Brain Aneurysm Coiling and Clipping

An aneurysm is a weak area in the wall of an artery which leads to a balloon or pouch formation. The wall of the pouch is thinner than the rest of the artery wall and is at risk of breaking. This type of aneurysm is known as a berry aneurysm, or saccular aneurysm, based on the way it appears. If the aneurysm breaks, then there can be bleeding in the brain. Other types of aneurysms include lateral aneurysm, where a bulge appears along one wall of the artery, or fusiform aneurysm, when the entire artery is enlarged.
The specific cause why aneurysms form is unknown. Aneurysms can be hereditary (run in families) or occur due to an abnormality which occurred during gestation. Some diseases can lead to weakness in artery walls and formation of aneurysms; these include polycystic kidney disease, some of the connective tissue disorders, or vascular malformations. Trauma, high blood pressure, or drug use may also increase the risk of developing aneurysm. In rare cases, infection within the wall of the artery can cause an aneurysm to form.

What is endovascular coiling?

Endovascular coiling is a way to treat aneurysms without opening the skull or performing brain surgery. The coil refers to a thin wire which is bunched up (coiled) within the aneurysm. The coil prevents further blood flow into the aneurysm by causing a clot to form, while the rest of the artery remains open to transport blood to the brain. The wire is inserted through a catheter which is fed through the large arteries of the body and into the arteries of the brain. This procedure is done as an alternative to aneurysm clipping (surgically isolating the aneurysm by placing a clip at the base of the aneurysm to keep blood from entering), which requires brain surgery. to isolate the area of the aneurysm.

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Clipping is a surgery performed to treat an aneurysm — a balloon-like bulge of an artery wall. As an aneurysm grows it can become so thin that it leaks or ruptures, releasing blood into the spaces around the brain. A neurosurgeon opens the skull (craniotomy) and places a tiny clip across the neck of the aneurysm to stop or prevent it from bleeding. The goal of surgical clipping is to isolate an aneurysm from the normal circulation without blocking off any small perforating arteries nearby. Under general anesthesia, an opening is made in the skull, called a craniotomy. The brain is gently retracted to locate the aneurysm. A small clip is placed across the base, or neck, of the aneurysm to block the normal blood flow from entering. The clip works like a tiny coil-spring clothespin, in which the blades of the clip remain tightly closed until pressure is applied to open the blades. Clips are made of titanium and remain on the artery permanently. Aneurysms vary in their size and shape. Saccular aneurysms have a neck at their origin on the main artery and a dome that can expand and grow like a balloon (Fig. 1). These are the easiest to place a clip across. Some aneurysms have a wide neck or are fusiform in shape having no defineable neck. These are more difficult to place a clip across. Since aneurysms have various neck configurations, clips are made in a variety of shapes, sizes, and lengths. The choice of aneurysm treatment (observation, surgical clipping or bypass, or endovascular coiling) must be weighed against the risk of rupture and the overall health of the patient. Because clipping involves the use of anesthesia and surgically entering the skull, patients with other health conditions or who are in poor health may be treated with observation or coiling.

Clipping may be an effective treatment for the following:

Ruptured aneurysms burst open and release blood into the space between the brain and skull, called a subarachnoid hemorrhage (SAH). The risk of repeated bleeding is 22% within the first 14 days after the first bleed. So, timing of surgery is important – usually within 72 hours of the first bleed.

Unruptured aneurysms may not cause symptoms and are typically detected during routine testing for another condition. The risk of aneurysm rupture is about 1% per year but may be higher or lower depending on the size and location of the aneurysm. However, when rupture occurs, the risk of death is 40%, and the risk of disability is 80%.