Brain Aneurysms: The Silent Threat

by Dr. Vipul Gupta A brain aneurysm, also called a cerebral or intracranial aneurysm, is a weakened area in the wall of a blo od vessel in the brain that develops into a bulge or balloon like sac. Many aneurysms remain unruptured and may never cause symptoms, but rupture can result in bleeding around the brain, known as subarachnoid haemorrhage, which is a medical emergency.

September is observed as Aneurysm Awareness Month, providing an important opportunity to understand a condition that can remain silent for years but may become life-threatening if it ruptures. A 30-year-old woman from Uttar Pradesh, who had been leading a healthy life, developed sudden right-sided weakness, severe headache and vomiting.

She initially sought treatment at a local hospital, where a brain MRI revealed a massive, densely enhancing lesion suspected to be a swollen blood vessel. Subsequent CT Angiography and MR Angiography confirmed the presence of an exceptionally large brain aneurysm measuring approximately 4 × 5 cm, one of the largest reported sizes.

The aneurysm had completely involved the Posterior Cerebral Artery, making conventional repair extremely complex and carrying significant risk to the brain. The patient was referred for specialised neurointerventional treatment to Dr Vipul Gupta. Detailed evaluation using high-resolution Digital Subtraction Angiography (DSA), 3D Angiography and Angio-CT was performed to assess the aneurysm and the affected blood vessel.

As the entire artery was involved, the medical team opted for a minimally invasive strategy aimed at safely managing the aneurysm while preserving adequate blood supply to the brain through alternative vascular pathways. Using two microcatheters simultaneously, the doctors carefully closed the smallest and safest segment of the affected blood vessel.

This resulted in redirection of blood flow through alternative routes, allowing the patient to remain clinically stable while minimising the risk of neurological complications. Following the procedure, she was closely monitored, including management of intracranial pressure. She received medications, steroids and blood thinners as part of her post-procedure care.

Her clinical condition continued to improve, and she remained stable during recovery. The case highlights the complexity of treating giant brain aneurysms and the role of advanced minimally invasive neurointerventional techniques in managing such high-risk vascular conditions. One of the most concerning aspects of a brain aneurysm is that it may remain completely asymptomatic until it becomes large or ruptures.

However, some larger aneurysms can exert pressure on surrounding nerves or brain structures, causing symptoms such as pain around or behind the eye, visual disturbances, double vision, a drooping eyelid, or changes in pupil size. A sudden, extremely severe headache, often described as the “worst headache of life”, particularly when accompanied by nausea, vomiting, neck stiffness, sensitivity to light, confusion, seizures or loss of consciousness, should never be ignored.

Such symptoms can indicate aneurysmal rupture and require immediate emergency evaluation. Certain individuals are more susceptible to developing an aneurysm or experiencing its rupture. Important risk factors include uncontrolled high blood pressure, smoking, increasing age and a family history of brain aneurysms.

Some inherited conditions, including polycystic kidney disease and certain connective-tissue disorders, are also associated with increased risk. Women, particularly in older age groups, may have a higher risk of aneurysmal subarachnoid haemorrhage. Family history deserves particular attention, especially when more than one close relative has been affected.

Advances in neuroimaging and neurointervention have significantly expanded treatment options. The decision to monitor or treat an aneurysm depends on several factors, including its size, location, shape, growth pattern, relationship with surrounding blood vessels, patient’s age and overall health, and estimated risk of rupture.

Not every unruptured aneurysm requires immediate intervention, making individualised assessment essential. Endovascular coiling: A minimally invasive technique in which a catheter is guided through the blood vessels, usually from the wrist or groin, into the blood vessels of the brain.

Tiny detachable platinum coils are then placed inside the aneurysm to promote clot formation and prevent blood from flowing into it. Unlike open surgical procedures, coiling does not require opening the skull and can provide a minimally invasive treatment option for appropriately selected patients.

Stent-assisted coiling: This technique is particularly useful for aneurysms with a wide neck or challenging anatomy. A small stent is placed across the opening of the aneurysm to provide support and help keep the coils securely within the aneurysm while maintaining normal blood flow through the parent artery.

This approach has expanded the range of aneurysms that can be treated using endovascular techniques. Intrasaccular Devices – These are mesh-like, wire-based devices available in oval or cup-shaped designs. They are placed directly within the aneurysm to block blood flow into the sac, promoting rapid closure and allowing the procedure to be completed in a relatively short time.

Flow-diverter stents: These specialised, densely woven stents are increasingly used for selected large, wide-necked or complex aneurysms. The device is placed within the parent artery across the aneurysm opening. Rather than directly filling the aneurysm, it redirects blood flow away from the aneurysm, encouraging gradual clot formation and allowing the vessel wall to heal and remodel over time.

Modern aneurysm care therefore increasingly relies on a combination of high-resolution imaging, advanced endovascular devices and multidisciplinary decision-making. Early identification can provide an opportunity to assess an aneurysm before rupture and, where treatment is indicated, select the safest and most appropriate strategy.

Awareness, however, remains the first line of protection. Controlling blood pressure, avoiding smoking, maintaining a healthy lifestyle and discussing appropriate screening with a physician when there is a significant family history can help address modifiable risks. Most importantly, a sudden, severe and unusual headache—especially when accompanied by neurological symptoms—should be treated as an emergency rather than dismissed as a routine headache.

In brain aneurysm, recognising the warning signs and reaching a specialised centre without delay can make a critical difference. Author is Director, Neurointerventional Surgery, Sir H.N Reliance Foundation Hospital, Mumbai