Introduction

An aneurysm is defined as an abnormal dilatation of a blood vessel by more than 50% of its normal
diameter. Aneurysms occur intracranially, with an approximate prevalence of intracranial aneurysms in
adult populations around 3%.

Aneurysms often form at sites where blood vessels bifurcate or merge, and as such the majority form
around the Circle of Willis (Fig. 1).

Whilst some caused by hereditary weakness in the arterial walls, other causes include hypertension or
smoking (causing defects in the tunica media), trauma, or connective tissue diseases. The main concern
regarding intracranial aneurysms is their risk of rupture.
Approximately 90% of all intracranial aneurysms are defined as saccular aneurysms, with the remainder
being fusiform. They can be classified by size, with <10mm = small, 10-24mm = large, >24mm = giant.

Risk Factors

Main risk factors include female gender, family history*, hypertension, and smoking

Autosomal dominant polycystic kidney disease (ADPKD) and connective tissue disorders (e.g. Marfans)
are at increased risk of developing intracranial aneurysms.

*Patients are approximately 30% more likely to develop an intracranial aneurysm if a first-degree
relative also has one

Risk Factors for Rupture

Risk factors for aneurysmal rupture include location and size (Table 1). The International Study of
Unruptured Intracranial Aneurysms (ISUIA) revealed that the aneurysms with increasing size arising from
the posterior circulation have a higher 5-year cumulative risk of rupture.

< 7mm

7 – 12mm 13 – 24mm

24mm

Cavernous carotid

0%

0% 3.0% 6.4%

Anterior circulation

0%
2.6% 14.5%

40%

Posterior circulation

2.5% 14.5% 18.4%

50%

Table 1 – Five year cumulative rupture rates of unruptured aneurysm, according to location and size

Clinical Features

Most small unruptured aneurysms produce no symptoms at all, typically being found incidentally found
on MRI.

Unruptured symptomatic aneurysms can result in headaches or nausea, or in rarer cases resulting in
focal neurological deficits, seizures, or isolated cranial nerve palsies*

Ruptured aneurysms will present with intracranial haemorrhage, most commonly as a subarachnoid
haemorrhage (SAH)

*A well-described palsy in this scenario is a CN III palsy secondary to a posterior communicating artery
aneurysm causing local compression

Investigations

The mainstay of diagnosis of intracranial aneurysms is with a CT angiogram (CTA), allowing visualisation
of the aneurysm and identifying its location. Additional imaging via a Magnetic Resonance Angiography
(MRA) may be useful for operative planning.

CTA:
MRA:
Patients who present with clinical features of a SAH will typically a non-contrast CT head performed
initially, prior to any further imaging performed if a ruptured aneurysm is suspected.

Management

The management depends on patient factors (co-morbidities, functional status) and aneurysm factors
(size, type, and position). All patients should have any modifiable risk factors optimised, most commonly
via improved blood pressure control and smoking cessation.

The majority of aneurysms will be monitored only (at least initially), with regular interval imaging,
assessing for any progression in size. Indeed, many incidental aneurysms will not grow and patients only
ever require routine follow-up.

Surgical Management

For those that are requiring surgical intervention, the mainstay of treatment is either surgical clipping,
bypass or endovascular coiling (Fig. 3).

Surgical clipping is seen more suitable in aneurysms that have branching arteries or are wide-necked,
and often has lower reported rates or recurrence and rebleeding

Endovascular coiling is usually more favourable in posterior circulation aneurysms or co-morbid or older
patients

Jnrutledge, CC BY-SA 3.0 , via Wikimedia Commons

Prognosis

Patients with unruptured aneurysms of favourable size and location carry less than 1% risk of rupture per
year.

For patients with aneurysmal rupture, around half of all patients will even reach a hospital on time, and
of those, around a half will die. Of those that survive, a half will develop significant neurological
impairment.

Operative video case:

https://www.neurosurgicalatlas.com/cases/mca-aneurysm-classic-clip-ligation-strategies?texttrack=en-U
S

https://www.neurosurgicalatlas.com/cases/proximal-to-distal-pica-bypass-for-calcified-fusiform-aneurys
m?texttrack=en-US&highlight=Bypass