Endovascular treatment | Embolization of a ruptured brain aneurysm after a bleeding
A brain aneurysm is a focal bulging of a blood vessel in the head. The most common treatment for this is called coiling or embolization. In the following you will get information about the events surrounding this treatment. With this information we don’t want to unnecessarily scare you for the procedure, but we want to try to give you a better idea of the condition, treatment and possible, yet rare risks and complications, so you are better prepared for the procedure.
A brain aneurysm is a localized bulge of the blood vessel wall. A brain aneurysm is often only a few millimeters in size. These protrusions have an increased risk of bleeding due to bursting of this weak spot, because the wall is gradually thinning during the growth of the aneurysm. Such a stroke can have different symptoms, such as sudden severe headache with nausea and vomiting and even death. This specific brain hemorrhage is called a subarachnoid hemorrhage (SAH). The bleeding is not only at the site of the aneurysm, but spreads in the head around the brain and to the neck. Such a bleeding is very severe with a high mortality and morbidity as a result. In the people who survive the bleeding and are brought to the hospital, the cause of the hemorrhage, the aneurysm, needs to be treated as soon as possible, because the risk of a second bleeding from the aneurysm the first period after the initial bleeding is very high and usually fatal.
For a more detailed explanation of the cerebral aneurysm can look at the chapter diseases.
After a SAH, the patient stays for at least 2 weeks (sometimes longer) in the hospital. This is usually in the Intensive care or Medium Care and afterwards on the ward A4 (4th floor) at the neurosurgery department. The patient is closely monitored. Visitation is limited because the patient should be nursed with minimal environmental stimuli (sound, light, etc) to better recover.
The examinations and treatment
To diagnose stroke a brain scan (CT scan) is made. To detect the cause of the stroke, the SAH, the blood vessels are subsequently examined with contrast on the scanner to look for the aneurysm. Subsequently, the treatment is decided by agreement between the interventional neuroradiologist and the neurosurgeon. This is usually an embolization of the aneurysm with coils (coiling) and sometimes a surgical skull surgery to place a clip (clipping). Often an external ventricular drain (EVD) is placed into the cerebrospinal fluid (brain fluid collection system) by the neurosurgeon.
Under general anesthesia, a blood vessel study (angiography) is performed at the radiology department to visualize precisely the aneurysm and determine the best treatment.
For the treatment, you have to lie perfectly still. This requires that you be completely put to sleep (general anesthesia). This is done by a specialist doctor (anesthesiologist). In order to undergo the narcosis as safe as possible you might get an appointment for a consultation with the anesthesiologist in the period prior to the treatment. It is also possible that you should undergo some additional studies (eg EKG, blood test, heart or lung examination, ...).
Because of the anesthesia, you should be sober for at least 6 hours, but usually longer. Often alongside an intravenous drip, a urinary catheter is inserted during anesthesia.
To close the aneurysm, it is filled with very fine metal wires, called coils. This ensures that the weak spot no more fills with blood and no new bleeding can occur. This endovascular treatment is called embolization with coils or "coiling". This procedure is performed by specialized interventional neuroradiologists on the angiography room of the radiology department. The duration of the investigation can vary from one to several hours depending on the accessibility and the size of the aneurysm.
The anesthesiologist will put you to sleep. So you will feel nothing during the procedure. Then a thin catheter (small tube) is placed from the femoral artery (usually right) in one of the head and neck arteries. Through this catheter an even thinner tube (micro catheter) is then guided very carefully into the aneurysm. Subsequently the aneurysm is gradually filled with coils until it is isolated from the bloodstream. Usually, in addition to the coil micro catheter a small balloon micro catheter is also inserted. This balloon micro catheter is placed at the neck of the aneurysm for temporary additional support to the coiling.
After treatment, the catheters are removed and the hole in the femoral artery is closed with a special plug (Angioseal ®). This Angioseal® is naturally degraded by the body in about 2 to 3 months. During this period caution should be exercised with any re-puncture of the groin.
After the treatment
The patient wakes up in the angio room or in the recovery room (recovery, PACU or recovery room). In case of a severe bleeding, the patient remains asleep. The patient is constantly monitored. The puncture site in the groin is regularly controlled. The patient will stay on the medium care (MC) or intensive care unit (ICU) with strict bed rest. Because the bleeding itself is not removed, the patient still has headaches and other symptoms, despite the treatment of the aneurysm. The coil treatment aims to prevent a second hemorrhage and enables an optimum support in intensive care to let the stroke gradually heal.
Despite the closure of the aneurysm, the first days to 2 weeks after the bleeding, complications can occur which could have serious and lasting consequences. This concerns, among others infections, vasospasm, expansion of the cerebrospinal fluid (hydrocephalus), heart and lung problems, problems with moisture etc etc. Despite the closure of the aneurysm, a patient can still die from a severe brain hemorrhage. In patients with a minor stroke the closure of the aneurysm is required to prevent a second fatal bleeding.
Further recovery is individual and depends on several factors (severity of the bleeding, damage caused by the hemorrhage and any complications during or after treatment).
If the situation permits, the patient is transferred to the neurosurgery ward (A4). The total hospital stay is about 2 weeks in relatively good patients, but can be much longer in patients with severe strokes.
Complications and risks
Allergic reactions due to the use of contrast and / or medication (redness, rashes / swelling, hoarseness, chest tightness, …) or adverse effects on the kidneys (especially in people with preexisting poorer kidney function) is rare. Sometimes a bleeding in the groin can happen (bruising and swelling) which usually resolves itself within a few weeks.
The risk of serious complications during embolization with coils is less than the risk of a brain haemorrhage when an aneurysm is left untreated. Hence, we advice in most cases a treatment. The most feared complication is the occurrence of a bleeding during or after the procedure. Fortunately, this is rare, but when it happens it can have serious consequences (up to death). The other serious complication is the occurrence of cerebral infarction (stroke) by the formation of blood clots (thrombi) or vasospasm. This can result in paralysis, aphasia among others. To prevent blood clots, blood thinners are given around and after the procedure.
For most complications, there are treatments and recovery is frequently possible. The list of complications is not exhaustive, but the above are the most drastic.
Alternative to embolization with coils
An aneurysm can also be treated with a skull operation by placing a vascular clip on the neck of the aneurysm (transition from the aneurysm to the normal blood vessel). Of course there are specific advantages and disadvantages associated with this procedure (see the chapter surgical aneurysm clipping).
Before a treatment is proposed, the various treatment options and their risks are discussed within the team of interventional neuroradiologists and neurosurgeons.
After discharge from the hospital
At hospital discharge you get instructions for medication and an appointment for a consultation at the neurovascular consultation (approximately 6 weeks after treatment). To see if the aneurysm remains closed, about 3 to 6 months after treatment, a control angiography is usually performed.
After a stroke many patients suffer from irritability, memory problems, headaches, forgetfulness and concentration weakness. Some patients recover to the same level as before the stroke. Usually there are changes in character and there can be neurological disorders such as paralysis (arm, leg) or speech problems by damaging the speech center in the brains (aphasia). Generally, these symptoms continue to improve during the first six months, but they can also be permanent.
The first 4 to 6 weeks it is wise to take it easy and resume gradually to your normal life. Your treating physician will discuss with you can and cannot do (work, sports, hobbies etc).
If you have any further questions, please feel free to contact your treating physician, neurosurgeon, specialist nurse or interventional neuroradiologist via the telephone number of the department of angiography of the UZA (03-821 3803).