Incidentally discovered aneurysms in the brain-what to do about them?

Incidentally discovered aneurysms in the brain-what to do about them?

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

 

Recently I saw a patient in my office. She had undergone a MRI scan for headache. The MRI scan revealed a 4 mm aneurysm in the left middle cerebral artery with a 2 mm neck. I reassured her that the aneurysm was not the cause of her headache and that she more than likely had migraine headaches when she asked me the million dollar question which I had been expecting all along.

Dr. Sethi, but what to do about the aneurysm? Can it rupture? Do I need surgery to take care of it she asked me? I answered her questions according to the best scientific evidence I had at my disposal. That patient visit though got me thinking about how many patients face the same dilemma. That is the purpose of this post. When aneurysms are discovered incidentally in the brain, what needs to be done?

In keeping with my style of writing, I shall keep this simple. Simply put when an aneurysm is discovered in the brain, there are 2 avenues open to us.

 

Avenue 1. DO NOTHING (otherwise called the WAIT AND WATCH policy). The aneurysm may never rupture in the patient’s lifetime so why touch it. The wait and watch policy works best for aneurysms which are small in size (less that 5 mm in size, some books say aneurysms less that 7 mm in size may be safety observed). Small sized aneurysms in hard to reach areas of the brain can be justifiably observed. What do I mean by hard to reach areas of the brain? Let me explain with the aid of an example. Let us assume Kim our fictitious patient has a 3 mm aneurysm in the cavernous portion of the left internal carotid artery. This is the portion of the internal carotid artery that traverses the cavernous sinus. Now this area is difficult to reach “safely” by the neurosurgeon. The risks of surgery are tangible and may outweigh the potential benefits (remember as the aneurysm is small in size the risk of rupture is low). Better to wait and watch rather than go about chasing this aneurysm.

I said WAIT AND WATCH not WAIT AND FORGET. Meaning the patient should be advised to remain in follow up. The aneurysm should be followed by serial MRI scans done at intervals varying from 6 months to 1 year. Initially the follow up is more frequent, once we have documented that the aneurysm is not increasing in size, the scans can be repeated less frequently. If the aneurysm starts increasing in size then a more “active” course can be pursued. If the patient is hypertensive, good blood pressure control should be the goal as risk of aneurysm growth and rupture increases if blood pressure remains elevated.

 

Avenue 2. PURSUE AN ACTIVE STRATERGY. Simply put it means “taking care” of the aneurysm surgically either via open craniotomy or via an endovascular approach. Let me explain this. Let us assume Kim has a 10 mm sized aneurysm is the right middle cerebral artery territory. We can approach this aneurysm in 2 ways. First is via an open craniotomy, meaning that open up the skull (we call this a craniotomy), visualize the aneurysm and then secure it with a clip or a band. Once the aneurysm is clipped it cannot rupture as it is excluded from the circulation. PROBLEM SOLVED!!!

 

Second approach is via an endovascular route. No craniotomy is required. The endovascular surgeon or the interventional neuroradiologist threads a catheter via the femoral artery in the groin and reaches the aneurysm in the brain. Once there he coils it (coils of platinum coated with a thrombogenic material are deployed inside the aneurysm). Over time the aneurysm clots and seals itself from the circulation. PROBLEM SOLVED!!!

 

Broadly speaking endovascular coiling is superior to open craniotomy (at least in some respects). As no craniotomy is required hospital stay is shorter and post-operative recovery quicker. The endovascular surgeon can reach areas where the neurosurgeon may fear to tread. Certain aneurysm though are not amenable to coiling (example those with a broad neck as the coils fall out). Also once an aneurysm is coiled it takes time before it gets completely thrombosed, surgery on the other hand takes care of the problem then and there.

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31 thoughts on “Incidentally discovered aneurysms in the brain-what to do about them?

  1. There is so much interesting information here, Dr. Sethi, I believe I could occupy your good graces with too many questions.

    I can’t believe the arterial walls are that tough to allow something to enter the femoral artery and be threaded into the brain without being punctured. I assume that once in the brain you may also enter the smaller veins, even more delicate. It would seem to me that the tip of whatever is being threaded would catch on something or scrape a wall too hard. It’s amazing that such miniature work can be done deep inside us. The coming Nanotechnology should keep you guys from getting bored.

    Of the two though, I’d prefer that approach rather than entering my skull. Perhaps I’ve watched too many horror movies, I don’t know. 🙂
    Hope you are well, Doctor.

  2. Dear Paul,
    as always thank you for writing in. The guide wires which are threaded into the arteries are flexible. The procedure is quite safe in experienced hands. That said and done like every other procedure, endovascular procedures too have their risks of morbidity and mortality. A lot depends upon the skill and experience of the endovascular surgeon.
    I too would prefer the endovascular route. The procedure is essentially “sterile”. No blood or gory. But I have to admit it is something when you see the skull sawed open in the OR or burr holes drilled into it.

    Hmmm maybe I should stop seeing horror movies finally.

    Hope you and your family are well. Enjoy your summer and stay in touch.

    Personal Regards,
    Nitin Sethi, MD

  3. Hi. I read youir blog and am now very frightened. I was just diagnosed with a 2.5 x 2.5 x 3.5mm saccular aneurysm involving the mid cavernous left internal carotid artery oriented inferolatterally.It is in an extradural location. So,this cant be removed?

    1. Dear Hanna,
      please do not be frightened. Aneurysms which are in the cavernous sinsus are at times hard to approach neurosurgically. You should follow with your doctor. He/she shall be the best person to advice you further.

      Personal Regards,
      Nitin Sethi, MD

  4. Dr. Sethi-
    I can’t believe I came across your post regarding the major question small aneurysm patients face: what do I do about it? I had an MRA last week that my primary care doc says shows an incidental finding of a very small 3mm aneurysm in the anterior communicating artery. He was very low key about this finding. I’m 36 yrs old. I have no symptoms, have managed blood pressure, absolutely no family history of aneurysm or stroke related deaths. But I’m going to see a neurosurgeon for a consult. I am scared to death of open brain surgery. I’ve got 2 kids and a third on the way in October and I’ve ready horror stories of people being off work for months recovering from craniotomy surgery like this. Do you think a watch and wait approach is possible given the small size of mine? Is it possible for these to remain unchanged and not grow or is inevitable that they will grow making treatment inevitable at some point? My PCP doesn’t seem to be able to answer that fundamental question. Thanks,
    -J in Cincinnati.

    1. Dear Jason,
      thank you for writing in. Anterior communicating artery (ACoM) aneurysms can be tricky with respect to prognostication about the risk of rupture at a future date. I shall not offer a opinion here (as I have neither seen you nor reviewed your MRI/MRA myself). Follow up with the neurosurgeon. Remember you can always seek a second opinion and then make an informed decision.
      There is no reason to restrict your normal activities. I would do what you are already doing-keep your blood pressure well under control and avoid contact sports.

      Personal Regards,
      Nitin Sethi, MD

  5. One last hypothetical question. If you give a patient the wait and see approach (like the fictitious patient “Kim” above with the 3 mm aneurysm, do you significantly limit their activities? If they were active people (I run 3 days a week and play non-contact sports like basketball and soccer), are they permitted to live their normal lives while watching or must they walk on egg shells and quit all activities that raise their heart rate?

  6. Thanks so much for your response Doctor. I realize you can’t give medical advice without reviewing tests, exams, etc. I do have a general question regarding small acom aneurysms like mine. Is endovascular coiling an option for these? Do small anuerysms like this sometimes not grow/increase in size? Its the one thing I don’t seem to be able to get a straight answer on: is the idea of watching and waiting because some may never grow over one’s life and remain small and low risk, or do they always grow over time/years? Thanks,

    1. Dear Jason,
      like I said in my post, small aneurysms at times can be watched. Some may never grow in size and hence no active intervention is warranted. We usually follow these aneurysms with serial MRI/ MRA scans. Only a doctor who has looked at your scans shall be able to advise further. Small anterior communicating artery aneurysms can be endovascularly coiled. Again this can only be determined after looking at your scans. Sometimes a formal angiogram is done prior to any intervention (surgical versus endovascular coiling vs watchful waiting).

      Personal Regards,
      Nitin Sethi, MD

  7. Hello Doctor,

    I am a 27 year old otherwise healthy female. I work as a nurse and I recently got an MRI MRA due to some mild dizziness I was experiencing at work. I was shocked to learn that I have a 3mm aneurysm arising from the anterior aspect of the supracliniod portion of the left internal carotid artery consistent with ophthalmic artery aneurysm. I would greatly appreciate any advice/opinions you could provide….thanks so much.

    Erika RN

  8. This is such a simple, easy to read post that I have been looking for! Thanks you!! My daughter has had headaches for going on 3 years, 24/7. One neuro refused to run an MRA. A year later, still looking for cause, a new dr. ran it and we found 3 aneurysms. 1.5mm, 2mm and 2.5mm. Still haven’t proceeded, but this post made me calmer. They don’t think these are the cause of her headaches as they are in different parts of the brain.

  9. Dear S,
    thank you for writing in to me. Your mother’s neurosurgeon shall be the best person to advice you on activity restriction. In general we advice patients that the blood pressure be checked on a regular basis and kept in the normal range. Also extreme exercises are best avoided. I personally ask my patients who do yoga not to do inversions and head stands.
    But again this like any other question posted on this blog is best answered by the concerned physician/ surgeon. I send her my very best.

    Personal Regards,
    Nitin Sethi, MD

  10. My family has a history of aneurysms as 3 aunts have passed away with these. A doctor suggested family member have test. I did and the results were : show a small rounded bulbous like extension of the left internal carotid artery just distal to the caverjnous portion of the left internal carotid artery and proximal to the bifurcation of the left anterior and middle cerebral artery circulation.
    OPINION: the possibility of a small aneurysm just distal to the cavernous portion of the left internal carotid artery projecting anteriorly
    Can you put this in layman terms and advise is this serious? I have been advised to have it checked annually to see if it has grown

  11. My CTA of the head showed a 2.5 x 2mm aneurysm seen arising from the medial aspect of the distal cavernous segment of the left internal carotid artery. It has a wide neck measuring about 2mm in size.
    That was 12/17/2010. I got a second opinion on it and was told to not worry about it. It should be checked on in 5yrs. Isn’t that awful long to wait?

    1. Dear Ella,
      unfortunately there are no guidelines on how frequently the patients should be monitored with serial MRI scans/MRAs. The decision is made on a case to case basis based on the size of the aneurysm and other patient related factors. Talk to you doctor about your concerns.

      Nitin K Sethi, MD

  12. Dear Doc, you may want to rethink your stance on the aneurysms not causing the headaches. My doctor said that they did, that in fact, I probably had a couple subarachnoid hemorhages and got VERY lucky that they didn’t totally burst. Now, two craniotomies later for 3 annies, and more to follow, the headaches are under control, I just have two additional aneurysms to go. I have a disease called fibromuscular dysplasia. It is often undiagnosed because doctors aren’t taught about it in medical school. They figure it effects 3-5% of the general population though kidney donor studies. This seems consistent across the world.

  13. Hi Dr.S. Thank you so much for your blog. Reading it has cleared so many misconceptions. Actually, my mother, age 40 has recently been diagnosed with a 3mm unruptured cerebral aneurysm. Her neurologist said that since her migraine headaches have been going on for approx. 15 years now, it is not clear as to whether this is a new development or whether it has been there for years now. They are keeping an eye on the growth of it and have put her on medications. However, once in a couple of months, she gets a SEVERE headache. What are the precautions for that? That headache causes nausea, vomiting, weakness and sensitivity to light. Also, her colleague found out about her condition and quickly replied with “My uncle had one of those and died in his sleep.” She did not mention anything else relating to his problem. (size, place, other health problems) Anyway, this has REALLY worried my mom. Is this really that dangerous and life threatening? Please PLEASE do answer my questions as this is really worrying me also. My mom is a healthy woman, does not have high BP, doesn’t smoke or drink, is active and has migraines running in her family.

    1. Dear Minha,
      thank you for writing in to me. Like I said in my blog post, aneurysms at times are discovered incidentally like when a MRI scan of the brain is carried out for some other reason like headaches. While I have not examined your mother and hence this may or may not pertain to her clinical case, it is possible that her episodic severe headaches associated with nausea and photosensitivity are migraine attacks and not related to her aneurysm.
      She needs to remain in follow up with her neurologist who shall be the best person to determine if the severe headaches are migraines or are on account of her aneurysm. He shall also determine if the aneurysm warrants surgical intervention and if yes, when and how.

      Personal Regards,

      Nitin K Sethi, MD

  14. So glad I found your site. Thanks for the information. I was displaying what I thought were stroke symptons. Having trouble speaking mixing up my words. I had an MRI and it revealed 3mm left aca aneurysm. Decided to wait and see. Every now and then my speech problems surface. I am concerned. Is this the aneurysm causing this problem? If it is I am thinking about the coiling method.

  15. Dr, Sethi,
    I’m so glad I found this blog. I am 45 and had a stroke 11 years ago. In November 2012, I had several TIAs and have continued to have migraines for years. My hospital stay in 2012, a 2mm aneurysm was found in my left internal carotid artery. I’ve had several MRIs since my first stroke, so I have no idea when this aneurysm happened. I had a TEE two weeks ago to see if I had a hole in my heart which was okay. I see a neuro-surgeon tomorrow. I have been so worried about this. I worry over what causes them to rupture (such as worry, getting angry, etc.). I appreciate your comments and information you’ve provided. This has helped me understand some things I did not before. I know I will have a ton of questions for the surgeon tomorrow.

  16. Dr. Sethi:

    I had an MRI of the brain recently and one of the findings was “Axial T2 weighted images demonstrate nodular prominence in the region of the anterior communicating artery measuring approximately 3mm. Recommend MRA of the Circle of Willis to further assess.” I am a 34 year old otherwise healthy male who has been experiencing headaches. CT scan from a year ago was clear. Does “nodular prominence in the region of the anterior communicating artery” definitely mean aneurysm or could it just be some sort of thickening or blip from the MRI and that is why an MRA is being recommended?

  17. I got diagnosed with small aneurism… Just like Kim your fictitious patient… I was having severe migraine and through the test being done they discovered it in October last year. I just had another ct scan done and it already grew about 1mm… Should I be concerned?

    1. Dear La,
      thank you for writing in. As I stated in my post incidentally detected aneurysms (especially if small in size) are at times simpy followed with the aid of serial MRIs/MRAs or other neuroimaging modality. Since your aneurysm has increased in size, you should discuss this with your doctor. He shall be the best person to guide you further and answer your question whether surgical or neurointerventional treatment is indicated.

      Nitin K Sethi, MD

  18. Hello, just one question for me if you are able to answer it, my MRI report states i have a 6mm height, 5mm width saccular aneurysm arising from the left internal carotid artery DISTAL to the ORIGIN of the left ophthalmic artery. My question is what does the words capitalized mean in the context? and where exactly in the ICA is the aneurysm located? is it in the C6 section or somewhere else? Thank you for your time.
    Sincerely
    Megan

  19. Just an interesting tidbit. I am a research coordinator for aneurysm clinical trials and was just diagnosed with a 3.5 mm saccular aneurysm in the cavernous portion of the left internal carotid artery. Gives my job a whole new meaning!!! I’m in the wait-and-watch group.
    Robyn

  20. In November 2012, I experienced severe headaches and went to the doctors twice within 4 days. They did nothing, but gave me pain meds and acted like I was there just to get pain medication. Two days later, I was in ER with a bursting aneurysm. The hospital transported me to a hospital in Portland, Oregon that same day. They placed a coil in my brain via the femural artery. and I was in ICU for 10 days. After the 11th day, they discharged me from the hospital and told me to go back to work after two weeks off. I felt horrible, but went back to work. I was then fired from my job of 25 years for not performing. I went back to the Portland Hospital in February 2013 for an angiogram. Then they sent me a notice of another angiogram for August 2013. At that point, I wrote to them and asked them why. I received a phone call at which point I was told I had a 2 mm residual aneurysm. They never once told me about it in the past 9 months. I have been having headaches every day since the operation and my neck always hurts. I feel so betrayed that they kept it a secret as to my condition and the fact that there is still the 2 mm aneurysm. Also the fact that they didn’t include me in on any of my care. Every time I go it costs me out of pocket $4,000 not counting the insurance and cost of travel and lodging. I cannot keep on having headaches day after day and not knowing when or if they will fix it. I have written subsequent letters and they avoid answering all the important stuff. I don’t know who or what to trust. My life is miserable. I have read numerous articles that a residual aneurysm is caused by an incomplete treatment of the aneurysm. I am scared to death at this point.

  21. Hey doc. I was recently given a CT scan for headaches came back normal. But because my mother passed from an intracranial hemorrhage, a MRI was recommended. The MRI “detected a questionable 2mm aneurysm located in the internal cartoid artery at the junction of the supraclinoid and the cavernous segment.” And a CTA is coming up to confirm or deny findings. Obviously I’m terrified and I read that aneurysms at junctions are more likely to rupture. I’m 24 year old female with anxiety. No high blood pressure. I’m a hairstylist so I’m not very athletic. I’m just very concerned they say you’re risk is much higher if your family member has had it, and I’m not sure what my mother had. I knew she was on a lot of medication for her disease sarcoidosis. She had a difibulater and was on blood thinners, prednisone and a host of other medications. And right before her passing she was introduced to an infusion she could take which was supposed to help control the sarcoidosis. Any input??

    1. Thank you for writing in to me Jeelan. I can understand the cause of your concern. Well the CTA (CT angiogram) shall help to further delineate whether the aneurysm is actually there or not (as at times the MRI can “over read” the findings). Once the CTA is done (and based on what the CTA findings are) your doctor shall be the best person to help guide your treatment further 9if any intervention is warranted or not?).

      Nitin K Sethi, MD

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