Aortic aneurysm

Abdominal aortic aneurysms are often diagnosed during a routine physical examination when a doctor notices the distinctive vibrating sensation in the abdomen.

A diagnosis can be confirmed using an ultrasound scan. Ultrasounds can also determine the size of the aneurysm, which is an important factor in deciding on a course of treatment.

Intracranial aneurysm

A brain aneurysm can be detected using a special kind of X-ray that is called an angiogram or arteriogram. To highlight the aneurysm, a dye is injected into the bloodstream. The blood in the vessels shows up on the film as white columns. If a blood vessel is swollen due to an aneurysm, the dye in the blood will pass into it and the X-ray will show the swelling.

Computer topography (CT) scans and magnetic resonance imaging (MRI) scans can also be used to produce detailed images of the structure of blood vessels inside the brain.

Screening

It is recommended that you undergo screening for intracranial aneurysms every five years if you have two or more close (first-degree) blood relatives, such as your mother, father, brother, aunt or uncle (but not your grandmother or grandfather) who have experienced a subarachnoid haemorrhage. Your doctor can refer you to a neurologist for further assessment.

Treatments 

There are two main types of treatment for aneurysm:

• preventative treatment: where an aneurysm is treated to prevent it from rupturing, and
• emergency treatment: where an aneurysm is repaired after it ruptures.

Preventative treatment is the preferred option but, as with any type of surgery, it does carry a risk of complications, some of which are serious, such as brain damage or organ failure.

Therefore, preventative treatment is usually only recommended if it is thought that the risk of a rupture is significant enough to justify the risk of treatment.

If you are diagnosed with an aortic aneurysm, a risk assessment will be carried out to assess the risk of the aneurysm rupturing.

The assessment is usually based on five factors:

• Your age.
• The size of the aneurysm.
• How quickly the aneurysm is growing.
• Whether you have a first-degree relative (defined as parents, siblings, aunts or uncles) who has experienced a ruptured aneurysm.
• Whether you have high levels of a chemical called MMP-9 in your blood. High levels of MMP-9 can be caused by extensive weakening of the aortic wall.

Usually, the recommended treatment options are:

• A policy of watchful waiting, if the size of the aneurysm is less than 5cm (see below for more details).
• Preventative surgery, if the size of the aneurysm is from 5 to 5.5cm (2 to 2.2 inches), and you have one of the risk factors mentioned above,.
• Surgery, if the aneurysm is larger than 5.5cm regardless of whether or not you have any associated risk factors.

Watchful waiting

Watchful waiting means that you will not receive immediate surgery, but you will be given regular check-ups so that your aneurysm can be carefully monitored. This usually involves having an ultrasound every three or six months.

You may be given medication to treat any underlying conditions.

Lifestyle changes that will help decrease your risk of a rupture may also be recommended. These may include:

• eating a healthy, balanced diet and reducing the amount of fat in your diet,
• stopping smoking (if you are a smoker), and
• losing weight (if you are overweight).

Surgery

The most commonly used surgical treatment for aortic aneurysms is grafting. This involves removing the affected section of the aorta, and replacing it with a piece of synthetic tubing known as a graft.

There are two ways that grafting can be done:

• Open surgery. A large incision (cut) is made in your abdomen to expose the aorta and insert the graft.
• Endovascular surgery. This involves sticking a thin tube, called a catheter, into one of the veins in your legs and then guiding it to the aorta. The graft is then moved through the catheter and used to reinforce the aorta wall.

Open or endovascular surgery?

Each surgical technique has its own set of advantages and disadvantages. As endovascular surgery is non-invasive (does not involve making major incisions into the body) it has a quicker recovery time. Research also suggests that it offers a slightly better chance of reducing the risk of death from an aneurysm (by about 3%).

However, the same research found that rates of complications after the endovascular surgery, such as the graft splitting or becoming infected, were much higher than in open surgery. Approximately 41% of people who received endovascular surgery experience complications compared with only 9% of people who received open surgery.

The main disadvantage in open surgery is that it requires making a major incision in your abdomen. Therefore it could take you several months to recover from the operation. Open surgery may also not be suitable for people who are unwell due to other health conditions.

Before deciding on a type of surgery, discuss the risks and benefits of each treatment option with your surgical team.

Preventative treatment for intracranial aneurysm

If you are diagnosed with an intracranial aneurysm, a risk assessment will be carried out to assess the risk of the aneurysm rupturing.

The assessment process is usually based on the following factors:

• Your age.
• The size of the aneurysm.
• Where in the brain the aneurysm is located. Intracranial aneurysms that are located near larger blood vessels have a high risk of a rupture.
• Whether you have a family history of ruptured intracranial aneurysm.
• Whether you have an underlying health condition that increases the risk of a rupture, such as polycystic kidney disease.

Watchful waiting is usually recommended if the aneurysm is less than 3mm (0.1 inches) in diameter and there are no associated risk factors.

Surgery is usually recommended if the aneurysm is larger than 7mm (0.3 inches) in diameter or larger than 3mm (0.3 inches) and there are associated risk factors.

Watchful waiting

If watchful waiting is recommended, you will be referred for regular angiograms so that the size of the aneurysm can be carefully monitored.

You may also be given medication to lower your blood pressure. You will probably be asked to make the same lifestyle changes that are outlined above, such as losing weight and reducing the amount of fat in your diet.

Surgery

Two surgical techniques have proved to be successful in the treatment of intracranial aneurysms: neurosurgical clipping and endovascular coiling.

Neurosurgical clipping

Neurosurgical clipping is a procedure that is carried out under general anaesthetic (you are asleep). An incision (cut) is made in your scalp and a small flap of bone is removed to reveal your brain underneath.

When the aneurysm is located, the neurosurgeon (an expert in surgery of the brain and nervous system) will seal it shut using a tiny metal clip. After the bone flap has been replaced, the scalp is stitched together.

Endovascular coiling

Endovascular coiling involves a plastic tube, or catheter, being inserted into an artery in your leg or groin. The tube is guided through the network of blood vessels into your head and finally into the aneurysm.

Tiny platinum coils are then passed through the tube into the aneurysm. The coils block the flow of blood into the aneurysm.

Clipping or coiling?

Both coiling and clipping carry their own set of advantages and disadvantages.

As clipping is invasive surgery, the risks of complications and death during or shortly after surgery are greater. It is estimated that between 4 and 10% of people undergoing clipping will experience complications, and between 1 and 3% of people will die.

In comparison, an estimated 3 to 5% of people undergoing coiling will experience complications, and 1 to 1.5% will die.

However, as clipping seals the aneurysm, rather than just blocking the flow of blood, it is thought to be more effective in preventing ruptures in the long-term.

There is considerable debate within the medical community about which is the most effective treatment and, as yet, no consensus has been reached.

Before deciding on a particular type of surgery, discuss the risks and benefits of each procedure with your surgical team.

Emergency treatment

Emergency treatment is based on the same principles as preventative treatment. Grafts are used to repair ruptured aortic aneurysms, and coils or clipping are used to repair ruptured intracranial aneurysms.

Additional medications and treatments may also be used to prevent blood loss and organ damage. For example, nimodipine may be recommended. This medication is used to prevent ruptured blood vessels going into spasm and causing further blood loss.

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