Aneurysm repair aims to prevent rupture of cerebral or vascular aneurysms that could lead to fatal hemorrhage, primarily through surgical or endovascular techniques to isolate or occlude the aneurysm. This treatment is suitable for high-risk aneurysm patients and can significantly reduce the threat of subarachnoid hemorrhage and subsequent stroke. The choice of method depends on the aneurysm's location, size, and the patient's overall health status, and should be determined after evaluation by a neurosurgeon or vascular surgeon.
The core goal of treatment is to block blood flow into the aneurysm sac, preventing its expansion and rupture. Traditional craniotomy and modern endovascular embolization are the main options, each with advantages and disadvantages, requiring case-specific selection. Postoperative rehabilitation and long-term follow-up are also crucial for successful treatment.
1. Craniotomy and Aneurysm Clipping: The surgical team performs a craniotomy to directly place a metal clip at the neck of the aneurysm, blocking blood flow into the aneurysm. This method can immediately isolate the aneurysm and is suitable for accessible anterior cranial base aneurysms, but involves risks associated with craniotomy and anesthesia.
2. Endovascular Embolization: A microcatheter is inserted via the femoral artery to place coils or flow-diverting devices into the aneurysm cavity, promoting thrombosis and occlusion. This minimally invasive technique has small incisions and quick recovery, suitable for deep or complex-shaped aneurysms, but may require adjunctive stent placement.
Mainly applicable in the following situations:
Non-emergency patients should be evaluated for rupture risk scores (such as PHASES score). If the score exceeds a certain threshold, active treatment is recommended. In special cases, such as neurological deficits after aneurysm rupture, emergency surgery is necessary to save lives.
Craniotomy requires general anesthesia, with a surgical duration of approximately 3-6 hours, performed in a laminar flow operating room. Endovascular procedures are carried out in a catheterization lab under local anesthesia, with vascular puncture and catheter placement at the target aneurysm. The choice of technique depends on the aneurysm's shape, location, and patient age.
The amount of embolization material, such as coils, is calculated based on aneurysm volume; typically, 1-3 coils per millimeter of diameter are used, with additional stents for complex cases. Postoperative monitoring includes blood pressure, neurological function, and headache symptoms.
Craniotomy can achieve 100% immediate aneurysm occlusion, with a long-term rebleeding rate below 5%. Endovascular treatment shortens hospitalization to an average of 3-5 days, with significantly less pain and faster recovery.
Combined techniques (e.g., stent-assisted coiling) can manage narrow-necked aneurysms that are difficult with traditional methods. For elderly or cardiopulmonary compromised patients, endovascular approaches carry lower risks and are often the preferred option.
Craniotomy may cause intracranial hemorrhage, infection, or nerve injury, with a permanent neurological deficit risk of approximately 2-5%. Endovascular treatment may lead to vascular injury, thrombosis, or displacement of embolic materials.
Postoperative complications include paralysis, speech difficulties, or memory issues. Elderly patients may experience temporary cognitive decline. Rarely, residual aneurysm may be observed within 6 weeks post-surgery, requiring secondary intervention.
Contraindications include:
Preoperative digital subtraction angiography (DSA) is necessary for precise localization, along with assessment of liver and kidney functions. Patients with diabetes or hypertension should have medication adjustments to prevent blood pressure fluctuations that could cause rupture.
Postoperative management includes temporarily discontinuing antiplatelet drugs (e.g., aspirin) and switching to low-dose anticoagulants to prevent thrombosis. When combined with antithrombotic devices, coagulation parameters such as INR should be maintained between 2.0-3.0.
Patients undergoing radiotherapy (e.g., Gamma Knife) should wait at least 6 months before embolization to avoid tissue fibrosis affecting the procedure. Chemotherapy patients should be evaluated for bone marrow suppression impacting wound healing.
Five-year survival rate after craniotomy reaches 95%, with rebleeding rates after endovascular treatment around 7-10% over 10 years. Large studies show that untreated unruptured aneurysms have an annual rupture rate of about 1-2%, while treated cases have a mortality rate below 1%.
A 2020 systematic review indicated that endovascular treatment has a lower complication rate within 30 days compared to craniotomy (12% vs 18%), though with a slightly higher recurrence rate. Elderly patients (>75 years) undergoing embolization tend to have better neurological outcomes.
Conservative management options include:
In emergency situations, ventricular drainage may be performed first to reduce intracranial pressure, followed by definitive repair. Pharmacological treatment is reserved for high-risk patients unable to undergo surgery, with close monitoring of aneurysm growth.
What preparations are needed before surgery?
Patients should undergo cerebral angiography or CT scans to confirm the aneurysm's location and size, and adjust any anticoagulant or diabetic medications. Fasting is required the day before surgery, and discussions with the doctor about the surgical approach and risks are essential. Family members should be informed about postoperative care, including blood pressure monitoring and neurological assessments.
When can I resume normal activities after endovascular embolization?
Typically, patients stay hospitalized for 1-3 days for observation. Light activities such as walking can usually begin within 24 hours. Lifting heavy objects, driving for extended periods, or vigorous exercise should be delayed at least 2 weeks. Follow-up imaging at one month is recommended to confirm blood flow reconstruction before full activity resumption.
How to prevent cerebrospinal fluid leakage after craniotomy?
Postoperative care includes maintaining a supine position for at least 48 hours, avoiding coughing or nose blowing to reduce intracranial pressure. Wounds are regularly checked for fluid leakage, and pain medications are used to control headaches and reduce agitation. Immediate reporting of dizziness when upright or swelling at the incision site is necessary for imaging assessment.
What medications are needed after surgery?
Most patients require ongoing antiplatelet (e.g., aspirin) or anticoagulant therapy for 6-12 months to prevent thrombosis within the stent. Hypertensive patients should take antihypertensive drugs to keep systolic blood pressure below 140 mmHg, with regular lipid and blood sugar monitoring. Medication doses should follow medical advice and not be adjusted independently.
When is vascular re-evaluation necessary after surgery?
Follow-up cerebral angiography or MRI should be performed every 3-6 months within the first year to ensure complete aneurysm occlusion and stable stent placement. Any new symptoms such as headache, blurred vision, or limb weakness should prompt urgent imaging to rule out re-rupture or new aneurysm formation.
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