Stroke Center – Brain Aneurysms
What is a brain aneurysm?
Brain (cerebral) aneurysms are abnormal bubbles, blisters or balloon-like pouches that can develop on brain arteries. Like balloons, these pouches can burst, causing a devastating type of stroke as blood leaks in and around the brain. Brain aneurysms are estimated to be present in about 5 percent of the general population. About 20 percent of aneurysm patients may actually have more than one aneurysm.
Also known as “berry aneurysms,” most brain aneurysms are sporadic. This means they occur without any particular cause or reason. Although the exact cause of brain aneurysms is not known, both smoking and high blood pressure (hypertension) are risk factors.
Aneurysms are associated with other brain blood vessel problems, including AVMs and moyamoya disease. Some patients with rare diseases may be prone to developing brain aneurysms. These include:
- Polycystic kidney disease (condition where cysts develop in the kidneys)
- Fibromuscular dysplasia (condition where blood vessels become twisted)
- Connective tissue disorders (disease that affect the tissues of the body)
- Coarctation of the aorta aneurysms (narrowing of the artery that leads to the heart)
Many physicians recommend that patients with these disorders get screened. Also, patients who have a family history of brain aneurysms should be screened. Family history means two or more first-degree relatives. Screening can be done using magnetic resonance angiography (MRA).
The diagnosis of a brain aneurysm is usually made after the aneurysm leaks or ruptures. A CT scan or MRI/MRA scan may show evidence of bleeding from an aneurysm or sometimes show a portion of the aneurysm itself.
An MRA scan is usually adequate to screen patients for an aneurysm. However, a brain angiogram (X-ray of the blood vessels) is required to see the complete aneurysm and to plan the appropriate treatment.
Rupture of an aneurysm is the most feared aneurysm complication. The initial bleeding may be fatal or cause other problems. The subarachnoid hemorrhage produced can lead to hydrocephalus (build up of fluid in the brain) and/or vasospasm (narrowing of a blood vessel).
For this reason, the major focus of aneurysm treatment is to destroy the aneurysm before it has a chance to burst. When this is not possible, occlusion (blockage or closing) of the aneurysm is usually performed as soon as possible after the initial hemorrhage. This is to prevent repeated bleeding.
Treatments for brain aneurysms
Depending on the size and location of the aneurysm as well as the health of the individual patient, some aneurysms may not need to be treated at all. Alternatively, some complex aneurysms may require a combination of both major treatment techniques or other types of procedures.
The two major methods for aneurysm treatment are microsurgical aneurysm clipping and endovascular surgery. Both the microsurgical and endovascular therapies have advantages and disadvantages. A treatment that is appropriate for one patient may not be appropriate for another.
At Penn State Health, we have had considerable experience and special training in evaluating patients for both microsurgical and endovascular aneurysm treatment. Patients are discussed by a team of physicians well versed in all aspects of aneurysm management, and a treatment plan is carefully individualized to each patient.
Microsurgical aneurysm clipping
Microsurgical aneurysm clipping is a well-established method for treating brain aneurysms. Microsurgical treatment for aneurysms involves a procedure called a craniotomy. Your surgeon opens up your skull to expose the aneurysm using delicate instruments and high-powered microscope magnification. Once the aneurysm has been located, the surgeon places a titanium clip across the neck (base) of the aneurysm. The clip stops blood from entering the aneurysm and prevents it from bleeding.
Microsurgical techniques have been around for many years and are constantly advancing. Surgeons are able to follow up with their patients over the years after microsurgical clipping. Surgery and follow-up have an excellent success rate in preventing rebleeding. However, in some patients with severe bleeding, other medical problems or aneurysms that are difficult to get to with surgery, the risks of surgical treatment may be quite high.
Endovascular surgery is a newer, less invasive technique for treating brain aneurysms. Your surgeon inserts a catheter (small, thin tube) into a peripheral artery and navigates using an angiogram (X-ray of the blood vessels) to the aneurysm. Once found, the aneurysm is filled from the inside with tiny platinum coils. The coils react with the surrounding blood, causing it to clot. This destroys the aneurysm.
Endovascular treatment can be particularly effective for aneurysms that are difficult to reach with "open" microsurgery. In addition, the risks of treatment in older patients, patients with major medical problems and patients with severe bleeding is less than traditional surgery. The short-term results using endovascular treatment for brain aneurysms are excellent.
However, its long-term effectiveness is uncertain, and some aneurysms may re-grow even after complete treatment. For this reason, patients require close follow-up with repeated angiograms or magnetic resonance angiography (MRA) studies. Occasionally, additional treatment may be necessary.
Penn State Health is the first and only hospital in Central Pennsylvania to perform a minimally invasive brain aneurysm treatment called aneurysm coil embolization, or aneurysm coiling.
During an aneurysm coiling procedure, doctors first insert a catheter (small, flexible tube) into an artery in the upper leg through a small, quarter-inch incision. This catheter is guided up into an artery in the neck that is delivering blood to the brain.
From there, doctors place a smaller, thinner micro-catheter into the brain aneurysm itself. Fine, soft loops of platinum wire, called coils, are then placed inside the aneurysm to close it off.
This procedure has a high rate of initial success, and patients recover very quickly. However, some aneurysms, particularly those with large or wide bases, can re-grow over time as continued blood flow compresses the coil mass. A new technique using Onyx HD allows for more complete aneurysm filling. Onyx HD has a lower rate of recurrence for these challenging, broad-based aneurysms.
Penn State Health is one of three hospitals in Pennsylvania, and one of only about 30 institutions in the country, to offer a new, minimally invasive treatment for brain aneurysms.
This new treatment uses a liquid, glue-like substance called Onyx HD to completely fill aneurysms from the inside of the blood vessel. This prevents them from ever bleeding or causing a stroke.
The Onyx HD procedure is similar to the coil embolization procedure. However, instead of placing coils in the aneurysm, the liquid Onyx HD is used. The Onyx HD is carefully injected directly into the aneurysm through a microcatheter (small, thin tube). The bottom or base of the aneurysm is temporarily sealed with a separate catheter that has a balloon on it. The entire procedure takes about three hours. Patients usually stay in the hospital one or two days. Recovery time is very short, and many people return to work within in a week or two.
For inquiries regarding the Onyx HD procedure or any form of brain aneurysm treatments, please contact 717-531-3828.
Subarachnoid hemorrhage and vasospasm
The most common problem associated with cerebral aneurysms is rupture, which usually leads to subarachnoid hemorrhage. Subarachnoid hemorrhage (SAH) simply means hemorrhage, or bleeding, in the subarachnoid space. The subarachnoid space is the space around the brain where cerebrospinal fluid (CSF) circulates, and where the major blood vessels are located.
The most common symptom of spontaneous SAH is a severe headache. Patients often describe it as “the worst headache of my life.”
In the later days after subarachnoid hemorrhage, the arteries of the brain may become irritated and go into spasm. This spasm or narrowing is known as a “vasospasm.” Severe spasm can lead to a stroke. Although there is no cure of vasospasm, there are some treatments available.
Treatment for hemorrhage and vasospasm
At Penn State Health, we are able to treat vasospasm in a conventional manner with medications and fluids. We also use newer, endovascular techniques. Endovascular treatment for vasospasm is only available at specialized centers. It involves stretching open the narrowed blood vessel with a balloon and/or putting drugs that open up blood vessels directly into the effected blood vessel.
Carotid artery disease
The carotid artery is the major artery supplying blood to the brain. It is a frequent site of blood clots. This includes both thrombus (blood clot that forms in a blood vessel and stays there) and embolus (blood clot that travels from another part of the body) blood clots.
Carotid artery disease is when the carotid arteries in the neck become narrowed by arteriosclerosis (build up of fats or cholesterol) or atherosclerotic plaque (hardening of the arteries).
Studies have shown that narrowing of the carotid arteries in such a manner increases a person’s risk for stroke. If the narrowing is severe, a procedure may be required to open up the artery.
Treatments for carotid artery disease
Carotid artery disease can be treated using the following treatment methods.
Carotid endarterectomy is the most common surgical procedure performed for stroke prevention. The purpose is to remove plaque blocking the carotid artery. The surgeon makes an incision in the neck, opens the affected artery and removes plaque.
Our neurosurgeons at Penn State Health have special training and experience in this procedure. The majority of carotid endarterectomies are performed under regional anesthesia (the area of the operation is made numb with an injection so patients are not uncomfortable during surgery). Since you are awake, you are less likely to suffer side effects to the heart or lungs from the anesthesia, and overall recovery is faster. Most patients will leave the hospital the next day.
Carotid angioplasty and stenting (CAS)
Carotid angioplasty is a technique used to remove plaque blocking your carotid artery. The surgeon inserts a catheter (a small, flexible tube) into the femoral artery in your groin area through an incision. He or she guides the catheter up to the carotid artery in your neck. A balloon is passed through the catheter to the area of blockage and inflated. After the blockage has been opened, your surgeon places a stent (mesh-like tube) to keep the artery wide open. The procedure is performed while you are awake, and most patients will go home the next day.
Moyamoya disease is a progressive disease that affects the blood vessels in the brain. It is characterized by the narrowing and/or closing of the main arteries to the brain (usually the carotid arteries) just as they enter the skull. The brain attempts to overcome this narrowing and subsequent reduction in blood flow by enlarging other smaller blood vessels, a process called “forming collaterals.”
In patients with Moyamoya disease, the enlargement of some of the usually small vessels at the base of the brain (called lenticulostriate arteries) leads to a pattern on an angiogram (X-ray of the blood vessels) that somewhat resembles a “puff of smoke.” Moyamoya disease is most common in the Asian population, and the term “moyamoya” comes from the Japanese word for “puff of smoke.”
Treatments for moyamoya disease
Patients with moyamoya disease are prone to strokes and brain hemorrhages. Patients may require medical attention either as children or adults. Symptoms may vary widely.
Medical treatments for moyamoya disease are often ineffective, and surgery is frequently required. The goal of surgery is to provide more blood flow in order to decrease the future risk of stroke. Several procedures or combinations of procedures may be tried. Some of the most common include an encephalo-duro-arterio-synangiosis (EDAS), an intracranial to extracranial (EC-IC) bypass and an encephalo-myo-synangiosis (EMS).
An EDAS involves placing an unaffected scalp artery directly on the brain and allowing connections (collaterals) to develop between the artery and the existing brain arteries. This improves blood flow to the brain. An EMS uses muscle from the side of the head (temporalis muscle), which has a good blood supply, to accomplish the same purpose. An EC-IC bypass creates a direct connection between a scalp artery and a brain (intracranial) artery.
Penn State Health uses a multidisciplinary approach to the treatment of patients with moyamoya disease. Your team may include adult and pediatric neurosurgeons, stroke-neurologists and neuroradiologists.
Occlusive cerebrovascular disease
Occlusive cerebrovascular disease refers to blockages or narrowing that occurs in blood vessels that supply the brain or in the brain blood vessels themselves. These blockages or areas of narrowing may result from atherosclerotic (fatty) deposits in the blood vessels.
Treatments for cerebrovascular disease
Sometimes, despite medications and preventative procedures, a brain blood vessel may become completely blocked, and an ischemic stroke will begin to develop.
Solitaire FR Device (clot retrieval)
The Solitaire FR Device is one of the newest tools to be approved for the treatment of ischemic stroke. Ischemic strokes are the most common type of stroke. They happen when an artery in the brain is blocked, so blood can’t flow to the brain.
The Solitaire FR Device is one of a class of devices called stent retrievers. It combines a stent (mesh-like tube used to prop open narrowed blood vessels) and a retriever (a grasping device used to remove material such as blood clots). This combination makes the Solitaire FR Device extremely effective in opening up brain arteries that are blocked by a clot during a stroke.
Your surgeon will place a catheter into your femoral artery in the groin through an incision. He or she will direct it up into the artery in your neck that leads to the blocked brain artery. Your surgeon will then feed a microcatheter (small, flexible tube) through the blockage, deliver the Solitaire FR Device, and open it in the area of the clot. This disrupts the clot or allows your surgeon to remove it.
Penn State Health neuroendovascular surgeons were the first physicians in central Pennsylvania to use the Solitaire FR Device.
The Solitaire PR Device and other devices are not appropriate for all stroke patients. Penn State Health Stroke Center uses a multidisciplinary team of stroke neurologists and neuroendovascular surgeons to evaluate each patient individually before making a personalized treatment recommendation.