Internal carotid artery aneurysm - watch & wait vs surgery

Hello all - my sister,70 recently diagnosed with an aneurysm is weighing the option of
surgery (FRED) for a 2x3 mm aneurysm vs a watch and wait approach. She is not in that great
shape, trying to give up cigarettes & limiting alcohol. The dr says only 1% chance it
will rupture. She is well aware of 40% morbidity if it does. I know this is somewhat of a personal decision. I think that she is leaning towards watch & wait as she thinks the side effects of the surgery will be debilitating to her. Any advice?

Welcome! Boy that’s a tough one, since I ruptured I try to not be bias. I can share with you what I’ve learned along the way, don’t trust statistics unless the source has the numbers to prove them. Does your sister’s surgeon keep statistics? And does the hospital s/he works at? Some hospitals might but in NC, I understand statistics are not kept at hospitals unless there’s a fatality and then the State also keeps them. Although I’ve never written to DHHS to see what they have to say.

Every doc I see says aneurysms rarely ever rupture, my neurosurgeon said they’re usually found upon autopsy but many never go detected. Incidental finds are usually because someone had a CT or MRA for non related issues. Aneurysms can happen anywhere in the body.

The most important thing I’ve learned is medical science keeps coming up with something better. Me telling you what I would choose won’t help your sister much and I don’t believe in getting on the absolutely fix it podium, because some never rupture. We have had many members over the years that get put on the WW list and theirs don’t grow so surgery wasn’t needed. We’ve had a couple dozen where the initial imaging said they did and it ended up being something else on the angiogram.

There are a lot of risks associated with having a catheter in our brain from the an anesthesia to dye to the procedure itself. We’ve had some members who’ve had an ischemic stroke during a procedure and some who have ruptured. Is the doctor thinking she doesn’t need the diagnostic angiogram or has she had one already?

What I would suggest is she write down a pro vs con list being honest. But if she has a lot of health issues, those could be a tie breaker as the risk coupled with the health issues would be that much greater. But it sounds like she’s made her decision and is comfortable being on the WW list. My guess is she’ll have another imaging in 6 months to a year to see if it’s grown, which seems to be the norm here. Hang in there, it’s tough being a sister.

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Thank you so much for your response. Yes she did have an angiogram. The finding was incidental and she is currently asymptomatic. When she emailed her surgeon to cancel her scheduled surgery, he seemed unconcerned & told her to schedule another MRA in a year.
I have learned a lot from this forum & appreciate all who have shared their experiences. I have encouraged my sister to check this support group out. I applaud all who have gone through this & commend their courage.

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For as long as I’ve known about cerebral aneurysms (11 years and some change) the angiogram has always been said to be the “gold star”. It’s really good to know what the doc sees, even if mine has to slow down and explains numerous times because my brain gets wonky​:crazy_face::joy:

We are really glad we have been some help and most definitely your sister is welcomed any time. You’ve probably read where some members get sentinel bleeds I think they’re called, I did not. I did get the horrendous thunder clap headache whilst others have not. Best thing I did when I eventually got out of the cellar and to a phone was to call 911. I hope your sister remembers to do that as well if she ever gets one, don’t try to drive. I passed out again just about a mile down the road. With you in her corner, I’m sure you’ll keep a good eye on her.

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Give up cigarettes for sure. I had to stop when I ruptured. There was a family in the ICU whose mom (45 yrs old) refused to quit smoking. She died. Cigarettes are a strong addiction but ultimately the choice is was) hers.

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Hello. 49 year old female who on 12-12-2024 had a Pipeline Embolization Device (PED) to repair a 10x7mm Annie on my ICA on my left optic nerve. I was told that there was only a 3% chance of rupture, but because I was having problems with Vision, Headaches, Nausea and Vomiting, my Surgeon and I decided to repair. Best decision ever! It was a super easy surgery with almost zero pain (groin incision). My quality of life has improved so much since then. Not only has most of my symptoms improved but the anxiety and sense of doom that I had is gone! I am a previous smoker, however I do consume nicotine by Vaping only and have for the last 8 years. I am so very very glad I had the surgery. I hope that whatever your sister chooses that it brings her health and peace!

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I had a brain aneurysm that was diagnosed on 2005. I had a stroke and they found it. They said that it would not rupture and in 2011 it ruptured and I had to have a craniotomy. I was in a coma for five days then wait and watch was not a good idea, I could have died so it might opinion it is not a good thing to wait-and-see but it all depends on the person

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interesting. Did yours rupture ? is that what you mean by “thunder clap”?

Yes! So far so good with quitting cigarettes. And because she is not smoking she is eating more. Such a hard habit to quit. Thanks for your response.

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I’m glad that you had such good results with your surgery. My sister has decided to get a second opinion in Boston. The finding of her aneurysm was incidental, she has no symptoms.

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During exploratory surgery in 2012 (after a brain bleed), two unruptured aneurysms were identified. One was coiled; the other one has been watched for 13 YEARS via MRA (I’m allergic to the contrast). In December, the MRA revealed that the 4mm aneurysm had grown much larger – finally. I was scheduled for a procedure after the holidays. My surgeon used angiograms and embolization of the basilar aneurysm with a WEB device on Jan. 13th, a relatively newly approved device that eliminates surgery through the cranium. The procedure was 3-1/4 hours, then I spent 24 hours in the Neuro ICU, and then I was discharged. Three weeks later, and I’m feeling fine, except for some fatigue. Follow up is in 6 months, and will continue annually.

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Yes, it ruptured, I usually just say I popped my pipe as an explanation. It’s a reference to the old hose pipes (garden hose) that used to get a weak bubble and popped that I remember as a child.

A thunderclap headache is like a migraine, but a thousand times worse I guess. I never had migraines prior but then had one nonstop for what seemed like years. It’s often described “as the worse headache of your life”.

Hello
I am sorry to hear about your sister. It is a hard decision to make. I had a 3mm cerebral aneurysm which ruptured 23 years ago. I didn’t know I had the aneurysm until it ruptured. The doctors said that they were surprised it ruptured as it was a small aneurysm and I had low blood pressure at the time. I had a couple of coils put in after the rupture. It is a very personal decision for your sister to have to make as its not fair to give advice as every case is different. Has she been told exactly what the surgery entails? She needs to weigh up all the pros and cons and then make her decision with the help of the experts. I wish her all the luck in the world and pray that she will come to a very comfortable decision.

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Hi - Yes the surgery was explained to her. My sister did not care for the surgeon she saw which is why in part she is seeking a second opinion. Brain surgery is a scary thing so I think it is imperative that you have confidence in your surgeon. It’s good to hear that 23 years after your rupture you are still with us & doing well? Thanks for your response.

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Good luck and God bless you both

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I’m hesitant about the comment that it has 1 percent chance of rupturing. How does the doctor know this with such certainty? I will say, that since it smaller, it does have less of chance of rupturing. I would be curious about the growth rate.

I just had a flow diverter stent procedure this month. I was told this procedure was less risky as it did not require brain surgery. I was told this procedure unlike the other procedures was the recommended procedure because my aneurysm was smaller, and there was no immediate need to remove it ASAP. Its location was not in a good place either.

I guess waiting maybe good if the aneurysm is in a “safe location.” Otherwise, if it can be removed in a safe manner, why wait. My understanding is that as it grows bigger, the surgery is risker. I hope this helps.

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I’m going to try to respond to your questions and hope others will as well.

Doctors base their percentages on available statistics, their experiences and what they’ve been taught has been explained to me. On the other hand, my Neurosurgeon doesn’t give statistics, at least never to me. Interestingly, AHWFBH (Baptist) where I had mine repaired doesn’t keep statistics on cerebral aneurysms. Would be nice for the med students or Residents to gather statistics though wouldn’t it?

There are more variables than just size that helps with the surgeon’s decision or suggestion. There’s also location and shape, overall health and age of the patient etc.

The doctor for Melanie’s sister and the sister of course, has decided to watch and wait to see if it grows. In the meantime Mel’s sister (sorry Melanie but it’s the nickname I used for my best friend way back in HS) is addressing her life style in a positive way. She will be getting more images along the way, in her case a year. If the MRA shows that it’s growing they will have another conversation about any procedures. Not all aneurysms grow. However, she is also getting a second opinion as she and the first didn’t “click”. Seems the sister is being proactive for her care at least in my opinion.

Flow diverter is in the stent category and there are several different types. All stents divert the flow away from the aneurysm. They are normally used with coils. This method is called endovascular brain surgery, or just endovascular procedure. It is still brain surgery, the risks are lower than a craniotomy (craniotomy procedure) according to every study I’ve read.

From what I’ve learned here is doctors choose the type of stent based on location and what they’re comfortable with. For instance, your type of stent couldn’t work with my aneurysm because of location so I waited around until medical science developed one that could be used. I’ve often wondered if certain facilities encourage a use of one stent over another because the one they use was developed by doctors working at that facility. I will most likely never know, seems feasible.

Aneurysms are not removed, they are occluded. This means whichever device or procedure was used be it clips, glue, coils, or stents, the surgeon has blocked the path of the artery away from the aneurysm. When you go for your follow up with your surgeon ask to see the images and have him/her show you yours. I find it quite fascinating to see my coils and the stent


the arrow shows the placement of my stent

The white blob is from all the coils shoved into my aneurysm to try to occlude it. The blood flow is intact where it looks like everything is broken off, it just didn’t show up in this particular image. I like the torturous (squiggly) nature of all the blood flow, my surgeon isn’t particularly keen on it. However she is an expert with AVMs and can easily navigate throw all the arteries she uses to get in and out of my brain.

I’ve learned an amazing amount of things from our members over the years! I hope this helps you.

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Hi - I am the sister. Around three years ago, I went to the ER for blurred vision and light headedness. I was given either a CAT scan or MRI and was told they thought I had an aneurysm. After the test, they said I was cleared to go. I was relieved and didn’t really think any more about it until this September when I had another MRI due to dizziness which was diagnosed as vertigo. In the discharge report was mention of an aneurysm that hadn’t changed in size! Imagine my surprise. My primary didn’t say anything about it so I asked her about a follow up.
The surgeon I saw told me that my aneurysm was in a bad place and if it did rupture it would most likely be fatal. He also said that the surgery was 98% successful. To me, at that time, it was a no brainer. Sign me up for the surgery.
Then I read his report where he said he told me there was less than a 1% chance of rupture and said he told me to watch for that headache. He never told me either of these things. Also in the report, it said nothing about the location of it being so bad. The topper to me was that he said he spent 50 minutes with me when it was less than 15 minutes! To me, it seemed like he was presenting my office visit as a thorough informative discussion of my options, when I feel it was a one sided view of what I should do, steering me to surgery. My sister is the one who told me about the headache.
I haven’t been able to read much about this yet. I am trying to process and well, yeah, quitting smoking has been difficult, but so far day 12. I don’t think I have a lot of health issues, though my family thinks of me as frail. I think as time goes on and I gain weight that will change.
I am grateful for my sister for her amazing research and will now try to educate myself with the help of this forum. Thank you all!

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Hey Sis (Michelle) Welcome to our little group, I’m really happy you joined! I get miffed when my record doesn’t match my appointment. Really miffed, so I address it in my patient portal which then becomes part of my medical record. Keep all your records, even the images. Learned that one from our wonderful members. Hopefully you can find another surgeon who communicates better. Keep us in the loop and again thanks for posting. Oh, don’t forget to use our search feature to see if there’s any recommendations for one in your area. If you can’t find one, just start a new topic. Our only rule about medical professionals is if we have had an issue we can’t use their names for legal reasons. If they’re good, by all means share name and location!

i have to take partial responsibility for my first appointment. I actually thought it was going to be a waste of time as no doctors seemed alarmed by the fact that I had an aneurysm. I was not prepared with questions and was actually surprised that I needed (supposedly) surgery. I have an appointment at Beth Isreal in a month. I am trying to read as much as I can in the meantime but am not good at navigating internet information. Fortunately, I have my sister. I will have her go with me to the appointment and will hopefully have more faith in this next doctor. I am just enjoying not having to buy a pack of cigarettes every day! Thank you for the suggestion of the portal.

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