Asymptomatic Right MCA (Middle Cerebral Artery) Aneurysm

Contributor:

Dr. Chris Ekong

Consultants:

Dr. J Max Findlay
Dr. John Wong
Dr. Renn Holness
Dr. Christopher Wallace
Dr. R Willinsky
Dr. Fred Gentili
Dr. Cameron McDougall
Dr. Gary Steinberg
Dr. G Sutherland

Case 26

Age: 70

Sex: Female

History: CT head done in the course of investigating 2 years of headache. Examination normal.

September 20, 2004 - Dr. Chris Ekong, Neurosurgeon, Regina

Dear Max, Garnette, Mike, et all.

What would you do for this 70 year old lady with asymptomatic aneurysm?

Would you:

1. Leave it alone?

2. Coil it?

3. Clip it?

4. Other?

Chris

September 20, 2004 - Dr. Chris Wallace, Neurosurgeon, Toronto

70 year old lady asymptomatic. I'd leave it alone. Her risk is about 2.6% per 5 years according to ISUIA 2 (Lancet) and so you'd have to have a super low treatment risk to make it worth her while.

Neck is wide... interventional therapy should not be considered even if someone is tempted to treat her! Legit question is whether an angiogram is necessary given advances in CTA and MRA.

Chris

September 20, 2004 - Dr. John Wong, Neurosurgeon, Calgary

Hi Chris and everyone,

I would recommend conservative observation and control of any modifiable risk factors such as hypertension or smoking.

The risk of open surgery in the elderly age group is not insignificant, the natural history could be considered benign given the infrequency of spontaneous rupture, and endovascular coiling would not be appropriate given the incorporation of the efferent middle cerebral vessels.

John Wong

September 20, 2004 - Dr. Robert Willinsky, Neuroradiologist, Toronto

Agree with Chris and John,

Bob

September 21, 2004 - Dr. Gary Steinberg, Neurosurgeon, Stanford

I would not treat her, if she is asymptomatic. However, I would follow her clinically and with annual CTAs. If the aneurysm enlarged or she became

symptomatic, I would consider surgical treatment. Perhaps advances in endovascular therapy will offer a safer option within a few years.

Gary

September 21, 2004 - Dr. Mike Tymianski, Neurosurgeon, Toronto

I am in France...Sporadic email contact through my wireless... Ne touchez pas cet aneurysm...

Salut et au revoir

Michel Tymianski

(Editor's note: He wouldn't touch it with a 40 ft pole).

September 21, 2004 - Dr. Max Findlay, Neurosurgeon, Winnipeg

Dear Chris,

It would seem that her age is the big concern here. I would not dismiss this patient out of hand, sight unseen without knowing more about her health, attitude and so forth. It is large, multilobed and appears to have a high aspect ratio, and over the next 10 years of her life she bears a roughly 20% risk of rupture (with a minumum 1.5% annual risk of rupture--which is an ISUIA estimate) and that rupture a 65% mortality (an ISUIA finding).

Of course surgery, the only way to treat this, carries with it its own considerable risks in this 70 year old lady. What is she comfortable with? We would hope conservative therapy, blood pressure control and cessation of any cigarette habit she might have.

September 21, 2004 - Dr. Joseph Buwembo, Neurosurgeon, Regina

Hi Chris,

This is an interesting case. I certainly agree with all consultants to just observe and control risk factors for rupturing. Besides, her headache is unlikely to be caused by this lesion.

Joe

September 29, 2004 - Dr. Fred Gentili, Neurosurgeon, Toronto

Dear Chris,

Just back from Europe, thus the delay in responding. I would agree with the consensus that a conservative approach is preferable. Nevertheless I recently operated on a 69 year-old with a slightly larger aneurysm who felt that she could not live with even the small risk of rupture. Fortunately she did very well but these aneurysm do often require the use of several clips and remodeling of the neck.

Best Regards,

Fred

A Project of The Emmanuel Charitable Foundation