Elective treatment of brain aneurysm by coil occlusion or stent

Introduction including who the leaflet is for and what is its aim

This leaflet is for patients who have opted for elective treatment of a brain aneurysm by coil or stent.

What is a brain aneurysm?

A brain aneurysm is a fault or weakness in the wall of one of the blood vessels supplying blood to the brain. This causes a ‘’blister’’ or balloon like swelling on the blood vessel.

There is a small risk that the aneurysm will burst and cause a brain haemorrhage (subarachnoid haemorrhage). This is the reason treatment is offered.

What is coil occlusion of aneurysm?

This is an endovascular treatment which means it is performed through a blood vessel by a consultant interventional neuroradiologist. It is carried out whilst you are asleep under general anaesthetic.

A catheter (tube) is inserted into an artery in your groin in the same way as an angiogram. The catheter is moved up to the aneurysm using x-ray screening for guidance. The coils are then carefully placed inside the aneurysm.

The size, shape, and position of the aneurysm will determine which type and how many coils are used.

The aim is to pack the aneurysm with coils so that blood is not able to enter it and allow the aneurysm to seal over.

What is ‘stent assisted’ coil occlusion?

Occasionally, a stent (artificial tube) is used as well as coils to help seal off the aneurysm. These are used depending on the type, shape and position of the aneurysm.

What is a ‘flow-diverter stent’ treatment of an aneurysm?

Occasionally, some people may have a stent without the coiling procedure. A stent (artificial tube) is placed across the opening of the aneurysm to divert the flow of blood away from the sac. This will reconstruct the inside of the blood vessel, creating a protective barrier for the aneurysm.

This will be discussed with you.

Medications after the procedure

You should have clear instructions on the medication such as aspirin and any other anti-platelet (blood thinning) tablets you may need to take after the procedure, before you go home. If you are unsure please ask your medical team. You should not stop this medication unless you are advised to do so by your medical team. Stopping this medication could result in the blockage of this stent, which can cause a stroke.

Who will perform my procedure?

This procedure will be performed by a consultant interventional neuroradiologist.

Before your procedure

You will be kept nil by mouth for six hours before the procedure.

We will ask if you take any tablets or use any other types of medication either prescribed by a doctor or bought over the counter in a pharmacy. Please bring all your medications and any packaging (if available) with you. Please tell the ward staff about all of the medicines you use. If you wish to take your medication yourself (self-medicate), please ask your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

During this appointment, you should have clear instructions on the medication such as aspirin and any other antiplatelet (blood thinning) tablets you may need to take before and after the procedure.

If another patient comes in as an emergency, your procedure may need to be postponed as emergencies will always take priority. We will make every effort to prevent this.

This procedure involves the use of anaesthesia. We explain about the different types of anaesthesia or sedation we may use at the end of this leaflet. You will see an anaesthetist before your procedure.

Most people who have this type of procedure will need to stay in hospital for two to three days. Your doctor will discuss the length of stay with you.

During the procedure

During the procedure, you may lose blood. If you lose a considerable amount of blood your doctor may want to replace the loss with a blood transfusion as significant blood loss can cause you harm. The blood transfusion can involve giving you other blood components such as plasma and platelets which are necessary for blood clotting. Your doctor will only give you a transfusion of blood or blood components during surgery, or recommend for you to have a transfusion after surgery, if you need it.

Compared to other everyday risks the likelihood of getting a serious side effect from a transfusion of blood or blood component is very low. Your doctor can explain to you the benefits and risks from a blood transfusion. Your doctor can also give you information about whether there are suitable alternatives to blood transfusion for your treatment.

Coiling is a complex and delicate procedure that may take a few hours or longer. The neuroradiologist inserts a catheter (tube) into your femoral artery. This is then guided by x ray screening through other blood vessels in your body until it reaches your neck and then into your brain.

The coils are then carefully inserted into the aneurysm. Coils are made of platinum, and are about the thickness of human hair. The length of them varies. The number of coils needed depends on the size of the aneurysm.

After the procedure

Once your procedure is completed you will be transferred to a recovery ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist. The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. They will monitor your heart rate, blood pressure and oxygen levels too. You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward.

Once back on the ward, you will need to lie down on bed rest for a few hours. This helps to minimise the pressure on the artery that has been used as the access.

Sometimes it is necessary for you go to the critical care unit where there are more facilities to treat and monitor you if that is what your interventional neuroradiologist orders. This will be discussed with you in preadmission assessment clinic.

If your neuroradiologist or anaesthetist believes you should go to one of these areas after your operation, they will tell you and explain to you what you should expect.

If there are no beds available in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after a major procedure.

You will have regular observation of your conscious level, blood pressure and pulse as well as the puncture site. You may have a drip to make sure you don’t get dehydrated.

Once the drip is out we will expect you to drink plenty of fluids the next day to wash out the contrast (dye) used in the procedure. You will have stockings and compression devices on your legs. You will normally have blood thinning injections after the procedure until you go home. This is to prevent venous clots (DVTs) in your legs whilst you aren’t moving around as much and these injections are discontinued when you get home.

After this procedure, you should not have anything to eat or drink until advised.

You will be allowed to gradually sit up after four hours and gently mobilise with supervision if the nurse looking after you feels it is safe to do so.

The puncture site in your groin is sometimes painful afterwards. There may be some bruising or swelling. Occasionally this can be excessive. If you notice this then you must let your medical team know. The site should not bleed afterwards. It is advisable to hold this area whilst coughing or straining afterwards if possible.

Once your medical team are happy that you no longer need treatment you will be allowed to go home. This is often two or three days after the procedure, if there are no complications.

You will normally go home on a course of aspirin. Sometimes other blood thinning tablets are added such as clopidogrel, or a similar drug. You should have instructions on the dose and length of time you should take this before you go home.

Aspirin can sometimes worsen indigestion or heart burn, and may make breathing worse in those with asthma. Occasionally, it can cause bleeding or skin reactions. Clopidogrel can rarely cause stomach upset and bruising or bleeding. If these side effects occur seek medical advice as well as contacting us for advice.

Returning to work

You can return to work as soon as you feel able although most people need about two weeks off to recover. (Occasionally more if there have been complications.)

Driving

You do not normally have to inform the DVLA following this procedure unless there are complications with vision or stroke. You should always check with your medical team before you go home. However, you should not drive until you feel recovered and go out on a quiet road on a quiet day to see how you cope.

Flying

You should be able to fly as soon as you feel able. It is safe to go through the metal detectors in the airport. They will not affect the coils. You should always inform your insurance company before flying.

Smoking cigarettes

As cigarettes are one of the biggest risk factors in rupture of aneurysms it is advisable that you give up smoking completely. A free help line number is printed at the end of this booklet.

Drinking alcohol

Alcohol in moderation is acceptable. The government suggests that woman do not drink more than two to three units each day and men three to four units a day. Information websites on alcohol awareness are printed at the back of this booklet.

Sexual activity

You can resume normal sexual activity as soon as you feel able.

Starting a family

For ladies it is advisable not to start a family for the first six months. You will not normally be prevented from a normal delivery but this will depend on your obstetrician. Contact your neurovascular nurse or medical team if you wish to start a family.

Sport and swimming

Exercise is encouraged. Most sports can be resumed gradually once you have recovered, although it is best to avoid extreme and contact sport until you have had your six month follow up scan.

Hair washing and hair dyeing

You can wash your hair as soon as you feel up to it. The coils will not be affected by dyeing or perming it.

Dental treatment

Dental treatment is safe after coiling of aneurysm but your dentist may not be happy to treat you whilst you are taking aspirin or clopidogrel. If treatment isn’t urgent you should wait until the course finishes. Please contact us for further advice if you need treatment whilst taking aspirin or clopidogrel.

Whilst there are no scars from this procedure please be aware that you may need time to recover as it is a complicated intricate procedure. You may feel a little ‘under the weather’ or tired for a few weeks following the procedure.

Whilst there are no scars from this procedure please be aware that you may need time to recover as it is a complicated intricate procedure. You may feel a little ‘under the weather’ or tired for a few weeks following the procedure.

Headaches

Headaches sometimes occur following the procedure. They usually ease after a few weeks. Simple medication such as paracetamol should help.

Headaches can be triggered by dehydration, stress, too much or too little sleep and missing meals.

Drinking two litres of water a day should help reduce the frequency and severity.

Pacing

Recovery is helped by pacing your activity for the first week or so following going home. Tiredness is common for the first few weeks so take a daily rest if you need to. Gentle exercise is beneficial to build up stamina and wellbeing so increase activity as you improve.

Unusual sensations

Some people experience unusual sensations in their head following coiling of aneurysm. Some examples are ‘cotton wool’ sensation or ‘water trickling’. We are not sure why this occurs, but they should ease with time.

You will receive a follow-up appointment for an outpatient clinic once discharged from hospital.

Fear of the aneurysm bleeding

The aneurysm will be secured by the coils. Fortunately the risk of bleeding from a coiled aneurysm is extremely rare.

You will be followed up and scanned regularly once you have gone home. This is usually at six months, two years and five years. We stop follow up after this time if the secured aneurysm remains unchanged.

Benefits

There is a small risk that the aneurysm will burst and cause a brain haemorrhage (subarachnoid haemorrhage). This is the reason treatment is offered.

Risks

The procedure will not be carried out unless it is considered that the benefits outweigh any possible risks. You will have discussed the procedure and risks with your neurosurgeon/ interventional neuroradiologist and given your consent before you decide to go ahead with the procedure.

The risks of coiling are complications that include:

• Stroke-like symptoms such as weakness or numbness in an arm or leg; problems with speech or problems with vision. In rare cases, this can be very serious and result in serious disability or death.
• Risk of bleeding, infection or arterial damage at the entry site in the groin.

Can the coils move?

The coils may settle into the space within the aneurysm. This is called coil compaction. This may mean that more coils are required to seal off the aneurysm fully or the situation may simply be kept under surveillance if your doctors feel the aneurysm remains safe from bleeding.

Radiation – Risks vs Benefits

• You have been referred for a Neuro Interventional Radiology procedure to help deliver your treatment. A specialist in radiology agrees that this is the best procedure to treat your clinical condition and that the benefit of the examination is greater than the risk.
• The x-ray involves a dose of ionising radiation equivalent to a few months or years of natural background radiation which we are all exposed to every day.
• Ionising radiation can cause cell damage that may turn cancerous however the risk of this happening from your examination is considered low.
• Depending on the length of the procedure there may also be a small risk of an excess radiation dose to the skin leading to short term and long term effects (e.g. reddening of the skin and burns).
• If this happens as a result of this procedure, you will receive further advice following the procedure. The dose delivered will be kept as low as is practicable
• For further information please see the CUH radiology page.

Alternatives

• Intracranial aneurysms can be treated either by means of an open operation – traditional surgical methods, or by means of the endovascular route whereby a coil is placed within the aneurysm by means of a thin tube passed up through an artery from the groin.
• Both procedures will be fully explained to you. The initial risks are similar. However, some aneurysms are better treated with surgery compared to endovascular treatment, and vice versa. A full discussion of these two procedures will be offered from your treating surgeon.
• You can decide not to have this or any treatment, eg you might wish to wait until you are more certain or have sufficient information to make an informed decision. The risks of not having this aneurysm treated will be discussed with you.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

My Chart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

More information is available on our website: My Chart

Contacts/further information

Please call the specialist nurse on telephone number 01223 216189 if you have any questions or concerns about this procedure or your appointment.

Neurosurgical Nurse Specialist: 01223 216189

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DVLA (opens in a new tab)
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Telephone: 01223 156981

Brain and Spine foundation (opens in a new tab)
Telephone: 0808 808 1000

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