Some aneurysms, in fact, have an indication for surgery, others for endovascular treatment. The surgeon will evaluate the chosen treatment based on each case.
The microsurgical treatment consists in excluding the aneurysmal sac by placing one or more small clips. It is performed with the aid of the most modern technologies:
- Surgical microscope
- Intraoperative angiography
- Intraoperative Neurophysiological monitoring
- 3D Endoscopy
- Intraoperative micro-doppler
The risks are limited, considering that the cerebral vessels are resting on the surface of the brain and not inside and that therefore, the microsurgical intervention works on the surface without entering the brain tissue. The use of intraoperative monitoring for the motor and sensory evaluation of the patient during treatment is fundamental.
Endovascular treatment is a normal angiography procedure that involves reaching the cerebral vessels through the femoral artery and filling the aneurysmal sac with small titanium filaments or positioning stents.The risks are related to the possibility of having transient or permanent ischemic events and in the possible rupture.The results of endovascular treatment may not be definitive and require serious follow-up over the years.