Aneurysm repair aims to prevent rupture of cerebral or vascular aneurysms that could lead to fatal hemorrhage, primarily through surgical or endovascular techniques to isolate or occlude the aneurysm. This treatment is suitable for high-risk aneurysm patients and can significantly reduce the threat of subarachnoid hemorrhage and subsequent strokes. The choice of treatment depends on the aneurysm's location, size, and the patient's overall health status, and should be evaluated by neurosurgeons or vascular surgeons.
The core goal of treatment is to block blood flow into the aneurysm sac, preventing its expansion and rupture. Traditional craniotomy and modern endovascular embolization are the main options, each with advantages and disadvantages. The most appropriate approach should be selected based on individual case features. Postoperative rehabilitation and long-term follow-up are also crucial for treatment success.
1. Surgical Clipping of Aneurysm: The surgical team performs a craniotomy to directly place a metal clip at the neck of the aneurysm, blocking blood flow into the aneurysm. This method can immediately isolate the aneurysm and is suitable for accessible anterior circulation aneurysms, but involves risks associated with craniotomy and anesthesia.
2. Endovascular Coiling: A microcatheter is inserted via the femoral artery to place coils or flow-diverting devices into the aneurysm cavity, promoting thrombosis and occlusion of the aneurysm. This minimally invasive technique results in small wounds and rapid recovery, suitable for deep or complex-shaped aneurysms, but may require adjunctive stent placement.
Mainly applicable in the following situations:
Non-emergency patients should be evaluated using rupture risk scores (such as PHASES score). If the score exceeds a certain threshold, active treatment is recommended. In special cases, such as neurological deficits after aneurysm rupture, emergency surgery is necessary to save lives.
Craniotomy requires general anesthesia, with a procedure duration of approximately 3-6 hours, performed in a laminar flow operating room. Endovascular treatment is performed in a catheterization lab, with local anesthesia, puncturing the blood vessel and inserting the catheter to the target aneurysm. The choice of technique depends on the aneurysm's shape, location, and patient age.
The amount of embolization materials, such as coils, should be calculated based on the aneurysm volume; typically, 1-3 coils per millimeter of diameter are used, with additional stents for complex cases. Postoperative monitoring includes blood pressure, neurological function, and headache symptoms.
Surgical clipping can achieve 100% immediate aneurysm occlusion, with a long-term rebleeding rate below 5%. Endovascular treatment shortens hospital stay to an average of 3-5 days, with significantly less pain and faster recovery. When combined (e.g., stent-assisted coiling), it can treat narrow-necked aneurysms that are difficult with traditional methods. For elderly or patients with poor cardiopulmonary function, endovascular approaches carry lower risks and are often the preferred option.
Surgical procedures may cause intracranial hemorrhage, infection, or nerve damage, with a permanent neurological deficit risk of approximately 2-5%. Endovascular treatment may lead to vascular injury, thrombosis, or displacement of embolic materials. Postoperative complications include paralysis, speech difficulties, or memory issues. Older patients may experience temporary cognitive decline. Rarely, residual aneurysm may be observed within 6 weeks post-surgery, requiring secondary intervention.
Contraindications include:
Preoperative digital subtraction angiography (DSA) is necessary for precise localization and assessment of liver and kidney functions. Patients with diabetes or hypertension should have medication adjustments to prevent blood pressure fluctuations that could cause rupture.
Postoperative management includes temporarily discontinuing antiplatelet drugs (e.g., aspirin) and switching to low-dose anticoagulants to prevent thrombosis. When combined with antithrombotic devices, coagulation parameters such as INR should be maintained between 2.0-3.0. Patients receiving radiotherapy (e.g., Gamma Knife) should wait at least 6 months before embolization to avoid tissue fibrosis affecting the procedure. Chemotherapy patients should be evaluated for bone marrow suppression's impact on wound healing.
Five-year survival rate after surgical clipping reaches 95%, with a long-term rebleeding rate of approximately 7-10% after 10 years. Large studies show that untreated unruptured aneurysms have an annual rupture rate of about 1-2%, while treated aneurysms have a mortality rate reduced to below 1%. A 2020 systematic review indicates that endovascular treatment has a lower complication rate within 30 days (12% vs. 18%) compared to craniotomy, though with a slightly higher recurrence rate. Elderly patients (>75 years) undergoing embolization tend to have better neurological outcomes.
Conservative management options include:
In emergency situations, ventricular drainage may be performed first to reduce intracranial pressure, followed by definitive repair. Pharmacological treatment is reserved for high-risk patients unable to undergo surgery, with close monitoring of aneurysm expansion.
What preparations are needed before surgery?
Patients should undergo cerebral angiography or CT scans to confirm the aneurysm's location and size, and adjust anticoagulant or diabetic medications accordingly. Fasting is required the day before surgery. Discussions with the physician about surgical methods and potential risks are essential. Family members should understand postoperative care, including blood pressure monitoring and neurological assessment.
When can patients resume normal activities after endovascular coiling?
Typically, patients stay hospitalized for 1-3 days for observation. Light activities like walking can usually start within 24 hours. Heavy lifting, driving, or vigorous exercise should be delayed at least 2 weeks. Follow-up imaging at one month is recommended to confirm blood flow reconstruction before full activity resumption.
How to prevent cerebrospinal fluid leakage after craniotomy?
Patients should remain supine for at least 48 hours, avoiding coughing or nose blowing to prevent increased intracranial pressure. Wound checks are performed regularly, and pain medications are used to control headaches. If dizziness when upright or wound swelling occurs, immediate medical attention is necessary for imaging assessment.
What medications are required postoperatively?
Most patients need to continue antiplatelet drugs (e.g., aspirin) or anticoagulants for 6-12 months to prevent thrombosis within the stent. Hypertensive patients should use antihypertensives to maintain systolic blood pressure below 140 mmHg, with regular lipid and blood sugar monitoring. Medication doses should follow medical advice and not be adjusted independently.
When is vascular re-evaluation necessary after surgery?
Follow-up cerebral angiography or MRI should be performed every 3-6 months within the first year to confirm complete aneurysm occlusion and stable stent position. Any new symptoms such as headache, blurred vision, or limb weakness require urgent imaging to exclude re-rupture or new aneurysm formation.
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