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Doctors Discuss Brain Aneurysms

Who is at Heightened Risk and Who Should Be Screened?

New York (Jun 15, 2011)

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The brain is an avid consumer of oxygen, glucose, and other nutrients, and blood carrying this sustenance travels through the brain's 400 miles of vessels at a higher flow rate than elsewhere in the body. Under this stress, thinned, weakened areas can develop in the walls of the brain's arteries, particularly where they branch. Over time these thinned walls can bulge out into sacs called brain aneurysms (also called intracranial or cerebral aneurysms). Aneurysms may then expand, weaken further, and, in rare instances, rupture. When aneurysms do rupture, they flood the skull with blood and are often lethal.

Cerebral aneurysms are thought to occur in 1 to 6 percent of the general population, and many of those who develop aneurysms have no known risk factors, said Y. Pierre Gobin, M.D., the Director of Interventional Radiology at NewYork-Presbyterian/Weill Cornell Medical Center. But some congenital factors and lifestyle choices are known to raise a person's risk of developing a cerebral aneurysm, he said.

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People with polycystic kidney disease, a genetic disorder characterized by the growth of numerous cysts in the kidney, and those with very rare collagen diseases, are at higher risk. In people with these types of congenital risk factors aneurysms tend to rupture earlier, Dr. Gobin said.

Another risk factor is having more than one close family member who has had an aneurysm, Dr. Gobin said. "When at least two close relatives – siblings and offspring – have had an aneurysm, especially when they are relatively young, the entire family should be checked." Familial diseases account for about 5 percent of aneurysms.

Age and sex are additional risk factors. Most aneurysms occur in people between 60 to 80 years old, and aneurysms are more common in women than men by a difference of three to two. Women's heightened risk is not completely understood, but may be due to the actions of hormones, including estrogen.

Robert A. Solomon, M.D., F.A.C.S.
Robert A. Solomon,
M.D., F.A.C.S.

For modifiable risks, the biggest risk factor is smoking, agreed Dr. Gobin and Robert A. Solomon, M.D., the Chairman and Director of Neurological Surgery at NewYork-Presbyterian/Columbia University Medical Center. Toxins in cigarette smoke cause a generalized loss of elastic tissue throughout the body and some loss of elastic integrity in the vessels of the brain, predisposing smokers to aneurysm formation, Dr. Solomon said. People who smoke also have higher levels of inflammatory markers in their body indicating that they may be more prone to inflammation, "and aneurysms are thought to form because of inflammation in the vessel walls."

Women – who are already at higher risk of aneurysm than men – have an even greater risk if they smoke, noted Dr. Solomon. "Ruptured aneurysms are seven times more common in women smokers than non-smoking women, while the risk is four to five times higher in smoking than non-smoking men."

Most aneurysms reach a stable state and never rupture, and "an unruptured aneurysm is absolutely silent in more than 95 percent of cases," Dr. Gobin said. "Aneurysms only manifest themselves if they rupture or become large enough to press on brain structures," he added. "And if they are not more than 25 millimeters or are not compressing a nearby nerve or in a sensitive location, they are unlikely to cause symptoms."

Y. Pierre Gobin, M.D.
Y. Pierre Gobin, M.D.

As is the case with screening tests for many types of cancer, there is no consensus on the best approach to screening for aneurysms. "I think screening should be really limited," Dr. Gobin said, "because there is no study showing the benefit of screening and there is a risk in treating aneurysms." He recommends periodic imaging screening only for those who have already had an aneurysm, people with familial aneurysms, and those with polycystic kidney disease.

Aneurysms are sometimes discovered when people are screened for headaches, dizziness, or other symptoms unrelated to the aneurysm, said Dr. Solomon. "We find aneurysms in about 1 percent of MRIs done for other reasons," he said. But patients with these incidentally detected aneurysms account for 50 percent of Dr. Solomon's practice. He follows these patients to catch changes in their aneurysms with periodic imaging tests including magnetic resonance angiography (MRA), CT angiography, and digital subtraction angiography, he said.

For most patients following and watching is a reasonable approach, said Dr. Gobin. "As we follow them we may see growth during the interval between imaging tests, suggesting that the aneurysm is hemodynamically unstable, and depending on the circumstances we may then treat it."

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Dr. Gobin treats aneurysms with a minimally invasive procedure called embolization. During embolization, doctors advance a tiny plastic tube called a microcatheter into the brain artery and the aneurysm, and through the plastic tube they fill the aneurysm with small metal coils to block blood flow into it. This approach entails fewer complications and speedier recovery than open surgery. The risks of treatment – death or stroke – are very low, but are potentially severe. "In many cases, though, the risk of rupture if nothing is done is extremely low, so we have to weigh all these factors in deciding on the best course for patients with aneurysms," Dr. Gobin said.

Coiling is an appropriate treatment for many aneurysms, "but some large and wide necked aneurysms have an unsatisfactory recurrence rate with coil embolization," Dr. Solomon said. He treats this type of aneurysm by clipping the neck of the aneurysm during open surgery. "Despite the longer recovery required, surgical clipping offers a durable cure, which is especially attractive for young, healthy patients who can easily tolerate a open cranial procedure."

Contributing faculty for this article:

Y. Pierre Gobin, M.D. is the Director of Interventional Radiology at NewYork-Presbyterian/Weill Cornell Medical Center and a Professor of Radiology, Professor of Radiology in Neurology, and Professor of Radiology in Neurological Surgery at Weill Cornell Medical College.

Robert A. Solomon, M.D., F.A.C.S. is the Chairman and Director of Neurological Surgery at NewYork-Presbyterian/Columbia University Medical Center and the Byron Stookey Professor of Neurosurgery at Columbia University College of Physicians and Surgeons.

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