The word “aneurysm” is scary. No one wants to think about having a weakened, bulging blood vessel that could lead to a brain bleed or hemorrhagic stroke.
But brain aneurysms are far more common than most people realize. About 1 in 50 people are living with a brain aneurysm – and few will ever know it. Asymptomatic brain aneurysms are frequently found on incidental imaging exams, such as an MRI after a sports injury or vehicle crash.
Most brain aneurysms are not “ticking time bombs.” Less than 1% of brain aneurysms rupture. Most people with small, asymptomatic aneurysms (less than 0.2 inches wide) will not require aneurysm surgery or endovascular repair.
Brain aneurysm experts at the UT Southwestern Peter O'Donnell Jr. Brain Institute do not rush to treat an aneurysm just because it exists. Any time we open the skull or enter the brain with a catheter, there is a small but real risk of injuring delicate brain tissues or introducing infection. For that reason, every decision to treat an aneurysm needs to be made cautiously and deliberately.
As an Advanced Comprehensive Stroke Center, UT Southwestern is equipped to manage every aspect of brain aneurysm care. We treat over 300 cases each year – from intentional monitoring of asymptomatic aneurysms to emergency surgery for brain bleeds – and we are a primary referral center for patients whose cases are more complex.
Rather than going straight to surgery for every aneurysm, we bring together specialists with decades of expertise to determine which patients can safely be monitored, who needs treatment, and what approach will offer the outcome that best fits the individual patient’s lifestyle and expectations.
What is a brain aneurysm?
A brain aneurysm is a weak, bulging spot in the wall of a blood vessel in the brain. At the risk of oversimplifying, I often tell my patients to think of brain aneurysms as a plumbing problem. They are created when a weak area of a blood vessel wall swells under the normal pulsations of the blood vessel and heart. Ruptured aneurysms cause about 3%-5% of strokes.
If an aneurysm grows and ruptures, it will cause irritation or bleeding in the brain – a hemorrhagic stroke, which is a medical emergency. Until an aneurysm ruptures, there are often no warning signs that you even have one – patients have described the symptoms of a bleed as the worst headache of their life.
Some small aneurysms may press on nerves or tissues in the brain, causing headaches behind the eyes, double vision, new facial pain, or difficulties with walking – these may require treatment. Most small brain aneurysms remain small. If they are asymptomatic:
- The risk of rupture is very low, less than 1% each year.
- You have time to ask questions, get opinions, and understand your options.
- It’s unlikely that you will need immediate surgery, and you may never need it.
You should never feel rushed into a procedure if the aneurysm was found incidentally and is not causing symptoms. As your neurosurgeon my job is to help answer an important question: Am I more likely to hurt you by treating this aneurysm, or are you more likely to be hurt by leaving it untreated?
If immediate treatment is likely to cause more harm than good, we may recommend regular monitoring, including routine MRIs to track any changes or growth in the aneurysm over time. Your care team may also suggest lifestyle changes to benefit your overall health and reduce the risk of a rupture. They include:
- Controlling your blood pressure
- Quitting smoking
- Limiting alcohol
- Treating sleep apnea
- Managing stress
If you and your care team decide that treatment is needed, there are several options to consider depending on the severity of your aneurysm and the amount of downtime that you can feasibly take to recover.
Choosing the right brain aneurysm treatment
Because every patient is different and every aneurysm is different, treatment is based on your anatomy, your health, and your lifestyle. The right choice is the one that ensures your safety now and your health decades from now. These are some of the main treatment options your care team may discuss with you.
Surgical clipping
In this traditional and reliable brain surgery, we open a small section of the skull and place a clip to permanently close off the aneurysm and separate it from the remaining blood vessel. Then, we close the skull with metal plates on the inside and staples in the skin that may need to be removed a few weeks after surgery.
Surgical clipping is an immediate, durable cure for brain aneurysms. It is the gold standard of care for aneurysms that require treatment. In expert hands, risks are minimized but never zero and can include tissue damage, seizure, stroke, unintended blood clots, and infection.
You will not need to take blood thinners after this surgery unless you were previously taking them for another condition. Follow your doctor’s recommendations closely – you may need to avoid certain drugs and take pain medications, antibiotics, or anti-seizure medication temporarily after surgery.
Brain surgery requires a lengthy recovery of four to six weeks off work, with an average of three to four days in the hospital. It is normal to feel tired for the first few weeks, but we always recommend returning to light physical activity as soon as you feel comfortable. You will have tenderness and swelling at the incision site for the first week. Your doctor will advise you about when it is safe to resume your regular medications and activities such as driving, heavy lifting, and more rigorous exercise.
Patients typically return for a follow-up imaging evaluation in a few years to ensure the aneurysm has healed as expected and that no new concerns have developed. Surveillance for other aneurysms will occur for life.
Bypass surgery
If a complex aneurysm cannot be clipped due to its location or size, your physician team may recommend extracranial-to-intracranial bypass surgery. Similar to a heart bypass surgery, this procedure grafts a vein from the leg or an artery from the scalp or arm into the brain to bypass blood flow around the aneurysm-affected brain artery. UT Southwestern neurosurgeons are highly experienced in this delicate procedure, which is performed at only a few major U.S. medical centers.
If aneurysm symptoms affected your mobility or cognition, you may benefit from a personalized neurorehabilitation program for physical, occupational, or speech therapy.
Endovascular procedures
These less-invasive approaches allow us to repair the aneurysm from inside the blood vessel. The specialist will insert a catheter through a small incision, usually in the groin, and thread it to the brain. There are two main endovascular treatments for brain aneurysms:
- Coiling: A tiny coil of soft wire is placed in the aneurysm through the catheter. The coil prevents blood from flowing into the aneurysm. This will cause the aneurysm to clot and eventually scar over.
- Flow diversion: A mesh-like stent is inserted in the aneurysm through a catheter to redirect blood flow away from the aneurysm, thereby reducing the risk of rupture. When blood flow is redirected, scar tissue may form, and the brain aneurysm may simply shrivel away. This can be a good option for large, complex aneurysms or those that are in difficult locations to reach with surgery or coiling.
While endovascular procedures don’t require us to open the skull, the risks are similar to surgical clipping. In some cases, endovascular treatment is not curative. Follow-up imaging is recommended at least annually to check for changes in the aneurysm’s size, shape, or severity.
Most people who get an endovascular procedure can go home the next day and can return to normal activities after about a week. Many endovascular patients must take blood thinners for three to six months after surgery. So, people who have chronic nosebleeds, heavy menstrual periods, stomach ulcers, or clotting disorders are not candidates for these treatments.
Why a team approach matters when it comes to brain aneurysms
At UT Southwestern Medical Center, brain aneurysm care is never a solo decision. We bring together experts from neurosurgery, neurology, neuroradiology, neuroanesthesiology, and neurocritical care to review each individual case. Depending on the aneurysm and your overall health, we also confer with other specialists, such as cardiology.
When we meet to review your case, we discuss your imaging, medical history, and personal circumstances from a variety of perspectives. Then we develop a recommendation as a group. Patients often tell us that it gives them peace of mind to know their treatment plan reflects the expertise of an entire team.
If you are diagnosed with a brain aneurysm, take a breath. Finding out you have a brain aneurysm can be scary, but it doesn’t necessarily mean you’re in immediate danger. Don’t rush into a treatment just because it is available – work with a team of experts who can answer your questions and help you make informed decisions to achieve the best long-term outcomes.
To talk with an expert about brain aneurysm treatment options, make an appointment by calling 214-645-2300 or request an appointment online.
