Intracranial Aneurysm: Diagnostic Monitoring, Current Interventional Practices, and Advances
- 204 Downloads
Purpose of review
Cerebral aneurysms are commonly diagnosed incidentally with non-invasive neuro-imaging modalities (i.e., brain MRA and/or head CTA). The first decision to be made in the management of patients with unruptured cerebral aneurysms is to determine if the aneurysm should undergo treatment as any intervention carries a risk of morbidity and mortality.
The multiple risk factors that are associated with increased risk of aneurysm rupture should be evaluated (size, shape, and location of aneurysm; history of hypertension and cigarette smoking and family history of cerebral aneurysms). With the advent and rapid evolution of less traumatic neuro-endovascular surgery techniques in the past two decades, many more patients are undergoing treatment of cerebral aneurysms. The neuro-endovascular surgeon has multiple options for the treatment of aneurysms including coiling, with or without balloon/stent assistance, and flow diversion. A number of intrasaccular devices for the neuro-endovascular treatment of cerebral aneurysms are being evaluated. The percentage of patients with cerebral aneurysms treated with craniotomy and clip ligation is decreasing. This is controversial as it has direct impact in neurosurgical training and the aneurysms that are usually recommended for microsurgical clipping are the ones with challenging anatomy that cannot be treated safely with endovascular approaches.
The best outcomes are achieved with management by experienced, high-volume practitioners at specialized cerebrovascular treatment centers that consist of individuals with dedicated training in neuro-endovascular surgery as well as individuals trained in open cerebrovascular neurosurgery.
KeywordsCerebral aneurysm Coiling Clipping Flow diversion
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 4.• Backes D, Rinkel GJE, Greving JP, Velthuis BK, Murayama Y, Takao H, et al. ELAPSS score for prediction of risk of growth of unruptured intracranial aneurysms. Neurology. 2017;88:1600–6 The ELAPSS score helps the practitioners to determine the risk of natural history of cerebral aneurysms.CrossRefGoogle Scholar
- 5.• Backes D, Rinkel GJE, Laban KG, Algra A, Vergouwen MDI. Patient- and aneurysm-specific risk factors for intracranial aneurysm growth: a systematic review and meta-analysis. Stroke. 2016;47:951–7 Close follow up of untreated incidental aneurysms is important as growth observed on follow up examination increases the risk of hemorrhage 12X when compared to aneurysms that don’t exhibit growth.CrossRefGoogle Scholar
- 8.Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, et al. Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2368–400.CrossRefGoogle Scholar
- 14.Lanterna LA, Tredici G, Dimitrov BD, Biroli F. Treatment of unruptured cerebral aneurysms by embolization with guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding--a systematic review of the literature. Neurosurgery. 2004;55:767–75 discussion 775-778.CrossRefGoogle Scholar
- 17.Koyanagi M, Ishii A, Imamura H, Satow T, Yoshida K, Hasegawa H, et al. Long-term outcomes of coil embolization of unruptured intracranial aneurysms. J Neurosurg. 2018:1–7.Google Scholar
- 29.Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, et al. Long-term clinical and angiographic outcomes following pipeline embolization device treatment of complex internal carotid artery aneurysms: five-year results of the pipeline for uncoilable or failed aneurysms trial. Neurosurgery. 2017;80:40–8.PubMedGoogle Scholar
- 31.Dmytriw AA, Adeeb N, Kumar A, Griessenauer CJ, Phan K, Ogilvy CS, et al. Flow diversion for the treatment of basilar apex aneurysms. Neurosurgery. 2018;0:1–8.Google Scholar