Personalised endovascular treatment for brain aneurysms

A brain aneurysm is a weakened area in the wall of an intracranial artery that bulges outward. Some aneurysms are found incidentally, while others present after bleeding around the brain. Treatment is recommended when the expected benefit of securing the aneurysm outweighs the risks of the procedure and observation.

At Apollo Adlux Hospital, Kochi, patients with suspected or confirmed aneurysms can be assessed for endovascular options such as coiling, balloon-assisted coiling, stent-assisted coiling, flow diversion, flow-diverter-assisted coiling and intrasaccular device insertion. No single technique is appropriate for every aneurysm. Emergency warning: A sudden, explosive or “worst-ever” headache, especially with vomiting, neck stiffness, fainting, seizure, weakness or confusion, may indicate aneurysm rupture and needs emergency assessment.

How is a brain aneurysm evaluated?

Assessment considers whether the aneurysm has ruptured, its size, shape, neck width and location, branch vessels arising nearby, the appearance of the vessel wall, patient age, family and medical history, and previous aneurysm treatment. Imaging may include CT angiography, MR angiography and catheter cerebral angiography with three-dimensional views when detailed planning is required.

Brain aneurysm coiling

Endovascular coiling treats an aneurysm from within the blood vessel. A microcatheter is navigated into the aneurysm and soft detachable coils are placed inside the sac. The coils slow blood flow and promote clot formation within the aneurysm while the parent artery is preserved. Coiling may be used for selected ruptured and unruptured aneurysms.

Advantages and considerations

Coiling avoids a craniotomy and can be valuable when aneurysm location, patient health or rupture status favours an endovascular approach. Some aneurysms may reopen or show a neck remnant over time, so follow-up imaging and occasional retreatment may be required.

Balloon-assisted coiling

In balloon-assisted coiling, a temporary balloon is positioned across the aneurysm neck and inflated while coils are placed. The balloon helps prevent coils from protruding into the parent artery and is removed at the end of the procedure. This technique may be considered for selected wide-necked aneurysms when temporary support is useful.

Stent-assisted coiling

Stent-assisted coiling uses a small mesh stent placed in the parent artery across the aneurysm neck. The stent acts as a scaffold to keep coils inside the aneurysm and helps maintain flow through the parent vessel. Because a permanent implant remains inside the artery, patients usually require antiplatelet medicines as directed by the treating team. Suitability depends on rupture status, anatomy and bleeding risk.

Flow diversion

A flow diverter is a finely braided device placed inside the parent artery across the aneurysm neck. Instead of filling the aneurysm directly, it redirects blood along the normal vessel and reduces flow into the aneurysm. Over time, tissue grows across the device and the aneurysm may progressively close.

Flow diversion may be considered for selected wide-necked, large, fusiform, recurrent or otherwise complex aneurysms. The effect develops over time rather than instantly, and antiplatelet treatment and scheduled imaging are essential. It is not automatically the best choice for every ruptured or unruptured aneurysm.

Flow-diverter-assisted coiling

Flow-diverter-assisted coiling combines a flow-diverting device in the parent artery with coils inside the aneurysm. In selected complex aneurysms, coils may provide additional protection of the sac while the flow diverter supports gradual reconstruction of the parent vessel. The decision to combine devices depends on aneurysm size, geometry, rupture risk, branch vessels and the specialist’s treatment strategy.

Intrasaccular device insertion

An intrasaccular device is a self-expanding mesh implant positioned inside the aneurysm sac, usually near the neck. It disrupts blood flow entering the aneurysm and promotes clot formation within it. Because the device is placed mainly inside the aneurysm rather than across the parent artery, it may be useful for selected wide-necked bifurcation aneurysms. Device suitability depends on exact aneurysm dimensions and anatomy.

How specialists choose the right technique

• Ruptured versus unruptured aneurysm and the urgency of securing it.
• Aneurysm size, shape, neck width and relationship to branch arteries.
• Location within the brain circulation and ease of catheter access.
• Need for immediate protection versus gradual closure over time.
• Ability to use antiplatelet medicines safely.
• Previous treatment, recurrence or residual aneurysm filling.
• Patient age, medical conditions and comparative risks of observation, clipping and endovascular treatment.

Preparation, recovery and follow-up

Before a planned procedure, patients may need blood tests, kidney-function assessment, medication review and instructions about fasting and antiplatelet medicines. Treatment is usually performed under general anaesthesia, although the anaesthetic plan is individualised. Afterward, monitoring focuses on neurological status, blood pressure, the access site and early complications.

Follow-up may include CT angiography, MR angiography or catheter angiography to assess aneurysm closure, parent-vessel patency and the implanted device. Do not stop antiplatelet medicines after stent or flow-diverter treatment unless the treating specialist specifically advises it.