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Melanie Cole (Host):  Welcome to the UAB Med Cast. I’m Melanie Cole and today, we’re talking about treatment of intracranial aneurysms. Joining me in this panel discussion are Dr. Elizabeth Liptrap. She’s a Neuroendovascular and Vascular Neuro Surgeon and an Assistant Professor at UAB Medicine. Dr. Mark Harrigan. He’s an Endovascular Neurosurgeon and a Professor of Neurosurgery at UAB and Dr. Jesse Jones. He’s an Assistant Professor and an Interventional Neuroradiologist at UAB Medicine. Doctors, thank you so much for joining us today. and Dr. Harrigan, I’d like to start with you. Why don’t you kind of give us a working definition of intracranial aneurysms? Tell us a little bit about the prevalence of them and the different types.

Mark Harrigan, MD (Guest):  Intracranial aneurysms are thought of as kind of a weak spot in the wall of an artery that bulges out over time. They can form the shape of a bubble or a blister. They are not rare. They are present in about 3% of the general population which means more than 30 million people alone in our country have intracranial aneurysms. They come in different sizes. They can be in different locations within the head. They are not always an emergency. So, an unruptured brain aneurysm is something that is present in quite a lot of people. They come in different sizes, different shapes. We see a lot of people with unruptured brain aneurysms. Now a ruptured brain aneurysm is different. So, when an aneurysm ruptures, that’s called subarachnoid hemorrhage. That’s typically the worst headache of a person’s life. And that is a surgical emergency.

Host:  Dr. Liptrap, as many people do not know that they have them and they’re found incidentally in many cases; do they present with any symptoms? For other providers listening, is there anything, any red flags you’d like them to know? Physical findings that might be characteristic of intracranial aneurysms?

Elizabeth Liptrap, MD (Guest):  Unruptured intracranial aneurysms are usually found incidentally when people are being worked up for headaches or some other issue. Typically, if the aneurysms are small, which is probably less than seven millimeters even less than a centimeter or so in size, it’s unlikely that they would cause any sort of symptoms. If aneurysms get very large; they can compress other things like nerves, or they can form clots in them and cause stroke like symptoms but that’s pretty rare. Usually, when people find aneurysms, it’s just because they were looking at something else and they’re not actually causing the patient’s symptoms. So, that’s a common question that we get from patients in clinic.

Jesse Jones, MD (Guest):  That’s a great introduction there. Typically these are silent lesions and are kind of found by accident. But there are a few things the alert practitioner may pick up on a typical history and physical examination that could alert them to pursuing aneurysms further. So, important things would be a family history of brain aneurysms or a family history of subarachnoid hemorrhage because aneurysms can cluster in families. There are some other conditions that are associated with brain aneurysms that are separate from them. Those would be things like polycystic kidney disease, coarctation of the aorta or some connective tissue disorders like Marfan’s syndrome. And patients with those conditions are at a higher risk for aneurysms and it may be worth screening them for brain aneurysms.

Host:  Well Dr. Jones, thank you for following up on that. So, how important is early diagnosis as being crucial to improve outcome prediction? Tell us how advances in radiologic imaging have augmented your diagnostic and therapeutic capabilities and tell us a little bit about some of the valuable prognostic tools that can aid you in early diagnosis of aneurysms.

Dr. Jones:  I think we’ve come a long way to identifying and characterizing aneurysms in the last ten or fifteen years with the advances in MR imaging. And these lesions are very serious, but they can be identified basically with ease now if people are looking and order the right test. So, things like an MR angiogram of the brain is a very simple test. It doesn’t require any sort of IV contrast. That can be performed in about twenty or thirty minutes and that’s typically the screening modality of choice when looking for brain aneurysms.

Now once the aneurysm is detected, determining whether the risk profile of that aneurysm is really key to people like Mark and Elizabeth and me in terms of what to recommend these patients when they are found to have an aneurysm. I would say the vast majority of aneurysms are small and they don’t necessarily require treatment. We follow all aneurysms because they can change or grow over time, but I’d say the majority of patients I see in clinic, I’m not recommending treatment. I’m recommending imaging follow up.

Host:  Well then Dr. Harrigan, I’d like you to follow up on this. So, what factors other than size and location must be considered when deciding whether to repair an unruptured aneurysm? Are there some treatment guidelines for these? Tell us a little bit about why you would watch and wait and what multiple criteria would have to be met for a procedure to be considered?

Dr. Harrigan:  We always address risk of rupture and that corresponds to size and location. I’ll come back to that in a second. And then there are modifiable risk factors and then there are nonmodifiable risk factors. So, risk of rupture as I mentioned, does correspond very closely to size and location. So, aneurysms greater than 7 millimeters do carry an elevated risk of rupture, 7 millimeters in diameter. Aneurysms in the front of the brain carry a lower risk of rupture compared to aneurysms in the back of the brain by an order of magnitude. So, size and location are important. So, we always look at that very carefully.

Modifiable risk factors include blood pressure control, uncontrolled hypertension is a major risk factor for aneurysm growth and rupture. Cigarette smoking is another major risk factor as well. So, we try to persuade smokers to quit smoking and offer them help with that. Nonmodifiable risk factors would include like a family history but that can just raise our index of suspicion if a person has for example, a very strong family history of ruptured aneurysms. That might push us toward treating the aneurysm. Expectant management that is perhaps following with surveillance MRAs as Dr. Jones just mentioned is a reasonable option for people with what we view as low risk lesions like a small anterior circulation aneurysms with close attention to good blood pressure control and smoking cessation when appropriate.

Dr. Liptrap:  And I think that’s a great summary of what we often talk to patients about and then we also consider patient’s age, sometimes also the patient’s preferences. Some patients are very much against any sort of treatment and some patients just can’t live with the thought that there’s this potential threat that they are living with. So, both of those things also contribute to the decision making process.

Dr. Jones:  Yeah, I think there’s definitely an art and a science to what we do. The science as Dr. Harrigan mentioned is getting a good idea of the size of the aneurysms and looking at both the modifiable and the nonmodifiable risk factors. But there is also the patient to consider and what their own kind of wishes are. What we’re weighing here is the dilemma of between the risk of intervening and treating it with the complications associated with that intervention versus the risk of watching and knowing that there’s always a small risk that the aneurysm may rupture during the observation period. A lot of that decision comes down to kind of what the patient’s wishes are, giving them all the information that we can and helping them kind of through that decision.

Host:  Such good points, all. So, Dr. Liptrap, as conventional treatment options for intracranial aneurysms are surgical possibly or endovascular; tell us how these treatments are decided, how do you decide and are they insufficient when you’re dealing with special aneurysms or complex cases? Speak a little bit for us about clinical indications and contraindications for institution of the procedures and describe them a little for us.

Dr. Liptrap:  When I talk to patients, I say there’s three options. One is that we can observe the aneurysm. Another is that we can do a surgical treatment of the aneurysm and usually that would involve craniotomy which going in through the skull and putting a clip on the aneurysm to isolate it from the parent blood vessel so that the risk of rupture is obliterated. The other option would be to do endovascular treatment and so that would involve going in through the blood vessels and then there’s a variety of endovascular treatments we can do and they have a wide range and there’s always new treatments but they can range from coiling an aneurysm which is like putting little titanium threads in and packing the aneurysm with those. Sometimes you need to use a stent if an aneurysm has a wide neck and there’s also stents that can divert flow away from the aneurysm and there’s a variety of other new devices.

The way that we decide on how an aneurysm would be treated are one is the morphology or what the aneurysm looks like. If it has a wide neck or smaller neck. If there’s any important blood vessels coming off the aneurysm, the patient’s age, if they have any reason why they should or should not be on any antiplatelet agents because some of the endovascular treatments require antiplatelet agents for a period of time. And also patient preference.

Unruptured aneurysms also the treatments vary. Typically can aneurysms are ruptured; we try to avoid any treatments that would require antiplatelet agents. Obviously, because there’s risk of bleeding there.

Host:  Is there an optimal timing for surgery for these aneurysms Dr. Liptrap?

Dr. Liptrap:  For ruptured aneurysms, we typically try to treat those aneurysms within 24 hours if possible because there is a risk that the aneurysms can re-rupture and that can be devastating for patients. That’s our usual practice. As far as unruptured aneurysms go; the ideal thing would be to treat the aneurysm before it ruptures. No one can necessarily predict that but if you’re observing any aneurysm and it’s increasing in size, obviously, you want to intervene because the chances of it rupturing would be greater.

Host:  Dr. Harrigan, are there any measures that you’d like other providers to know to reduce operative morbidity in the treatment of a ruptured aneurysm and tell us a little bit about follow up care and what’s involved.

Dr. Harrigan:  With patients in the acute phase after a rupture, so we’re talking what within minutes to hours of a patient say presenting to an ED with a ruptured aneurysm; it’s very important to get in touch with a neurosurgeon right away to make the diagnosis with a CT scan and to make sure that blood pressure is under optimal control. After that, depends on how neurologically well the patient is. So, some patients can have a subarachnoid hemorrhage and have the worse headache of their life but be neurologically well. Other people get into trouble with acute hydrocephalus because of the subarachnoid hemorrhage and require placement of a ventriculostomy on an emergent basis. Stabilization of vital signs, blood pressure control, contact a neurosurgeon, get appropriate scanning and then get the patient to a center capable of treating a ruptured aneurysm. Those are all the key priorities in the acute phase.

Host:  So, Dr. Jones, why don’t you follow up on that. Tell us a little bit about what types of care are involved as far as the management of several aspects of care, a multidisciplinary care model and really what’s involved as you follow up with this patient.

Dr. Jones:  Like a lot of things in medicine it takes a village and that’s why I really like being in a place like UAB where we have a comprehensive focus to brain aneurysms and, in a rupture, setting like Dr. Harrigan had mentioned, people can be very sick and having an ICU, particularly a neuro ICU available to manage these patients is critical to get them through the acute phase and onto a recovery. Once we are able to treat the aneurysm and reduce risk of further bleeding; we focus on the recovery period and the follow up. In aneurysms, when they are clipped, it’s fairly durable technique but even then, there’s rare occasions where the aneurysms can recur or people who have had one aneurysm are at increased risk of developing a second aneurysm during their life.

So, continued clinical and imaging follow up is crucial for these patients. I’ll typically see them initially about a month after their procedure and then follow up imaging six months after that and then yearly until I feel comfortable that the aneurysm is not going to recur in the short term.

Host:  Dr. Liptrap, tell us a little bit about the prognosis of intracranial aneurysms and what you’d like other providers to know about the importance of early referral.

Dr. Liptrap:  For unruptured intracranial aneurysms, prognosis can be fairly good with observation or early treatment of the aneurysm. If you have a patient with an incidentally found aneurysm, we are happy to see them. It doesn’t matter how small they are or where it is, we’re happy to take that on and help counsel the patients about the best course of management.

Host:  Dr. Jones, what’s involved in patient education for aneurysms and what would you like other providers to know about counseling their patients?

Dr. Jones:  Well I think receiving a diagnosis of brain aneurysm can be very traumatic for a lot of patients. Because as Dr. Harrigan mentioned, these aneurysms are fairly common in the population and you’ll frequently talk to a patient who said oh you know my family member or a friend of mine had a brain aneurysm that ruptured, and they had a bad outcome, or they passed away. And so this can lead to a lot of stress in people’s lives. So, what I like to do is try to reassure these people that there are treatments for brain aneurysms that are very effective and safe and also they are empowered to change the natural history of thei brain aneurysm by changing things like stop smoking, and controlling their blood pressure so there’s a lot of things that they can do on their part to improve the natural history of their aneurysm. And barring that, we’re available with options to manage their aneurysm.

Host:  Dr. Harrigan, last word to you.

Dr. Harrigan:  Yeah, I like to expand on what we’ve been talking about a lot on the lines of how to handle a patient with a newly diagnosed unruptured aneurysm. So, from a neurosurgical standpoint, these are very seldom true urgent matters however, as Dr. Jones was mentioning, getting a new diagnosis of an unruptured brain aneurysm is extremely stressful for people. And they need reassurance, a very sober discussion of the natural history, a lot of reassurance, a focus on controlling risk factors is appropriate. When we get a referral for example, we always try to work these people in as quickly as possible so we can get ahead of the curve with the patient and really focus on risk factors and options. So, peace of mind is something that we try to give out people as well who have been newly diagnosed with an aneurysm.

Now, attention to risk factors I important and sometimes we elect to pursue expectant management usually with surveillance imaging like annual imaging. We also talk about activity restrictions by the way aren’t usually necessary for people with an unruptured brain aneurysm. It’s usually okay to fly, exercise, work, bend over. I usually joke that people shouldn’t take up bungee jumping when they’ve been diagnosed with unruptured aneurysm but aside from that, they can live a normal life as long as their blood pressure is under good control and they are not smoking.

Host:  That’s excellent information. Doctors, thank you so much for coming on and sharing your collective expertise for us today. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.