Unruptured Brain Aneurysm

Daniel Walsh FRCS | Consultant Neurosurgeon

Most brain aneurysms will never rupture but the challenge is to identify those at greatest risk and merit preventative treatment.

If an aneurysm is certain to bleed in the future the risks of treatment are usually acceptable. However a great many more aneurysms are found in the population than will bleed. Therefore could conservative management be reasonable on the balance of risks? How does one decide?

To Treat Or Not?

Illustration of a saccular bifurcation cerebral aneurysm created by Daniel Walsh FRCS

Estimating Risk of Bleeding

There have been several attempts to develop clinical decision support tools that attempt to synthesise the results of these studies with expert opinion and/or less reliable data about aneurysm shape and other illnesses. Examples of such tools are the PHASES and UIATS models. In our experience there is sometimes poor agreement between models and so no one should be regarded as definitive. It is likely in the future such models will also take account of individual genetic susceptibilities. For now they can inform but do not replace a considered discussion between you and a neurovascular specialist.

The smallest aneurysms appeared to have relatively small risks of bleeding in the short term. The results of ISUIA are frequently, but erronously, cited as indicating small anterior circulation aneurysms below 7mm in diameter have no risk of bleeding in the short term. It is more correct to say their risk of bleeding may be less than the risks of treatment in the short term. We may also see that the risks of treatment increase as the aneurysms grow larger

Balancing Risk of The Disease against Treatment

The decision to treat an unruptured aneurysm should always be a considered one and seldom needs to be rushed. Even if the aneurysm is considered at low risk of bleeding in the short term its discovery poses a real psychological burden for some. Therefore every case needs to be considered on its own merits.

Shared Decision Making

The decision to treat an unruptured aneurysm should always be a considered one and seldom needs to be rushed. Even if the aneurysm is considered at low risk of bleeding in the short term its discovery poses a real psychological burden for some and every case needs to be considered on its own merits. Most such aneurysms are treatable after all.

Our approach seeks to first educate the patient about the disease and about their options to manage the situation. Occasionally there is a strong case to recommend treatment but quite often a decision to treat may be more nuanced with strengths and drawbacks to the various options. Often it amounts to balancing the threat the aneurysm poses left untreated against the perceived hazard of treatment itself.

Choosing Wisely

It may feel daunting to be invited to help weigh a decision like this as opposed to someone simply telling you what to do. The intention is to ensure your management has at its centre your priorities- what is most important to you.

In the case of an unruptured aneurysm it may be to completely and permanently treat the aneurysm with the best balance of safety and efficiency thus affording peace of mind. For another person it may be to treat with the lowest possible procedural risk even if there is a chance of needing more treatment later. Some may feel safer living with the uncertainty posed by the aneurysm. An individual's personal risk-adversity, co-morbidities, belief systems and social support structure can inform such choices. Your doctor should be willing to talk these through with you.

Reflecting on an initial discussion with your doctor the following approach- B.R.A.N.- might be helpful.:

BENEFITS- What can I expect to gain from the treatment? What is the chance of the treatment being successful?
RISKS- Every treatment has risk. Do you understand what they are and how likely they are to happen? Is there a risk the treatment will not work? How might this treatment affect my quality of life?
ALTERNATIVES- Are there other ways to treat? What are their strengths and drawbacks? If my doctor is favouring a treatment do I understand why?
NOTHING- What if I do nothing? How will my condition change if I do not have treatment? Will my condition be more difficult to treat later?

Good Decisions Require Time

It is usually not necessary to make a decision immediately. Take a little time to reflect on the discussion Perhaps write down your understanding of the information you have been given using the B.R.A.N. framework described above. Speak with your family doctor, family members or others whose input you value. What other questions arise? Would an additional medical opinion be helpful to you? Then arrange to speak with your doctor again to discuss how you would prefer to move things onwards.

Should I Undergo Regular Scans?

If opting to manage an anerurysm conservatively you may opt to have it re-imaged after a time. At present it is believed 6 to 9% of aneurysms which change shape or size if monitored for 10 years. Such change is associated with an increased risk of rupture subsequently.

There is no rule that means an aneurysm may not rupture just before or just after a scheduled scan

One should however bear in mind that repeated scanning is not in itself demonstrably protective against subarachnoid haemorrhage. If an aneurysm is destined to bleed it will usually do so without warning. We are happy to discuss your needs on a case by case basis.

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