Brain Aneurysm Resource Center

To treat or not to treat

By:  Michael Chen, MD

The most common consultation I see in the office is for a patient with an unruptured brain aneurysm discovered by accident.  More and more scans of the brain are being ordered these days in emergency rooms after accidents, for the evaluation of progressing headaches or other neurologic symptoms.  It is obviously an anxiety provoking situation to be in.  Your consultation should be informative and by coming up with a reasonable, logical management plan, hopefully somewhat reassuring as well.  Here are some essential topics that should be covered during your office visit with a brain aneurysm expert.  

1.  You should have the problem explained to you.  Your physician should take the time to explain what aneurysms are, what normal anatomy should be like, why one should be concerned about brain aneurysms and what the potential ramifications are.  Analogies are useful to understand important concepts such as the Law of Laplace.  Having a clear understanding of what aneurysms are, the prevalence and incidence will actually go a long way in providing a degree of reassurance of what to expect in the future.

2. A thorough list of options.  Your physician should review all of your options, not just jump to the option they recommend.  One of the options should be a conservative one, but the risks and benefits of this option need to be made clear as well.   Conservative options often include surveillance imaging, and a general outline should be provided as well in terms of what types of pictures, how often, any risks associated with radiation, etc.  Of the invasive treatment options to be reviewed, different approaches should be discussed.  Even within the minimally invasive endovascular approaches, different devices are available now each with their own advantages and disadvantages.  The ability of the physician to review all of these options reflects on the breadth of their understanding.

3.  Several determinants should be used to make the final decision.  Aneurysm diameter is well-known to be correlated with risk of rupture.  Several other factors should also be considered before jumping to a conclusion regarding the specific treatment option.  A lot of times I consider whether there is a family history of a ruptured brain aneurysm, is there also carotid artery narrowing, is there an associated arteriovenous malformation, does the patient have connective tissue disease or polycystic kidney disease, etc.  Other anatomic details also matter that only result from studying the pictures closely and include the shape of the aneurysm, the configuration of the neighboring blood vessels, the brain that segment of artery supplies, etc.  There are many more.  You just want to get a sense that the physician rendering an opinion on your care has taken due diligence in evaluating all the pertinent details of your case. 

4.  Get a sense of how much experience and knowledge your physician has.  The most effective physicians who take care of patients with brain aneurysms likely spend some of their time doing research and exploring how to improve current treatment strategies.  Those physicians not involved with research will likely see their approaches and strategies become obsolete in a short time.  Look up online if they have any publications on brain aneurysms.  Are they involved with designing new devices or exploring new treatments?  You should actually get a good sense of how much they know about brain aneurysms by just engaging them in a conversation about the disease.  The most invested physicians have so much to say, it might be hard to get them to stop talking!

5.  How do they deal with complications?  Ask the physician about risks associated with the procedure.  Anyone who has taken care of many patients, particularly more complex and complicated cases knows that despite much experience, preparation, concentration and deliberation, complications unfortunately, still occasionally occur.  The question is if your physician acknowledges this and is prepared, or if he or she tries to pretend complications don’t happen.  Experienced physicians know how to handle the occasional complication and minimize the amount of damage that can occur.  They are honest and transparent with expectations, and do give you a reasonable appraisal of whether the procedure they are proposing is a low, medium or high risk procedure. 

6.  Is your doctor taking his time, being deliberate, careful and honest?  Pay attention to how your physician talks with you, carries himself in the office, examines you and explains things to you.  A lot of these professional habits in the office with patients may translate to how they go about performing a procedure or surgery.  Do they appear unorganized?  Do they appear prepared?  Do they rush through things?  Do they take their time and think about things?  Do they seem like they take the time to do things carefully?  Trust your instinct.  There are so many different doctors from so many backgrounds with such a wide variety of skill sets that it is worth your while to be picky.  If you have certain gut reactions, do not be afraid to travel a bit to perhaps a bigger city where you have other physicians to choose from and hopefully you will find someone who will earn your trust.