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Aneurysm Surgeries
According to a study done in 2008, approximately eight to ten million people in the
United States have brain aneurysms. Up to three percent of those are likely to face bleeding. A
brain or cerebral aneurysm is a serious medical condition associated with the malformation of the
elastic layer of a blood vessel in the brain. This defect in the wall allows ballooning in the vessel
wall when pressure rises which can lead to the blood vessel rupturing.
vessel. Currently, there are two primary options for the treatment of a brain aneurysm: clipping
and coiling. The optimal choice of treatment depends on the location and size of the particular
aneurysm.
Surgical clipping is a procedure in which the aneurysm is safely isolated from normal
flowing blood circulation. Before the surgery, swift preparation is necessary for both the
surgeons and the patient. Tests such as blood typing, urine and sodium output, and blood counts
occur for those whose aneurysms have not yet ruptured. An assessment of the patient’s airway,
breathing, circulation, and deficit (any particular health issue) is also made. Keeping the patient’s
blood pressure at a healthy and stable level is extremely important; most doctors will have the
patient placed in a quiet and calm environment before the procedure in addition to taking
medication or being sedated to reduce blood pressure. Within about six hours before the surgery,
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Aneurysm Surgeries
food and drink will no longer be permissible. In cases where a rupture has already taken place,
many will immediately take to the operating room after blood pressure stabilization. Swiftly, an
intravenous line (IV) in placed in the patient’s arm just before the procedure is set to begin.
The surgery generally lasts anywhere from three to five hours. In all forms of aneurysm
clipping, the patient is first given general anesthesia. Once asleep, the surgical team adjusts the
position of the patient and places their head on a holding device used to hold the skull in position
during surgery. The area of incision is then prepared by shaving (usually behind the hairline) that
particular area. Hairy sparing techniques do exist for those who are concerned. Occasionally,
some patients have a lumbar drain installed in their lower back to remove any cerebrospinal fluid
that may interfere with brain relaxation during surgery. A drug may be administered for the same
purpose.
The second step requires the neurosurgeon to perform a craniotomy. First, the skin
incision exposes the skull, creating a flap. This flap of skin and muscle is then lifted from the
bone and folded neatly back to allow a clear view of the patient’s
skull. Next, small holes known as burr holes are made in the skull
and used to cut a window of bone from the cranium which exposes
the dura matter, the outermost layer of the brain. Safely stored
away, the flap of bone will no longer be needed until the end of the
procedure.
Again, a folding occurs with the dura in order to fully expose the brain. A space between
the brain and the surrounding skull is necessary, so the surgeon uses retractors while operating
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Aneurysm Surgeries
under a microscope to gently ply a space. The surgeon then proceeds to locate the artery in
question and follows it to the aneurysm. Once located, blood flow in and out of the aneurysm
must be controlled; usually that control may be obtained by managing the carotid artery in the
neck. A safety clip to stop bleeding is kept nearby in case of accidental rupturing.
Inserting the actual clip involves using a clip applier to hold the clip open until released,
which will pinch and therefore isolate the aneurysm from the parent artery. A surgeon may use
multiple clips if necessary. In figure 1 below, a common clipping of the neck of the aneurysm,
also known as direct clipping, is shown. However, clipping the neck is not the only means of
clipping that a surgeon may use. The placement of the clip depends on the location and the size
bypass, surgeons surgically graft a smaller blood vessel to the artery, therefore rerouting the
circulation of blood away from the aneurysm. Both forms of clipping follow the same basic
procedures.
Of course, the surgeon cannot simply conclude the clip is in perfect place and will do its
job, so inspection immediately afterwards is imperative. The clip must not be cutting off or
narrowing the parent artery or any other arteries, including any nearby perforators. A hole in the
aneurysm is then made with a needle in order to insure that blood flow has been completely cut
off.
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Aneurysm Surgeries
The last step of the surgery occurs with replacing the coverings of the brain. First, the
retractors used previously are removed. Using sutures, the surgeon then closes the dura. The
bone flap set aside in the beginning of the operation is replaced and secured to the skull by using
titanium plates and screws. The flap of skin is then sutured back together over the newly secured
bone flap, and a soft adhesive is used over the incision made.
Upon the completion of surgery, the patient will be taken to the recovery room, where
their vital signs will be carefully monitored as they awake from the anesthesia. Once awake, they
will often be transferred to a neuroscience intensive care unit for more observation. The most
common immediate side-effects of the operation include nausea and headaches; pain medication
will usually be administered. During the entirety of the recuperation and observation period, it is
important for a patient to remain in bed until the bleeding completely stops. Gradually, those in
charge of monitoring the patient will help them increase their activity level and monitor the
patient throughout the duration. After a few days, the patient will be released from the hospital;
unless their aneurysm ruptured, in which case they will be monitored extensively from anywhere
between two to three weeks. Observation is especially important for such patients, since they are
Even after the surgical procedures end, and they are released from the hospital, patients
should monitor any conditions that can contribute to another aneurysm, such as high blood
pressure. According to the Mayfield Clinic in Cincinnati, Ohio, “the possibility of having a
rebleed [relapse of bleeding in the affected area] increases to 35% within the first 14 days after
the first bleed.” Unfortunately, clipping is not always the best solution, as risks to some might
For those individuals, there is a second option for treatment that does not require open
brain surgery. This treatment, commonly called coiling, is known as endovascular embolization.
incision being made in the groin area. The doctor then uses a needle to
inserted into the artery and guided up into the brain’s blood vessels until it
reaches the aneurysm. The catheter www.medscape.com deposits soft platinum coils into the
space of the aneurysm, which conform to its irregular shape. Anywhere from five to seven coils
are usually required to completely pack the aneurysm. Once completely packed, the coil is
released by a low voltage current that causes the pusher wire to detach from the coil inserted into
the aneurysm.
The ultimate goal of endovascular embolization is the same as that of clipping: to prevent
blood flow into the aneurysm. The approach, however, is the true difference, as no artery
blocking occurs. Rather, the coils fill the aneurysm so that no blood may enter into the sac and
cause bleeding. Unlike clipping, embolization cannot repair arteries already injured.
The treatment is performed under general anesthesia, taking only a few hours; and
generally the patient must stay in the hospital for two nights of observation after the procedure.
The Neurosurgical Intensive Care Unit will monitor the patient during their rest period of
approximately eight hours. Most patients do need to return for follow up tests and observation to
Unfortunately, for those individuals whose aneurysms rupture, many complications can
arise, including subarachnoid hemorrhage. The side effects can often leave them with a
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Aneurysm Surgeries
permanent disability or lost function to some degree. Patients often need rehabilitative, speech,
and occupational therapy in order to regain any of the lost function they experience. Thought
aneurysms can be difficult to detect, it is highly important that tests be run if there is any reason
at all to believe that a problem may exist within the circulatory system of the brain. It is even
Works Cited
Vyavhare, Amol. "Aneurysms." Articles Wave. Apr. 2008. Web. 22 Feb. 2010.
<http://www.articleswave.com/health-articles/brain-aneurysm.html>.