Brain Aneurysm Surgery
Reviewed By : Dr. Aarti Joshi
Listed below is the step by step procedure of brain aneurysm surgery:
- What is Brain Aneurysm Surgery?
- Why is Brain Aneurysm Surgery Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Brain Aneurysm Surgery
- Post Procedure
- Risks and Complications
What is Brain Aneurysm Surgery?
A balloon-like blood filled localised bulge in the wall of a blood vessel is known as aneurysm. The term aneurysm is derived from the Greek word aneurysma meaning 'dilation.' Brain aneurysms are formed because of ballooning of a weakened part of blood vessels in the brain. They go mostly undetected, but can be found out during routine examinations or in worst cases when they rupture. The surgery aims to cut down any more blood flow to the aneurysm; either by separating it from blood circulation of the brain or diverting the blood flow in that region.
Why is Brain Aneurysm Surgery Required?
Brain aneurysms are fatal in about 40% of the cases. The rest 60% can be treated if we are vigilant about the causes that may lead to it.
There are many reasons for which you may have to undergo brain aneurysm surgery:
- Hemodynamic disturbances: High blood pressure.
- Atherosclerosis: Thickening of arterial walls due to attack of white blood cells (WBCs).
- Congenital/Inherited disorders: Some disorders present from the time of birth put you at a greater risk of aneurysms such as Ehlers-Danlos syndrome (weakens blood vessels), polycystic kidney disease (increases BP), coarctation of aorta (very narrow aorta at birth), etc.
- Family history: If someone in your family has had an brain aneurysm, you are at a greater risk.
- Trauma: It can happen to anyone.
Certain factors can put you at more risk of having a brain anuerysm, which may ultimately lead to surgery:
- Smoking increases the chances of brain aneurysms.
- Arteriosclerosis (hardening of the arteries)
- Decrease in estrogen levels, especially after menopause due to decrease in its protective effects on the blood vessels
- Older age
- Excess consumption of alcohol
If you happen to see or feel the following, it's time you decide to consult a neurologist:
- Generally speaking, aneurysms are asymptomatic. It is important that you take the warning signs seriously.
- Sudden dizziness
- Nausea, vomiting
- Difficulty in speaking
- Sudden, severe headache
- Pupils dilate
- Visual disturbances – double vision, blurry vision, etc.
- Weakness and numbness in the body
Women are more prone to brain aneurysms than men and Africans are more at risk than Whites.
Most of the brain aneurysms are detected only after they rupture and become a medical emergency. But some of these can be detected on routine examinations too. Here is a small list of the tests you may need to do and show your neurologist for further evaluation:
- Computerized Tomography Scan (CT Scan): This scan produces 2-D slices of the images of your brain. It is helpful in detecting intra-cranial bleeding.
- Cerebrospinal Fluid (CSF) Test: CSF samples are withdrawn from your lower back region via a procedure known as 'spinal tap.' CSF if found with blood cells is indicative of intra-cranial bleeding.
- Cerebral Angiogram: A catheter in inserted from the artery of your groin region and injected with a radiocontrast dye. On a CT Scan, this dye will stand out and give the precise condition of the blood vessel and aneurysm.
- Magnetic Resonance Imaging (MRI) Scan: An MRI scan uses a magnetic field and low dose radiations to view images of the brain. They are particularly useful in imaging all sorts of soft tissues and can easily detect the status of the aneurysm.
On confirming that brain aneurysm surgery is inevitable, you will have to undergo a pre-operative assessment to evaluate your health status before the surgery:
- Medications: Give details of all the medications you are taking presently, especially pain killers, anti-epileptics (for seizures) or blood thinners (warfarin).
- Past medical history & treatments: Let your doctor know if you have been suffering from any disease such as some cardiac condition, diabetes, disorders of liver, kidney or respiratory system. It helps the doctor to be prepared for any untoward event during the surgery. Aspirin or other non-steroidal anti-inflammatory drugs should be stopped two weeks prior to surgery.
- Routine blood workup: Blood sugar, blood pressure (BP), Hemoglobin (Hb), complete blood count (CBC), Hematocrit (Erythrocyte Sedimentation Rate), etc.
- Urinalysis: Presence of sugar, protein, pus cells in urine. Color, specific gravity, creatinine etc. are checked.
- Electrocardiogram: Monitoring heart activity on a graph.
- Liver and kidney function tests: Especially important to assess the capacity of metabolising drugs.
- Evaluation of respiratory function: It is reviewed to ensure adequate oxygenation and ventilation capacity of lungs.
- Neurological examination: In this case and if the situation permits, it is important to see how the nervous system is working. The level of consciousness, status of sensory and motor systems are seen.
Day Before Surgery
- Your doctor would ask you to take certain medications. These include a corticosteroid (eg. Dexamethasone) to control the swelling of your brain, a protective medicine for the stomach and some anti-epileptic (control seizures).
- A special imaging technique called a WAND MRI or CT scan is used to see the images of your brain to pinpoint the exact location of the aneurysm.
- You would be staying for 2-3 days after your surgery. Be sure to bring along loose comfortable clothes and anything which you would like to use in your leisure time.
- Ask someone to accompany you. It's an important day, make sure someone is there to see you throughout.
- You would be asked not eat anything at least 8-12 hours before surgery. It helps in easier induction of anesthesia and lesser risk of aspiration during intubation.
- Take a nice bath before you go to the hospital, but don't apply any nail polish, perfumes, etc.
- You will most likely be admitted on the day of surgery.
- You can keep your jewellery and valuables at home.
- Once you reach the hospital, the nursing staff will again check your vitals. Your head may be shaved partially or completely as per requirements of the surgery.
- An I/V line will be placed. This contains antibiotics and other medications as needed.
- Before surgery, you will be required to sign a consent form. It outlines the entire treatment procedure, its risks and possible complications. Read it and clarify all your doubts with the doctors. Only when you are satisfied and ready, sign it.
- You will be draped in a clean surgical gown and taken to the operation theater. It is well disinfected with sterelised instruments.
- The operation table will have certain pointers or guides to position your head correctly with the best access and visibility for the neurosurgeon.
Methods/Techniques of Brain Aneurysm Surgery
Brain aneurysm surgery is attempted in an elective setting or in most cases, as a result of a ruptured aneurysm leading to brain hemorrhage (especially sub-arachnoid hemorrhage). The following section gives an insight into the various techniques used to go around a brain aneurysulm.
Before starting the surgery, all hair over the patient's head are completely shaved off. This helps in giving clear access to the part of brain where the aneurysm is located. The skin over scalp is cleaned with an antiseptic solution. General anesthesia is introduced into the patient's body in liquid form or as an inhalant. This makes the patient completely unconscious during surgery which is very important to keep the patient's body perfectly still during surgery. Once the patient is totally under the effect of anesthetic medicine, the surgery may begin.
The treatment for brain surgery has improved considerably over the years. Even the aneurysms that were considered inoperable previously are now operable. Newer, less invasive techniques have been designed to deal with the problem.
Surgical treatment of brain aneurysms may involve one or more of the following approaches:
- Microsurgical Clipping
- Endovascular Repair
- Tubular Retractor System
Here we will go through these approaches in brief:
In this technique, the blood supply to the aneurysm is stopped with the help of metal (titanium) clips. First, a small window is made into the skull with a procedure known a s craniotomy. A zig-zag incision is made to gain entry into the skull. Now, using microscope, the surgeon will slowly move across the lobes of the brain to get close to the aneurysm. Then he/she will place a small clip at the neck of the aneurysm and seal it off from the remaining circulation. Clips are available in a variety of shapes and sizes. After this, the section of bone is replaced and sutured (stitched).
This includes Endovascular coiling, artery occlusion and bypass and flow diversion with stents.
- Endovascular coiling: This blocks the blood flow into an aneurysm. A catheter is passed from the groin region to the cerebral circulation. Now a microcatheter is passed through the initial catheter. The platinum coil is attached to this microcatheter. Once it reaches near the base of aneurysm, an electric current is passed which separates the coil from the catheter. It then attaches itself to the base and seals it off. Depending on the size of the aneurysm, more number of coils can be used. Fluoroscopy (continuous X-ray) is used to check the location of the catheters.
- Artery Occlusion And Bypass: This technique is used in cases where standard techniques of closing the aneurysm don't work. It consists of open microsurgery and endovascular coiling. Unlike the coiling method which only blocks the aneurysm, here the entire artery containing the aneurysm will be filled with coils after the new route to circulation is established. This is made possible with the help of a donor vessel. The defective circulation is bypassed and normal brain function is restored.
- Flow Diversion: This approach is best suited for unruptured brain aneurysms. The best part is that there isn't any need to enter the aneurysm itself. Rather, a flow diverting pipeline is inserted in the parent vessel which diverts the flow of blood from the aneurysm.
Tubular Retractor System
It is a minimally invasive procedure where a small incision is made in the head to gain entry into the brain. The tubular retractor is especially useful in dealing with tumors or blood clots that are located deep inside the brain. They gently separate the structures in the brain without causing any damage to the surrounding tissues. Any attempt to remove the problem is done through the retractor. Once the procedure is done, surgical instruments and then tubular retractor are removed and the incision is closed.
The pre-op BP and fluid levels must be restored after performing the surgery. Extubation should be performed only after the breathing has returned to normal and you are conscious.
The decision whether to 'coil' or 'clip' an aneurysm is largely dependent on the patient's age, presence or absence of any other disease, structure of the blood vessels, location of the aneurysm etc.
Typically, a brain aneurysm surgery takes about 1-2 hours to reach completion.
Immediately after the surgery, you will be taken to a recovery room where the doctor will evaluate for your general health and any appearance of neurological symptoms. If any symptoms are found, a CT scan is performed to rule out presence of hematoma (localised pooling of blood).
The nursing staff would monitor your fluid and electrolyte balance (more importantly that of sodium to prevent the risk of hyponatremia which can lead to cerebral oedema). An angiogram may also be taken to see the placement of clips post surgery.
- The hospital stay mostly depends on the type of surgery performed and presence of complications if any. On an average, you would be expected to stay in the hospital for 2-5 days.
- You may feel tired for quite some days after surgery.
- Headaches may be experienced and you would have problem concentrating for longer periods of time.
- Your incisions will feel a bit sore for 4-5 days. Sometimes the area around your eyes or scalp may swell or feel numb.
- Since your incisions were stapled with metal clamps, they will be removed by the 7th or 10th day after surgery.
- Ice packs can be used on the incision area to reduce pain and swelling. Avoid hot fomentation (applying hot substances to ease body pain).
- Follow your doctor's instructions about how and when to take your medicines.
- If you are on blood thinners (Warfarin, Clopidogrel etc.), ask when can you resume taking them. You will be informed how to take those again.
- Two or more pain medications should not be taken simultaneously. Check if they contain paracetamol. Too much of it is harmful for your health.
- Let your doctor know if you feel sick after consuming any medication. He/she can substitute with a better alternative if possible.
- Take medications for seizures and antibiotics as directed. Don't stop the course of medicines in-between.
- The bandage/tape on your head needs to stay on your incision for at least 7-10 days. You should get your dressing changed every 2 days.
- Ask when you can start taking a bath. Be careful to keep your bandaged area dry. Sponge baths are best for the recovery period. Once you start bathing, always pat the incision dry after gently washing with warm water.
Exercise and Activity
- Try not to do any sort of strenuous activity for the first three months after surgery. No heavy weight lifting, bicycling, running or aerobic exercises.
- Avoid climbing the stairs much. Start proper physical activity only after the doctor gives you a green signal.
- Get as much sleep as possible. It helps in better recovery.
- Keep your head elevated when you sleep. You can prop your head using extra pillows or adjust the legs on one side of bed accordingly.
- Wake up very slowly by gently raising your head. You won't feel too dizzy this way.
- You can start washing your hair 2-3 days after surgery, but avoid soaking your head.
- If you consider coloring your hair, postpone it at least for 4 weeks after surgery.
- Start walking slowly 3 days after surgery. Increase the time as each day passes. Constipation and pneumonia wouldn't bother you much then.
- You can have your normal diet soon after surgery.
- If you feel nauseous, start with a simple, bland diet.
- Your doctor will set a limit on the amount of fluid you drink everyday.
- Some bowel irregularity is expected after surgery. But if it continues for long, you would be given fibrous food and laxatives to help with the problem.
A brain aneurysm is associated with several neurological problems. After removal of the offender, the symptoms may subside but leave their effects on certain bodily functions. Rehabilitation helps to regain normalcy of your routine activities in many cases completely.
- Speech therapists at the hospital will help you if your speech area is affected. They can also help in treating swallowing disorders.
- Physical therapists help in improving muscular strength and balance. They guide with your way of walking and activities like ascending and descending the stairs.
- With occupational therapy, your vision and ability to resume daily activities is evaluated. You are taught how to deal with day to day activities such as changing clothes, using the bathroom etc.
- Rehabilitation and complete recovery from the surgery may take about a few months to some years, depending on the severity of your condition.
- Rehabilitation is not a journey of you alone. The support, love and care from your near and dear ones is equally important. A positive attitude will bring a progressive change. It is important that your family should be prepared about the surgery and the road to recovery afterwards.
You would be called by your neurosurgeon for follow up appointments to check how you are coping up post surgery. CT and MRI scans are taken to check for any recurrence of aneurysms in the brain.
If you notice any of the following abnormalities, contact your doctor at the earliest:
- You have a headache and then throw-up (vomit).
- Feeling dizzy
- Sudden loss of consciousness
- Fever and other signs of infection
- Your pain does not subside.
- Stiff neck
- Jerky movements of the body
- Your incisions open
Risks And Complications
The complications can be divided into two general groups:
- General complications
- Complications because of brain aneurysm surgery
- Respiratory depression
- Allergies (anaphylaxis)
- Bleeding during or after the surgery
Complications Due to Surgery
- Formation of blood clot
- Recurrence of aneurysm post surgery
- Swelling in the brain
- Infections – These can reach to other parts of the head such as the skull, scalp.
- Stroke – Blood flow to the brain is cut-off, causing cell death.
- Seizures – It is an abnormal electrical activity in the brain caused due to sudden changes in its physiology.
- Behaviour changes
- Loss of neuro-muscular coordination
- Speech problems
- Problems in vision – From progressive loss of vision to complete blindness
- When can I start going back to work after brain aneurysm surgery?
A. You may feel that you are ready to rejoin work within one or two weeks. But complete recovery will take some time. Most people join work 6-7 weeks after surgery. You may discuss this with your neurosurgeon and then go ahead.
- When can I start driving?
A. If your aneurysm has been clipped or if you had an endovascular repair, you can resume driving after 2 weeks. But if you had suffered from a subarachnoid hemorrhage, its best to consult your doctor before taking any further steps.
- When can I wash my hair?
A. As soon as the doctor removes all the stitches from your head.
- Are those metallic clips used during surgery harmful? Will it hurt?
A. The metallic clips used for clipping your aneurysm are very small in size and are made of titanium. It is a very biocompatible material and will not react with your body.
- What are the chances of my complete recovery? Will I be normal like before?
A. There are chances with rigorous rehabilitation you will be able to regain most of your functions. However, a complete recovery is possible only in 30-40% of cases. In the rest, some form of disability is inevitable.
- Are my children at risk of a brain aneurysm too?
A. Even though there are chances of inheriting the risk of brain aneurysms, it is rarely seen in children. Brain aneurysms appear in the middle ages (35-60 years).
It is said that a brain aneurysm ruptures every 8 minutes. A brain aneurysm is what many people call a 'ticking time bomb.' Most of the risk factors leading to such a situation are lifestyle related, while some reasons are out of our hands. A routine health check up and awareness about such conditions may prevent any serious damage. But the journey from a brain aneurysm surgery to a complete recovery is a long one. A positive attitude and an undying spirit with the support of family and friends can lead to a better outcome.