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Cerebral Aneurysm

A Clinical Note on Cerebral Aneurysm

A cerebral aneurysm is described as a localized vascular pathology that involves the weakening and dilatation of an intracranial artery. Cerebral aneurysms carry a definite risk of rupture and if left undiagnosed, they might even lead to haemorrhage into the subarachnoid space.

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Intracranial aneurysms (inside the skull, as opposed to aortic and other aneurysm sites) result from either disease acquired during life or from pre-existing genetic conditions. Hypertension and lifestyle conditions, notably smoking, heavy alcohol consumption alcoholism and morbid obesity are associated with the development of brain aneurysms.

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In the general population, the prevalence of cerebral aneurysms is estimated to be around 3-5%. However, the rate of aneurysmal rupture is considered to be around 1 in every 12,500 individuals per year in the UK.

Recently, it has been suggested that cerebral aneurysms might be preceded by the pathogenesis of an inflammatory process mostly mediated by macrophages. Arterial inflammation can lead to progressive weakening of the smooth muscle layers, and eventually vascular dilatation and rupture.

Cerebral aneurysms could be associated with a wide range of clinical manifestations. Although nearly half of the aneurysms may go undiagnosed, others still persist with a multitude of clinical features such as severe headache, visual problems, altered state of consciousness, neck rigidity, seizures, or even limb weakness and paresthesias.

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Most of the cases are detected incidentally with the aid of cerebral imaging. The commonly preferred diagnostic tests include computed tomography (CT) or magnetic resonance imaging (MRI) scanning. In addition, angiography is exceptionally important in the perioperative analysis of the cerebral vasculature.

The surgical treatment of intracranial aneurysms has massively evolved throughout the previous century. Surgical intervention can be performed through a variety of approaches: clipping surgery; endovascular coiling and cerebrovascular bypass surgery. Surgical clipping is carried out via an open craniotomy, followed by the application of a clipping instrument at the site of the aneurysmal neck.

This helps exclude the aneurysmal sac from the main arterial blood flow, thereby minimizing the risk the vascular rupture. Studies have shown that clipping surgery carries a mortality risk of 1% and a morbidity rate of 3-4%. However, a favorable prognosis is exhibited in as many as 85% of the intervened cases. Endovascular coiling is a popular surgical option which involves gaining a transarterial access into the cerebral vasculature coupled with permanent thromboembolism of the dilated sac.

This technique has a comparatively better outcome than the former. The third surgical intervention involves cerebral bypass which could be carried out through extracranial-intracranial or intracranial-intracranial anastomoses. Still, however, this technique is largely suitable for giant-sized aneurysms measuring more than 2-3 cm in diameter.

In short, the early detection and management of cerebral aneurysms is strongly associated with promising results. Therefore, an inter-disciplinary approach between neurosurgery, interventional radiology and vascular surgery is of paramount importance in paving the roadmap of successful aneurysmal management.

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