Treating (or not treating) an unruptured aneurysm
Options include observation with imaging surveillance, microsurgical clipping, and endovascular therapy (coiling, stent-assisted coiling, flow diversion, and other devices). The “best” option depends on anatomy and patient factors.
Conservative management (watchful waiting)
Often used for lower-risk aneurysms, especially small anterior-circulation aneurysms without high-risk features.
- Risk-factor control: stop smoking, manage BP, treat sleep apnea, avoid stimulant drugs
- Surveillance imaging: CTA or MRA at intervals (varies by guideline/center)
- Safety planning: know emergency symptoms; avoid delays if thunderclap headache occurs
Surveillance is active care: the goal is to catch growth or morphological change early enough to intervene safely.
Microsurgical clipping (open surgery)
A neurosurgeon performs a craniotomy and places a clip across the aneurysm neck to exclude it from circulation.
- Pros: durable occlusion; often lower long-term retreatment rates
- Cons: more invasive; longer recovery; procedure-specific risks (stroke, infection, seizures)
- Best suited: certain middle cerebral artery aneurysms, wide necks, or anatomy less favorable for endovascular treatment
Endovascular therapy (interventional neuroradiology)
Catheters are guided through the blood vessels (usually from the groin or wrist) to treat the aneurysm from the inside.
- Coiling: platinum coils promote clotting inside the aneurysm
- Stent-assisted coiling: stent supports coils in wide-neck aneurysms
- Flow diversion: stent-like device redirects flow away from the aneurysm; useful for some large/wide-neck aneurysms
- Other devices: intrasaccular flow disruptors, balloons, etc.
Some endovascular options (especially stents/flow diverters) require dual antiplatelet medication for a period of time, which influences suitability (bleeding risk, upcoming surgery, pregnancy plans).
Treatment after rupture (aSAH)
After rupture, the goal is to secure the aneurysm rapidly to prevent rebleeding, then prevent secondary brain injury.
- Secure aneurysm: clipping or coiling (sometimes within 24–72 hours, center-dependent)
- ICU management: blood pressure targets, pain control, airway protection
- Prevent complications: vasospasm (nimodipine), hydrocephalus (CSF diversion), seizures, electrolyte disorders
How clinicians choose: a simplified framework
| Consideration | Tends to favor | Notes |
|---|---|---|
| Very low predicted rupture risk | Observation | Especially if older age/comorbidities increase procedural risk |
| MCA bifurcation anatomy | Clipping | Often surgically accessible; durable |
| Posterior circulation aneurysm | Endovascular | Many posterior aneurysms are challenging surgically |
| Wide neck / complex geometry | Stent-assisted, flow diversion, or clipping | Depends on branch vessels, neck width, and center expertise |
| Need to avoid long antiplatelet therapy | Clipping or coiling without stent | Important for bleeding risk, planned operations, or pregnancy |
Questions to ask a neurovascular team
- What is my estimated 5-year and lifetime rupture risk (and why)?
- What is the expected procedural risk at this center for my aneurysm type?
- If treated, what is the likelihood of needing retreatment or long-term surveillance?
- Would you recommend the same option if this were your family member?
- Do you offer both surgical and endovascular options in-house (or have a team discussion)?
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