Radiology - A Guide to Endovascular Treatment of a Cerebral Aneurysm

What is a cerebral aneurysm?

A cerebral aneurysm is a point of weakness of a blood vessel supplying the brain.

There is a risk that if the aneurysm is left untreated it can lead to the vessel bursting (rupture), which causes the brain to bleed (haemorrhage).

Patients who have an identified cerebral aneurysm will be offered the most suitable treatment.

What does endovascular treatment involve?

The first stage of endovascular treatment is a diagnostic angiogram (which you may have had previously). This involves a specialist doctor accessing your blood supply via your groin.

A catheter (long plastic tube) is carefully steered into the blood vessels they wish to examine.

An x-ray dye is then injected whilst acquiring pictures. This allows the doctor to examine the blood supply and cerebral aneurysm in detail.

From here the doctor can effectively choose the best method of blocking the aneurysm, the aim being to reduce the risk of aneurysm rupture and a brain haemorrhage.

Who will perform the endovascular treatment?

A specially trained doctor-Interventional Neuroradiologist (specially trained doctor) will perform the procedure.

The team helping to complete the procedure consists of anaesthetists, ODPs, interventional nurses and radiographers, who are all highly trained in helping the Radiologist and making you feel at ease.

Where will the procedure take place?

The procedure is undertaken in an Angiographic theatre within the Radiology department.

How long will it take?

The treatment of your cerebral aneurysm is variable and usually takes between 2-3 hours, and will be completed under a general anaesthetic.

What preparation is there for my treatment?

Before your procedure you will need a pre-operation outpatient appointment. This will help us to assess your medical condition and ensure your safety whilst you are being treated.

On the day of your treatment you will be asked to fast (not eat or drink) from midnight on the day of your appointment. If you require a small drink, sips of water are permitted up to 2 hours before your appointment. However, eating and drinking on the day of your appointment can cause delays and even cancellations.

If you are taking regular medication these should be taken as normal with a small amount of water, unless it has been specified in your appointment letter.

Please bring a list of your current medications with you.

You will need to attend to the area specified on your admissions letter on the day of your appointment. Prior to your procedure a member of staff will take clinical observations (blood pressure, oxygen saturations etc.) and complete a safety checklist.

At this time a small blood test may be performed. It is important that you tell the staff of any allergies you may have, as well as mentioning if you have diabetes, asthma or any heart problems. If you are female the staff may also require to check if you could be pregnant.
 
The Interventional Neuroradiologist and anaesthetist performing the procedure will visit you to explain the benefits of the procedure and any associated risks. They will then ask you to sign a consent form, and answer any questions that you may have about your procedure.

Before you are taken to the Angiography department you will be asked to change into a hospital gown and remove any jewellery or hair pieces that you are wearing. It is advisable not to bring valuables into the department for your procedure.

It is important to remember that the department treats emergency patients, which can cause postponements. The department will always try to limit this possibility, and will keep you informed of any emergency situations that could affect your treatment.

What happens during my procedure?

Once you arrive in the Angiography suite an anaesthetist will greet you and will complete final safety checks. From here you will be put to sleep using a general anaesthetic.

You will then be taken into the Angiography room where the treatment is completed. This is a specialised theatre which contains two x-ray machines, which will help guide treatment.

To ensure that the procedure is kept sterile your groin will be cleaned and you will be covered with sterile covers to reduce the chance of any infections.

The Interventional Neuroradiologist will access your blood supply via your groin and a catheter will be guided through the blood vessels until it reaches the correct area.
 
Contrast dye is then injected through the catheter whilst the x- ray machines collect images. The cerebral aneurysm will be examined in detail to ensure its dimensions are fully known.

Once these images have been examined the Neuroradiologist can decide on the exact method to treat the cerebral aneurysm.

The most common method to treat a cerebral aneurysm is known as a ‘coiling’. This involves using tiny coils, which are deposited inside the aneurysm until it is fully packed. The size and shape of the aneurysm determines how many coils are used. These coils once placed will not allow blood to enter the aneurysm and reduce the chance of aneurysm rupture.

Other methods of treatment are available depending on the size and location of your aneurysm. In specific cases a stent (artificial tube) can be placed inside the artery which helps to block the cerebral aneurysm.

Patients receiving alternative methods of treatment will have had this specifically explained to them prior to their procedure.
 
When the aneurysm has been treated further images will be collected to ensure that the aneurysm has been treated.

Once all the treatment is complete the Interventional Neuroradiologist will remove the equipment and insert a closure device into the vessel within your groin. This will ensure the site is closed which will prevent bleeding.

From here you will normally be woken from your general anaesthetic and be transferred to recovery, before going to your ward.

What happens after the procedure?

After your treatment you will be taken to a high dependency unit where you can be closely monitored, whilst here it is important to rest.

You will have to lie flat for 6 hours after your procedure, to ensure the entry site has healed. During this time, you will have regular clinical observations (blood pressure and blood saturations) performed.

After this time you will be required to avoid any heavy lifting or strenuous activity to reduce any risk of bleeding.

Will I get a follow-up?

These images may then be discussed with your referring consultant and a formal clinic appointment will be arranged to discuss further recommended imaging and treatment. Follow-up appointments take place at 6 months, 2 years, and 5 years.

Are there any potential risks?

Endovascular treatment will not be completed unless the benefits outweigh the risks. This will have been discussed with your Neuroradiologist or Neurosurgeon before you agreed to the treatment.

• Allergic reaction

Occasionally some patients have an allergic reaction to contrast dye. This is normally minor and would result in a skin rash or nausea. The team looking after you are trained to detect any reactions, but it is vital that any allergies are noted by the medical professionals looking after your care.

• Kidney function

Contrast can affect the kidneys due to the way it is broken down within the body. If you have poor renal function the doctor may prescribe some fluids and a blood test, which will help monitor your kidneys function.

• Bleeding/Bruising

As the procedure involves making a small puncture to the artery, there is normally a small amount of bruising to the site.
Occasionally the bleeding around the site may continue, if this occurs further treatment may be required.

• Infection

There is minimal chance of infection, as the procedure is completed in sterile conditions. If an infection around the site did occur, antibiotics would be prescribed.

• Further complications

Serious complications such as stroke and death can occur, but are extremely rare. These complications will all be discussed with the Interventional Neuroradiologist before you complete your angiogram.

What if I decide not to have the procedure done?

If you decide not to go ahead with your endovascular treatment after you have discussed any queries or questions with the radiologist, the department will notify your referring consultant.

From here the referring consultant can discuss any further options for treatment and imaging with you.

If you are diabetic

If you are diabetic, please contact the Diabetes centre on 0161 212 2095 - between 8.30am and 12 noon 

Do this as soon as you receive this appointment and ask to speak to a diabetes specialist nurse.

Failure to follow this advice may result in your appointment being cancelled.

Could you be pregnant?

If there is any chance you could be pregnant, please call 0161 206 5091 if your appointment is at Salford Royal Hospital. Please call 0161 656 1178 if your appointment is at Royal Oldham Hospital.

Is x-ray guidance dangerous?

All x-ray machines use potentially harmful x-rays. Modern equipment is designed to keep the dose you receive as low as possible. If your doctor has asked for this test, they will have decided that the benefits from the procedure outweigh the risks from the very small dose of radiation that you receive.

What if I cannot attend for my appointment?

If you have any questions about your examination or cannot make the appointment, please telephone the helpline on:

0161 206 2044/2404 - Salford Royal Hospital
0161 624 0420 - Royal Oldham Hospital
Monday to Friday between 8.30am and to 4.00pm

You can also email:
salford.radiology.booking@nca.nhs.uk - Salford Royal Hospital
bookingandscheduling.outpatients@nca.nhs.uk - Royal Oldham Hospital

Please include your name, address, date of birth and hospital number (if known) on all correspondence.

I need an ambulance, how do I arrange this?

If you need an ambulance there are contact details on your appointment letter.

Please inform the department, using the contact details in this leaflet, if you are arriving by ambulance.

Interpreters

If you need an interpreter for your examination and/or procedure (either verbal, non-English language or non-verbal, e.g. British Sign Language, Makaton etc.), please call the department so that we can try to arrange this, or there is information about interpretation services on the back page of this leaflet.

Contact Details

We hope your questions have been answered by this leaflet.

If you require help or any other information regarding your appointment you can contact: -

The Angiography Department, Salford Royal NHS Foundation Trust
Tel: 0161 206 2206/5091

Interventional Radiology, Royal Oldham Hospital
Tel: 0161 656 1178

Other sources of Information

Your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion about your treatment with the doctors looking after you.

Make sure you are satisfied that you have received enough information about the procedure, before you sign the consent form.

Further information regarding the examination can be found on the internet:

NHSUK
13/01/2017, NHS Choices, Angiography
www.nhs.uk/conditions/angiography/

Brain and Spine Foundations, 03/2017, Angiogram of the Brain
www.brainandspine.org.uk/angiogram-brain

Society of Interventional Radiology, 2017, Tiny incision, big result
www.sirweb.org

NHS 111 Service
when its less urgent than 999 111

Finally…

Hopefully some of the questions should have been answered by this leaflet but remember that this is only a starting point for discussion about your treatment with the doctors looking after you.

Make sure you are satisfied that you have received enough information about the procedure in advance.