Aneurysm clipping

Pathological dilation of arterial vessels, called aneurysm, is a very dangerous and life-threatening disorder. Timely prevention of the development of unfavorable complications can be prevented with the help of operative surgery, with aneurysm clipping being the most common. This is a complex intervention: when it is performed on the cerebral arteries, it requires trepanation of the skull. The operation is usually emergency, it is prescribed at high risk of rupture of the pathological expansion. [1]

Indications for the procedure

Vascular aneurysms are pathological changes in vessels, in which there is a local expansion and bulging, which threatens further rupture of the walls and internal bleeding. In the area of deformation, an aneurysmal cavity is formed. The threat to the patient's life becomes too high, and in such a situation radical treatment measures are necessary, in particular, surgical intervention in the form of clipping the aneurysm. [2]

The decision to perform the operation is made by the attending doctor. The main indications for intervention are:

• Aneurysmal dilation of 7 mm or more;
• hereditary predisposition to aneurysm rupture (there have been cases of such a complication in relatives).

Preparation

What does preparation for surgical clipping of an aneurysm include? The doctor may prescribe the following preoperative tests:

• general clinical blood and urine tests;
• blood chemistry;
• X-rays, cardiography;
• consultation with a therapist and neurologist, anesthesiologist;
• magnetic resonance angiography;
• CT scan (especially relevant for detecting calcium and thrombosis);
• digital subtractive angiography.

At the preparatory stage before clipping necessarily correct diabetes mellitus, bringing it into a state of compensation, stabilize blood pressure, treat or prevent exacerbations of chronic diseases. [3]

On the eve of surgery, the patient is not recommended to eat or drink liquids.

Technique of the aneurysm clipping

Clipping of cerebral aneurysms refers to direct interventions involving the use of general anesthesia. The incision is performed in the area of localization of the pathological bulge, and cranial trepanation is performed when the cerebral vessel is affected. In this case, we are talking about bone-plastic trepanation, when the incision is made, leaving the possibility of subsequent return of all bone elements to their original place. It turns out that after clipping the aneurysm, the integrity of the skull is fully restored. [4], [5]

In general, the clipping procedure involves the following manipulations:

• performing a tissue incision or opening of the skull to gain access to the arterial vessel affected by the aneurysm;
• elevation of the cerebral zone exposed after trepanation, followed by elevation of the pathologically altered vessel to the surface;
• application of a special clip on the pathologically altered area, cutting off the existing aneurysm;
• aneurysm dissection;
• to remove the spilled blood.

Such surgery is an effective method of treating an abnormal bulging artery, but it cannot prevent the formation of a new aneurysm, which should be considered for patients with multiple aneurysms or a propensity for them. [6]

Contraindications to the procedure

Contraindications can be relative or absolute, and the risk of complications, including the possibility of rupture of the altered artery, is always assessed. [7]

Among the most common contraindications to performing aneurysm clipping are:

• decompensated conditions;
• disorders of the blood coagulation system;
• acute septicemia;
• late stages of diabetes mellitus;
• acute infectious and inflammatory processes;
• severe bronchial asthma, respiratory failure;
• acute periods (relapses) of chronic pathologies.

The doctor may refuse to clip if the aneurysm is too deeply localized.

Consequences after the procedure

The development of adverse effects after aneurysm clipping is relatively rare, and is completely incommensurate with the consequences that can occur when a pathologically dilated arterial site ruptures. According to statistics, the frequency of various kinds of disorders after surgery does not exceed 10%. In most cases, we are talking about speech disorders, memory and attention impairment, head pain, development of tissue ischemia, and in complicated cases - pulmonary edema and death of the patient.

Despite the existing threats, it is not advisable to refuse to perform clipping for indications, because the operation is prescribed only when there is a real risk of rupture of the affected vessel. It is important to preliminarily make sure to choose qualified specialists with experience in such interventions. [8]

If a complication develops in the form of preoperative rupture or intraoperative bleeding, the following consequences may occur:

• paresis, paresthesias of the extremities;
• functional disorders of the speech and visual apparatus;
• intravascular thrombosis;
• psychopathology, the development of epilepsy.

Complications after the procedure

In order for the patient to be able to return to his or her usual lifestyle after aneurysm clipping, an optimistic attitude, emotional and mental peace play an important role. In the first time after surgery, the patient may be bothered by increased fatigue, general weakness. To minimize these manifestations, it is recommended to observe bed rest for the first time.

The recovery period involves specialists such as surgeons, psychologists, physiotherapists, rehabilitation therapists and physical therapy instructors. Patients will face the following tasks:

• to adapt to possible post-operative consequences;
• to restore lost function.

Often after clipping a cerebral aneurysm, headaches, prolonged migraines or spasms, which are caused by soft tissue trauma during surgery. The patient may feel a pressing discomfort in the temples, burning and heaviness in the head, painful throbbing. Usually in the process of treatment, such pain regresses for about two months. In some cases, the symptomatology persists longer: such patients are recommended to conduct a control CT scan. Mandatory diagnosis is prescribed for patients who have sudden headaches against the background of normal health - for example, against the background of increased blood pressure, physical activity, bending or carrying heavy loads.

The doctor decides how to treat head pain after clipping: at the initial stage, opioid analgesics or non-steroidal anti-inflammatory drugs are most often prescribed. Often the drug of choice is Naproxen, which is a propionic acid derivative tablet that eliminates pain and fever within half an hour of taking it.

The temperature after aneurysm clipping may rise to approximately 37-37.2°C. This situation is considered normal and is due to the peculiarities of the course of the wound process. Within 2-3 days, the temperature values should stabilize.

The pressure after clipping a brain aneurysm may fluctuate for some time, which is associated with regional circulatory disorders and the response of the sympathetic and parasympathetic nuclei of the brainstem. [9]

Care after the procedure

Rehabilitation program is developed individually for each patient.

Recovery after clipping a cerebral vascular aneurysm is faster and of higher quality if these conditions are met:

• nutritional correction;
• normalization of physical activity, revision of loads;
• regular follow-up with a neurologist;
• complete elimination of bad habits;
• systematic magnetic resonance angiography and computed tomography for the first two years after the intervention (every six months).

The possibility and necessity of assigning disability groups to a patient after aneurysm clipping is assessed individually, depending on the degree of consequences, the type and localization of the pathological site. The presence of additional pathologies is also important - in particular, diabetes mellitus or epilepsy.

Life after clipping of cerebral aneurysms is almost completely returned to the full course in 40% of operated patients. The rest of the patients are recommended to ease working conditions, switch to a gentle regime. The main criterion for adequate postoperative recovery is systematic medical supervision and periodic diagnostic preventive measures. Control computed tomography after aneurysm clipping is usually scheduled 6 months after the intervention. [10]

Childbirth after aneurysm clipping

The most dangerous threat to patients is rupture of a pathologically altered vessel. And during pregnancy, the probability of developing such a complication increases many times over, as hormonal and other changes occurring in the body of the future mother affect the vascular network. The volume of circulating blood increases, pressure increases, which can provoke aneurysm growth and rupture.

Another important and dangerous point: a woman may find out that she has an aneurysm only during pregnancy, when there is no possibility of surgical intervention. Such patients must be monitored by a vascular surgeon until the baby is born (such a situation is an absolute indication for cesarean section). [11]

If a pregnant woman has already undergone clipping, then under the condition of adequate rehabilitation, we can talk about the complete safety of the entire period of carrying the baby. If the therapeutic measures were performed in a timely manner and in full, the recurrence of pathology is unlikely. At the same time, special control on the part of specialists should be present without fail. Aneurysm clipping is also an indication for cesarean section.