Surgical clipping of brain aneurysm
Why treat a cerebral aneurysm?
The reason to treat a cerebral aneurysm is to prevent it from bleeding. The decision to treat a cerebral aneurysm is made by your neurosurgeon and interventional radiologist in a multidisciplinary team (MDT) meeting. The experts take into account your well-being and personal wishes but will ultimately recommend the type of treatment that is safest for you. Treatment depends on the size, shape and position of the aneurysm which can influence the risk of it bleeding over your lifetime. It can also depend on whether it has been treated before and if you have previously had a brain haemorrhage.
Choices include endovascular or surgical treatment.
Your team will advise surgery if the endovascular option isn’t possible or is thought to be the safest way to treat the aneurysm. Once a decision is made and discussed with you by your medical team; with your agreement you will be placed on the waiting list for treatment.
Preparing for the operation
You will be seen in the pre-operative clinic by one of the neurovascular nurses who will assess you for fitness for a general anaesthetic, explain the procedure and answer any concerns. The pre-operative clinic review takes approximately 1½ - 2 hours in total. Bloods and measurements of height and weight will also be taken. Please bring a urine sample with you and a copy of any medicines you are taking.
Further tests may be necessary according to your general well-being and other medical conditions before a decision is made that you are fit for the anaesthetic procedure. You will be assessed by an anaesthetist before the operation. The anaesthetist is the consultant doctor who administers the general anaesthetic and pain relief during the operation.
You should shower and wash your hair in the solution given to you in preop, as advised, before the operation in order to clean and reduce the risk of infection. You will normally come in the same day as your surgery unless otherwise stated. You will be expected to make your way to the hospital for 07:30 and present to Jefferson Ward. You should not eat anything from midnight before coming to hospital. You can sip water until you come in.
Apart from blood thinning medication which should be stopped for a period of time prior to your operations, you can take your normal medicines unless your pre op nurse advises against it.
Clipping for cerebral aneurysm is an effective procedure to permanently close it and prevent the risk of bleeding. The operation will be carried out whilst you are ‘asleep’ under general anaesthetic which means you will not be aware or feel anything.
A small metal clip (or clips) is placed over the neck of the aneurysm to prevent blood entering it. This is done through a craniotomy. A craniotomy is an operation to open the skull in order to expose the brain.
Once asleep, your head is stabilised; in some cases, a small amount of hair may be shaved. An incision is made in the skin to expose the bone. If possible, this will be behind the hair line. Small holes called burr holes are made in the skull bone and the surgeon uses these to form and pull back a bigger piece of bone. This is called a ‘bone flap’. The bone flap is temporary and necessary to expose the brain underneath.
The brain is covered in a lining called the dura. This is opened and the surgeon locates the aneurysm through the natural folds of the brain using a microscope, the aneurysm is visualised and one or more clips are placed over the neck of the aneurysm to seal it off. These clips are similar to tiny clamps. Once the clip is in position and closed, the aneurysm is secure.
The bone flap is then put back in place and secured using tiny metal plates and screws. The skull itself will take about six months to heal. You may be able to feel the indentations from the burr holes once the wounds heal. This is normal.
There are risks to the procedure which are dependent on the area of the brain the aneurysm is located. This will have been discussed with you by your neurosurgeon but the operation will only be advised if the benefits outweigh the risk. The more common risks include stroke like symptoms, headache, visual disturbance, speech disturbance and infection.
After the procedure
Once the operation is over you will go to the post-operative recovery unit to wake up and recover from the anaesthetic. You will be looked after here by skilled recovery nurses. Once you have woken up and been assessed by the anaesthetist, you will be moved to either the high dependency unit or the ward you came from. Where you go depends on how quickly you wake up, how long or complicated the procedure was and other medical conditions you may have.
The high dependency unit is used to monitor you more closely if needed. You will have a drip in your hand or arm to give you fluids through a vein. You will have a bandage on your head and you may have a drain under the skin in the head. You are likely to have a catheter in your bladder which will be removed as soon as possible. You may have compression devices or stockings on your legs to prevent complications such as deep venous thrombosis (DVT). DVT is a blood clot in the leg that is at risk of occurring when you can’t move around as much as normal.
Observations will be done of your blood pressure, pulse, respirations and you will have your consciousness level and pain assessed. Once you are stable you will move back to a ward to recover before going home.
Recovery can sometimes take longer if there have been complications as a result of the operation or afterwards. There is a very small risk of complications that may lead to a second operation.
You may benefit from some input from the therapy team before going home and rarely some people need inpatient rehabilitation. Your surgeon is likely to let you home once you are up and about, stable and pain is well controlled.
There is a small risk that the area of brain near to the aneurysm will be affected afterwards. This may be short term because of swelling or bruising but in rare cases can have a long-term effect. The area of brain affected would be specific to each aneurysm.
Bruising around the face and swelling to the eyes is common. This settles in several days but can be uncomfortable and painful. Regular pain relief can be given to help these symptoms. The affected eye should be kept clean to prevent infection.
Pain/headache following this operation is expected. The pain is due to the surgery. This is normal and usually eases with time. You will be prescribed regular pain killers.
As the wound heals the stitches can feel tight; this settles after the stitches are removed. The pain from the operation may persist for a few weeks to months, although will be less severe and the frequency of headaches should reduce with time.
In the early stages, the area around the wound feels numb. This is because the nerves have been cut. As the nerves grow back there is abnormal sensation such as pins and needles which settles over several months. The wound may itch as it heals. Please do not scratch it as you will risk infecting it. There is a very small risk the wound site may become infected. Infection is rare because you will have cleaned your hair/head as advised prior to your operation. Infection can happens later, sometimes after you have gone home. If the wound becomes, sore, inflamed, red, oozes or you get a temperature then you should get in touch with your neurovascular nurse, G.P., consultant or ward for a wound check and assessment urgently.Some infections require a second hospital stay if the antibiotics need to be given through a vein.
The muscle that is used for chewing food can be affected as this is cut as part of the craniotomy. As it heals it shrinks causing difficultly in opening the mouth or chewing. These symptoms usually settle within six months. Chewing gum may help.
The bone flap (the piece of bone cut out during the operation) might feel like it moves. Because the pressure in your head can vary, the flap of bone might feel like it moves in and out but it is secure. You might experience a “clicking” sensation. Although this feels strange, it is not dangerous. The bone flap is not loose: it is secured with plates when it is replaced and will heal
On very rare occasions, the bone flap can slip slightly- if you feel this has happened to you please let your doctor or specialist nurse know.
You will benefit from pacing activities for the first few weeks following going home. This includes keeping a routine such as going to bed and getting up at the same time each day; keeping hydrated, a good diet and not missing meals. This will help so you don’t get over tired which may slow your recovery. Enlist the help and support of your family and friends to help with household chores if you can. Take some gentle exercise to help build up your stamina each day, for example a short walk building up as you get stronger. You will benefit from an afternoon rest for the first couple of weeks after going home.
Full recovery can take a few months which means you may have to allocate some time off work. The time off work depends on the type of job you do and level of responsibility or whether it is a very physical role. Most people need about 2-3 months. If you have to go back sooner for financial or other reasons, this won’t do you any harm. In this case, it will simply take you a bit longer to recover as you may feel more tired.
Currently, the DVLA states you can drive a car on clinical recovery (about six weeks). This information can change and so up to date advice will be given to you whilst you are an inpatient. Your doctor is the person who assesses your recovery and ability to drive. This is because driving involves many different cognitive, physical and visual skills as well as multi-tasking, decision making and problem solving. Driving laws change all the time so please check with your doctor or nurse before going home from hospital. Driving restrictions are reviewed after one year for a group 2 licence (e.g. public service vehicle/ lorry). You have to inform the DVLA if you have had surgery for an aneurysm
You can wash your hair using a mild shampoo after 72 hours. You can dye your hair once the wounds have completely healed which usually takes a couple of months.
You can have sex as soon as you feel able.
There is a small risk of seizures after any type of brain surgery. The position of certain aneurysms carries a bigger risk of seizure. A single seizure provoked by the operation does not mean you have epilepsy. If you do have seizures you will be given information on safety for your protection. Alternatively, you can log on to epilepsyaction.org
It is advisable not to fly for six weeks after your operation. If you live in the Isle of Man and have flown for your treatment, you will have to take the boat or Sea cat’ home.
You can build up your exercise regime gradually as you feel able once you have recovered from the operation. Do not do any extreme exercise or contact sport for the first six months in order to allow the bone and wounds to heal. If you want to become involved in extreme or contact sport you should speak to your neurosurgeon or neurovascular nurse for further advice as you would need to have each type assessed individually and understand the risks. Safety helmets should also be worn as with any bone that has been opened or broken it will never be a strong as before.
Modern aneurysm clips are often compatible with most MR scans. You will need documentation of the type of aneurysm clip used to confirm it is safe for you to have an MR scan. The person requesting the scan can discuss this with your neurosurgeon or neurovascular nurse.
It is advisable not to drink alcohol until you feel recovered as you will be more susceptible to the effects. You are at a small risk of a seizure the first year after brain surgery and alcohol is known to lower seizure threshold making you more vulnerable to a seizure.
Smoking is the biggest risk factor in aneurysm formation and rupture so is not advised. Smoking cessation clinics are linked to every GP practice or you can ask for help during your stay in hospital. An advice number is printed at the end of this leaflet.
Illicit drugs such as cocaine and amphetamines can increase your risk of aneurysm formation and rupture and so you should not take them
You will be reviewed after two months to check on your recovery. You will usually have one formal angiogram to check on occlusion of the aneurysm and one last visit with your consultant after that. You will not normally need any further follow up unless there have specific problems or there are other aneurysms.
The brain haemorrhage support group offer practical advice and support for people who have had brain haemorrhage but will also support those who have aneurysms and feel they will benefit from their support.
Walton Centre contact details
- For any emergency see your G.P or your go to your local Accident and Emergency Department
- For information regarding appointments or DVLA contact your consultant’s secretary
- Patient Experience Team provides a PALS service: 0151 556 3090
- Neurovascular Nurse Specialists (practical advice; answerphone): 0151 556 3325
- Walton Centre switchboard - 0151 525 3611
- Dott Ward - 0151 529 5633 / 5634
- Cairns Ward - 0151 529 5637 / 5638
- Caton Ward - 0151 529 5628 / 5629
- Chavasse Ward - 0151 529 5079
- Sherrington Ward - 0151 529 5641 / 5642
- Lipton Ward - 0151 529 8884 / 8738
- High dependency - 0151 529 5489
- Intensive Care - 0151 529 5772/ 5773
Useful contact details
- NHS 111: 111 - Telephone advice if you need urgent medical help fast but it is not a 999 emergency (or you do not have a GP)
- Website: http://www.nhs.uk and search ‘emergency and urgent care’
- D.V.L.A. Driver Vehicle Licensing Authority - Drivers Medical Group, DVLA, Swansea, SA99 1DL / Medical enquiries: 0300 790 6806 / Email via www.dvla.gov.uk
- The Brain Charity: 0151 298 2999 / www.thebraincharity.org.uk - Offers practical help, emotional support and social activities for people with neurological injury and their families/carers
- Stroke association: 0303 3033 100 www.stroke.org.uk - Offers practical help, advise and local support groups
- Headway: 0808 800 2244 www.headway.org.uk - Offers support to improve life following brain injury
- Epilepsy Action: 0808 800 5050 www.epilepsyaction.org.uk - Offers practical help for people who have seizures
- Access to work: https://www.gov.uk/access-to-work - For practical advice on returning to work
- NHS Free smoking helpline: 0800 0224 332 / www.nhs.uk/smokefree / England: 0300 123 1044 Wales: 0800 085 2219
- Advice on Alcohol: www.drinkaware.co.uk / www.drinkingandyou.com
- Last Updated:01 May 2021
- Review Date:01 May 2023
- Author:C Stoneley
Treatment for a cerebral aneurysm