Treating Cerebral Aneurysms

Dr. Bress starts by describing the patient selection process for treatment of ruptured and unruptured aneurysms, which involves collaboration with critical care and neurosurgery teams. CTA is needed for evaluation of the quality and location of the aneurysm. He notes that it is important to check for parenchymal hemorrhage and mass effects since this warrants further consultation with neurosurgery. Generally, his practice will treat an unruptured aneurysm if it is 4mm or larger. The decision to treat also depends on the patient’s preferences and their personal evaluations of the risks regarding non-treatment as well as risks of intervention.

The major complications of interventions on unruptured aneurysms include rupture and stroke, which can range in severity. Other complications include aneurysm enlargement due to compaction of coils into the sac and introduction of thrombus into the parent vessel. To prevent this, Dr. Bress administers intraprocedural heparin and and prescribes antiplatelet agents. Dr. Bress emphasizes that complications are inevitable and it is important for IRs to develop this mindset while also taking ownership of outcomes and building rapport with patients.

Next, we discuss new endovascular technology and techniques used in the treatment of aneurysms. These include the use of flow diverters, stent or balloon-assisted coiling, and Woven EndoBridge (WEB). Each tool can be used based on different indications, and it is this creative problem solving that keeps Dr. Dhand and Dr. Bress engaged in the field.

Finally, the doctors present different pathways that trainees can use to enter the endovascular neurointerventional space. They can start from neurosurgery, neuroradiology, and neurology and go on to pursue further training.