Cerebral Aneurysms

Cerebral Aneurysms

Cerebral Aneurysms

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An aneurysm is an abnormal outpouching of an artery’s wall. Aneurysms affecting the arteries supplying the brain can cause a stroke. Aneurysms cause problems in other ways too. If the aneurysm ruptures, blood flows into the space surrounding the brain called the subarachnoid space. A patient with a subarachnoid hemorrhage usually suffers "the worst headache of his/her life" followed by nausea, vomiting, irritation and lethargy. Double vision, neck stiffness, weakness, loss of sensation, and loss of consciousness can also occur.

Aneurysmal subarachnoid hemorrhage is a medical emergency. 10-15% of patients with ruptured aneurysms will die before reaching the hospital. Over half will die within the first thirty days after the hemorrhage.

Aneurysm Treatment

Aneurysms can be treated from outside the blood vessel using surgical techniques or from inside the blood vessel using endovascular techniques.

A surgical approach requires brain surgery through an opening in the skull through which the surgeon’s instruments can enter. The surgeon can then place a clip across the neck of the aneurysm, closing off the leaky outpouching. If there is a clot in the aneurysm, the clip also prevents the clot from entering the artery and possibly causing a stroke.

In contrast to surgery, endovascular treatment of an aneurysm is performed in the angiography suite with a catheter (a thin hollow tube) similar to that used during the arteriogram. Through the catheter, the aneurysm is packed with material, usually platinum coils, that prevent arterial blood to flow into it and cause it to clot off (embolized). At the same time the parent vessel is kept open.

Sometimes the size, shape or location of an aneurysm make both surgical clipping and endovascular embolization impossible. In these cases your doctor may choose to close off (occlude) the artery itself. This can be performed by either surgical or endovascular methods. In either approach, this would be done after a preliminary test occlusion determines that the patient will tolerate this procedure without suffering a stroke. Endovascular treatment of aneurysms  requires specialized training. Most endovascular therapists are neuroradiologists who have completed additional training, from one to three years, in endovascular techniques.

It is important to understand that the embolization procedure does not repair areas of brain already injured by a stroke. It is performed to prevent the aneurysm from causing injury to other areas in the future. A patient who has had a severe stroke may continue to need intensive medical care even after the aneurysm has been embolized.

Most patients will also need to return for a follow-up arteriogram, usually performed several months after the embolization procedure. This is to make sure that the aneurysm is completely embolized and has not grown larger. Occasionally these follow-up studies show that a second or third embolization procedure is needed to completely cure the aneurysm.

How to Prepare:

You will be seen by a Neuroradiologist prior to your procedure, either in our clinic or on the day of the procedure.  We will perform a thorough history and physical and review medications and any allergies you might have.  Films such as CT scans and MRIs will be reviewed as well.  A plan of treatment will be established and the details will be discussed with you.  At that time, you will be given instructions for your procedure.  We will need to have current labs.  We will go over your medications and tell you which to take the morning of your procedure.  You may be put on additional medications specific for the type of procedure you are having.  If the Neuroradiologist orders the procedure to be done under General Anesthesia, you will be sent to the Pre Anesthesia Evaluation Center for part of the work-up.  If your procedure can be done with nursing sedation, you will not need an anesthesia evaluation.

When your appointment is made, you will be given instructions as to where and when to come in for the procedure.  You will also be given a phone number to call with questions.  We ask that you follow medication instructions carefully.  You will not be allowed to eat anything after midnight but you may drink clear liquids up until 2 hours before your procedure.  Leave jewelry and other valuables at home.  You must have someone to drive you home after your procedure.  If  your condition is treated during the angiogram, you will stay overnight in an ICU to be monitored, and go home the following day.

Where to go the day of the procedure:

You will need to check in at Radiology Reception one hour prior to your scheduled procedure time.  This will give us time to get you ready.  One of the staff will pick you up after you have registered.

Bring appropriate medical insurance materials.

Where to go the day of the procedure:
You may find directions to UVA here.

What to Expect:

Prior to Your Procedure

When you arrive, you will be greeted by a member of our staff and registered for your procedure. A physician will explain your procedure, answer any questions, and have you sign a consent form. An intravenous line will be started in your arm to give you fluids and medications to relax you if you require them. You will be taken to the procedure room, where you will lie on your back during your procedure. Cushions and pillows will be used to make you comfortable. The skin where the catheter will be inserted, which is usually in the upper thigh-groin region, will be cleansed, and you will be covered from the shoulders down with a sterile drape.

During your Procedure

The neuroradiologist will give you local anesthetic in your groin which may cause slight discomfort for a few seconds before going numb. A catheter will be inserted through a small incision in the skin. You will feel minimal pressure in the area. The catheter will be guided into the vessels to be examined.

When the neuroradiologist has placed the catheter in the correct position, contrast dye will be injected which may cause a warm, but not painful, feeling for a few seconds. During this time, you will also hear an x-ray machine taking pictures. It is important to remain still, without breathing or swallowing, while the dye is injected and the pictures are taken. A nurse will be with you at all times. Please tell us if you become uncomfortable.

You will not feel the coils going into the aneurysm when it is embolized. We will be checking on you constantly to make sure you are feeling OK and are not having any neurologic problems during the procedures. You may be asked to perform simple tasks to ensure that the procedure is safely performed.

After your Procedure

In general, diagnostic procedures require about two hours of time to perform; therapeutic procedures typically require more. When your procedure is completed, pressure will be applied to the incision site for 10-20 minutes, after which a small bandage will be placed over the incision. No stitches are required. You will then need to lie on your back with your leg straight and still for four to six hours. A meal will be provided during this time.

After this procedure, you will be admitted to the hospital. This is so that we can monitor you and make sure that the procedure was successful and that you will have no problems thereafter.

If you are already an inpatient, you will be returned to your room for observation by your floor nurse.

The neuroradiologist will communicate the results of your examination to your physician, who will discuss the results with you at an appropriate time. The referring physicians often prefer that we refrain from discussing the findings with the patients, particularly before they have been notified.

After you Leave

You may resume your usual diet after the procedure. Fluid intake of 48-64 ounces during the next 24 hours is recommended as this aids in x-ray dye elimination.

Do not exert yourself for 24 hours following the procedure, after which normal activity may be resumed. If you are an outpatient, a family member or friend should drive you home and stay with you during the 24-hour period.

It is not unusual to have minor bruising around the incision, but if you experience bleeding or swelling there, or develop a cold or painful leg, contact us immediately.

We try to call our patients (outpatients) or visit them (inpatients) the day after the procedure. Please contact us at any time if you have concerns.

X-Rays

We are trained in the use of x-rays and every effort is taken to use the minimum of radiation. The small amount of x-rays used during routine neuroangiography will not be harmful to you. If you notice that the staff wear leaded aprons, it is because they work with x-rays everyday and their occupational exposure is high.

Additional Information

For additional information on the web, we recommend you click on the link below to visit the ACR and RSNA patient information site:

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Billing and Insurance

If you are a self-pay patient, a bill will be issued at time of service and mailed to your home.

If you are covered by a commercial health insurance carrier, please bring your cards or proof of coverage should be brought with you the day of your study. We will file your claim for you. Please note that you will be billed for any balance not covered by your plan. If you belong to a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) with which we have a contract, you must bring the referral and authorization form for the procedure to be covered.

If your visit is due to an accident (work-related, automobile, etc.), you must provide us with an authorization from the guarantor of your bill.

Note that separate bills are issued by the UVA (to cover facilities, equipment, and support personnel) and the Health Science Foundation (to cover the services of the physician neuroradiologists). So expect to see two bills for your study.