Brain aneurysm rupture in a 45 year-old man. Clinical case. 11
A middle-aged man collapses on a street. Ruptured brain aneurysm is found on a CT scan. Neurosurgeons face a decision whether to do open brain surgery, “clipping” of aneurysm, or an endovascular treatment, “coiling”. What brain aneurysm treatment method would lead to best results? Dr. Anton Titov, MD. Is there a clinical case that would illustrate the topics that we discussed today? I can tell you about some brain aneurysm patients. Many of the brain aneurysm patients have sudden aneurysm rupture. Dr. Mika Niemela, MD. Maybe somebody falls on the street. Let’s say a 45 year-old man who is a smoker. Smoking happens less and less nowadays. But let’s say this patient is a smoker with hypertension. He falls on the street. He is brought to a hospital. He gets a head CT scan. Physicians suspect that there may be a brain aneurysm that ruptured. These patients go to CT angiography or MR angiography. A brain aneurysm is found. Then they consult neurosurgeons about the patient. There’s a 10 millimeter aneurysm in the MCA (middle cerebral artery). Should we operate or should we treat this brain aneurysm endovascularly? Dr. Mika Niemela, MD. The patient comes to a neurosurgery service. We talk with the patient. We think about the risk factors for brain aneurysm. Risk factors are gender, smoking status, whether the patient is hypertensive. Maybe there is other ruptured brain aneurysm cases in the family. Dr. Anton Titov, MD. What is the size of the brain aneurysm? In this case, a 45 year old man in Finland has almost 40 more years of life expectancy. Dr. Mika Niemela, MD. This patient is smoking. So that we ask a patient to quit smoking. Usually we recommend surgery in a 10-millimeter brain aneurysm in the MCA [Middle Cerebral Artery] at that age. We do not typically suggest endovascular coiling of this brain aneurysm. Because there is a high recanalization risk in MCA aneurysms after endovascular treatment. Sometimes this patient would be 75 years old. We would just treat this patient conservatively. Dr. Anton Titov, MD. It means that his hypertension should be treated well. The patient with treated brain aneurysm can live a normal life. We don’t give any restrictions. Patients can exercise. But they must quit smoking and take care of hypertension. It depends on the age of the patient. Dr. Anton Titov, MD. For a 45 year old patient you choose surgical treatment of brain aneurysm? Dr. Mika Niemela, MD. Yes. Surgical clipping of middle cerebral artery brain aneurysm. Yes. Then you would proceed with observing clinical situation in this patient. We follow elderly patients [we observe brain aneurysm]. In younger age groups, best clinical course of action depends on the location of the aneurysm. We can advocate surgery or endovascular brain aneurysm treatment. We treat endovascularly mostly aneurysms in the posterior brain circulation. Dr. Mika Niemela, MD. We do endovascular aneurysm coiling in about 50% of all brain aneurysm cases today. Professor Niemela, thank you very much for this very interesting conversation! My pleasure! Thank you very much! Dr. Anton Titov, MD. We’re looking forward to seeing you again in the future! Thank you very much!
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