Neuroradiology application in aneurysm

Aneurysm, which means that the weak point of the vessel creates a balloon, appears with or without bleeding. 1-6 percent of the population has aneurysm, and even 1 percent of these people do not know that they have an aneurysm.

Aneurysm sometimes occurs without any symptoms and 20 percent of patients who have brain hemorrhage due to aneurysm die at that time. The disease is related to heredity and it is absolutely necessary to take precautions.
. What is an aneurysm, what kind of problem is it?
Aneurysm is a vascular problem, a weak point of the vessel (congenital weakness or acquired weakness later on) is the formation of a balloon. We can think of this as the ballooning of a tire, which is a fabrication damage to a car.


. How can you tell if a person has an aneurysm? Are there many people who have an aneurysm but live without knowing it?
In recent studies, 1 to 6 percent of the population has been found to have aneurysms in the cerebral vessels, and this is a very serious figure. Perhaps even 1 percent of these people do not know they have an aneurysm. Unfortunately, most of the time, an aneurysm occurs in the brain vessel without any symptoms. One day, this aneurysm either bursts and the person becomes aware of it or ends his life with it. Since the aneurysm did not cause any problems, we are not aware of the aneurysm of the patient who died. It cannot be found unless specifically sought.

. Can people with aneurysms have some complaints? Can underrated headaches be caused by an aneurysm?
If we look at the question of how the aneurysm comes to us, we need to divide it into bleeding and non-bleeding. A bleeding aneurysm is a cerebral hemorrhage; It is almost impossible to overlook it.
The important thing is to catch non-bleeding aneurysms, which is an issue that concerns up to 6 percent of the population. Some never have any complaints. Some aneurysms may present with a headache in some people. Some of them are aneurysms that occur by chance if the person has been examined for another reason or if an MRI has been taken.
Another way of exiting is that if the aneurysm grows without bursting, it compresses the neighboring nerves, and then those tissues disrupt their work. When we look at why this has failed, we encounter an aneurysm that grows next to it and crushes that tissue.
This can affect the functions in the adjacent vein in whichever vein it is.”


. What are the risk factors? Who gets an aneurysm, is this disease related to heredity or some diseases?
“There is a part about heredity, but it concerns a small part of society. For example, it is frequently seen in diseases that we call polycystic kidneys or in diseases involving general organ systems with some other hereditary diseases. And if there is an aneurysm in the family, the likelihood of it being seen in those people is a little higher.”
. What is the importance of aneurysm? What other problems does this disease, which can cause death, cause, for example, can it lead to a stroke?
“Besides that because the aneurysm enlarges, it compresses the surrounding nerve and disrupts that work, 20 percent of patients who have a cerebral hemorrhage due to aneurysm die instantly. Some of them die within the following month, and some of the patients become disabled. About 30 percent of those who have had a brain hemorrhage, as a happy minority, regain their health later on.”
. If a person with an aneurysm is detected in his brain for any reason, if he has hypertension or smokes, does the risk of aneurysm bursting increase?
“The probability of having an aneurysm increases greatly in these patients. If the person with aneurysm has high blood pressure, uncontrolled blood pressure and smoking, the risk of bleeding from that aneurysm increases even more.

. What is the diagnostic method?

“The best way to see the vein is to do an angiography, but there is no need to do an angiography for everyone just because there is such a doubt. If the angiography is very large, it will show MR, but it may be possible to detect aneurysms if it is not very small in the angiography images we provide with computed tomography.”
. What do you do if an aneurysm is detected in the person as a result of any MRI or angiography? How is the approach to treatment here?
“In the concept of neurosurgery, if an aneurysm is detected in a patient, we definitely recommend surgery. It would not be right to say that nothing will happen from this aneurysm and continue with your life because it is not clear when or what will happen. It is just like the Istanbul earthquake, it is impossible to predict whether it will happen or not, when it will happen, how severe it will happen, what will happen to us. Therefore, in the presence of aneurysm, it is absolutely necessary to take precautions against it, just as we need to prepare for an earthquake, either personally or as a society.”

. What is interventional neuroradiology?

“Interventional neuroradiology has developed as a sub-branch of radiology all over the world. He received a lot of criticism, especially from neurosurgeons, until he proved himself. ‘Our surgery is getting better. There were criticisms that the operation you performed does not work, but we have seen in the last 20 years that all neurosurgeons dealing with aneurysms have started to say, ‘if we learn this job, we can do it too’ if possible. Therefore, interventional neuroradiology relies on imaging.
Diagnosis is made with images obtained with MRI and CT, but angiography is required to reveal the true condition of the vessel. These are done by radiological methods. In interventional neuroradiology, again using the angiography method, all the treatment is done through the vein by going through the vein. In other words, there are no cuts or wounds on the head, it is possible to enter through a hole of approximately 2 millimeters in the groin and operate on the vessels in the brain.”

. If the person has a non-bleeding aneurysm, what kind of treatment do you apply?
“If there is an aneurysm, it should be operated; It can be open surgery or closed surgery. We do closed surgeries. Even if there is a closed surgery, if there is a doctor somewhere, there is a risk, and when the doctor prescribes medication, there is a risk, especially if he is doing something with his hand, this risk increases. It is necessary to think that there may be risk, after all, this is a manual work. This also has risks. If we tell the patient that we will handle this closed, without surgery, then we will mistakenly lead the patient to fearlessness. What we will do is surgery, there may be risks, and the patient should be aware of this.”
. How is endovascular surgery performed when it comes to aneurysms in the brain? Is it done in operating room conditions? How long does it take? Does the patient need to stay in the hospital? What do you do to the aneurysm during the procedure?
“Our operating room is the angiography room. It is performed under sterile conditions like surgery, and the patient is given general anesthesia. The process takes an average of 1-2 hours. After anesthesia, we enter through the groin, we put a thick (2 millimeter) tube, which we call a guide catheter, into the carotid veins. We go through this with a micro-catheter (less than 1 millimeter) and go inside the aneurysms and weave a ball of wire spirals and fill it. The goal is to prevent blood from entering the aneurysm. It will either be stuffed or its neck will be closed, there is no other choice.
When we fill it completely, that aneurysm is considered to be cured. Sometimes the mouth of the aneurysm is wide, the ball we wrap around the mouth can overflow into the main vein. Then we put a wire braided tube, which we call a protective stent, around the neck so that it does not overflow into the main vein. If the mouth of the aneurysm is very wide and the aneurysm is very large, we put more special, more tightly braided stents at the mouth of the aneurysm so that it directs the blood flow in the direction of the normal vessel, so that blood flow does not enter the aneurysm… Then the job can be done without putting anything inside the aneurysm.”

. What should the patients with aneurysm in the brain and undergoing endovascular treatment pay attention to? Do these stents have a certain lifespan?

“The purpose is to fill it or prevent blood from getting into it. If we have filled the aneurysm, nothing special is needed, but checks are done. We would like to follow the patients undergoing endovascular treatment for at least 5 years. Because that area of ​​this patient’s vein is sick, can something new develop here, this patient has a criminal record in terms of vascular health, does something develop in his other veins, if this aneurysm is a very large aneurysm, his neck may recur over time. A second treatment may be necessary if necessary. If we used a stent, not just a coil, then we put a foreign substance into the vein, so of course, he needs to use blood thinners regularly.”
Patients should not smoke, pay attention to their blood pressure, and follow the rules of healthy living that we all try to follow.”

. If there is bleeding in the brain, that is, if the aneurysm has burst, how is the approach to treatment? Does endovascular surgery have a place besides open surgery?
“Of course there is, what needs to be done in a patient with a cerebral hemorrhage is to look for the cause of this hemorrhage. Therefore, without wasting time with things like MR, that patient is taken to angio with MR angio. Once an aneurysm is detected in the angiography, it should be treated as soon as possible because the risk of rebleeding from a bleeding aneurysm is very high. Patients who survive the first hemorrhage have much lower resistance in the second and third hemorrhages.
The method is the same, but it is necessary to choose the patients correctly. For example, each patient should be evaluated with fellow neurosurgeons; A correct accounting should be made as ‘that patient is suitable for which treatment, which branch would be more beneficial’.

. What are the risks of treatment methods?

“A lot of things can happen from the moment you enter the groin, but if you ask what is the probability of them, the risk of the work to be done in a non-bleeding patient is around 1-2 percent.
Aneurysm may bleed, a clot may form in the vein and there may be signs related to the vein where the clot goes somewhere and occludes, or there may be problems with anesthesia.

. What are the advantages of endovascular therapy?
“Depending on which vessel the aneurysm is in and its structure, the risk of endovascular treatment can sometimes be much lower than the risk of open surgery. The risk may be even greater if the patient is not selected correctly.
The procedure time is much shorter, patients who do not bleed often do not need intensive care. After the procedure, he is kept under observation in the hospital for 2-3 days, and he is discharged. At the latest, she can return to her normal life after 1 week, which is not the case in open surgery.

prof. Dr. Ozenc MINARECI

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