Open Surgery V/S Endovascular Coiling in Brain Aneurysms

A brain aneurysm is one of the most deadly neurological conditions one can have. It is sometimes referred to as a ticking time bomb inside the head. Patients might be diagnosed with one while they undergo investigations like CT or MRI of the brain for some other conditions or may be diagnosed after it has started leaking or ruptured leading to a hemorrhagic stroke in the brain. Once you or your loved one is diagnosed with a brain aneurysm neurosurgeons often offer two different modalities of treatment called surgical clipping or endovascular coiling. In this blog, we will try to explain both these modalities in brief and list out the advantages and disadvantages of both. We will also explain why sometimes surgeons may offer only one modality in particular situations. The danger of rupture and the patient's overall health must be considered before deciding on aneurysm treatment (observation, surgical clipping or bypass, or endovascular coiling). Patients with various health concerns or who are in poor health may be treated with observation or coiling instead of clipping because clipping requires anesthesia and surgical entry into the skull. Clipping is a procedure for treating an aneurysm using a titanium clip that is placed across the neck of the aneurysm. A neurosurgeon performs a craniotomy, which involves opening the skull and placing a tiny clip across the aneurysm's neck to stop or prevent bleeding. This isolates the aneurysm from the rest of the body's circulation without obstructing any neighboring minor perforating arteries. A craniotomy is a procedure that involves making a hole in the skull while under general anesthesia. To find the aneurysm, the brain is gently retracted. The titanium clips are permanently attached to the artery. They are made of titanium, they are MRI compatible and do not cause any problem in the future. Advantages of Clipping: • Considered gold standard technique as we can visualize the aneurysm directly with our eyes. • Cessation of blow flow in the aneurysm and patency of the normal vessels can be confirmed under direct visualization using ICG techniques. • Clip has no risk of slippage. • Any bleeding during the procedure can be controlled immediately. • Sometimes this is the only option in cases where there is a huge hemorrhagic stroke or a patient also requires decompression of the brain to relieve the pressure. Disadvantages of Clipping: • Highly morbid procedures which involve cutting of the skull bone. There is some amount of blood loss. • High recovery time.

• Pain at the skull incision site for a long time.

• Aneurysms in some locations are difficult to reach and involve extensive retraction of the brain.

The practice of endovascular coiling is used to stop blood flow into an aneurysm (a weakened area in the wall of an artery). Endovascular coiling is a newer treatment for aneurysms in the brain that has been used in patients since 1991. Endovascular coiling is a minimally invasive method that eliminates the need for a skull incision to treat a brain aneurysm. To reach the aneurysm in the brain, a catheter is used instead. A catheter is inserted via the femoral or radial artery and is guided into the artery containing the aneurysm during endovascular coiling. After that, platinum coils are passed into the aneurysm. The coils cause the aneurysm to thrombose(clot), preventing blood from entering it.. The coil is left in the aneurysm indefinitely. Depending on the aneurysm's size, more than one coil may be required to completely seal it off. The coils utilised in this treatment are formed like a spring and are made of soft platinum metal. These coils are extremely small and thin, ranging in size from twice the width of a human hair (biggest) to less than one hair's width (smallest) (smallest). This entire procedure is done under fluoroscopy (a specific type of x-ray that looks like an x-ray "movie") and requires a cath-lab. Advantage of endovascular coiling: • Modern and very less invasive procedure compared to open procedure.

• Recovery time is shortened.

• Aneurysms in difficult locations can also be tackled. Disadvantages of endovascular coiling: • Cannot be performed in some cases where there is a huge hematoma(collection of blood due to rupture of aneurysm) and the vessels cannot be visualized under fluoroscopy.

• Cannot be done in cases with raised ICP which requires decompression to reduce the pressure of the brain.

• Expensive procedure and is performed only at centers having a Cath Lab facility.

• Any rupture during the procedure is very dangerous as bleeding cannot be controlled.

• Risk of procedure failure as it relies on an aneurysm to thrombose which takes time. • Slippage of coils especially in wide-necked aneurysms however this is being overcome by flow diverters.( Only available in a few advanced centers.)

Apart from these basic principles, there are many other scientific parameters your doctor may consider while offering a particular procedure.

Dr. Raveesh Sunkara has ten years of experience in the field of neurosurgery and treats his patients who suffer from brain and spine illnesses with a strategy that blends competence, compassion, and cutting-edge technology. He and his team have an unrivaled track record of success in treating patients with all kinds of aneurysms. They offer best practices in both open surgical clipping and endovascular coiling. He is a firm believer that every patient deserves the greatest possible care, and the type of care he provides is comprehensive. He has a wealth of medical knowledge from working at prestigious institutions which have the best cath lab facilities. He and his team will help you make the right choice of treatment for such aneurysms and ensure the best possible results.