What if you had some reason for needing a brain scan? Maybe you got shook up in a car accident or maybe you have ringing and pressure in one of your ears that affects your hearing. So you get the scan, and the doctor comes back with good and bad news…

It turns out that you don’t have a brain injury or an acoustic neuroma (a tumor in the ear that affects hearing) or whatever you had the brain scan for, but you do have an unruptured intracranial aneurysm (UIA)—a bulging blood vessel smack in the middle of your brain! An estimated 6 million people in the United States have a UIA, and one of those UIAs bursts every 18 minutes. If you have a UIA and it bursts, causing a hemorrhagic stroke, there’s a 40% chance you won’t survive more than 30 days. So surgery to remove it before it bursts sounds pretty attractive.

But, surprisingly, the doctor says it’s relatively small and so you should you leave the aneurysm alone and take a watch-and-wait approach. What do you do?

A second opinion certainly might be in order, but, frankly, when small UIAs (one-quarter inch or smaller) are found on brain scans, docs usually leave them alone, believing that their risk of bursting is small. In fact, the unruptured aneurysm lodged in your brain might not ever burst—but not necessarily because of its size. A Finnish study found that certain telltale characteristics determine whether or not a UIA should be removed. And this is a key point that American doctors have not been in the know about. For them, size is what matters most, even though small aneurysms have been known to burst, too.

TOP REASON TO HAVE THAT UIA REMOVED

So which people with UIAs are really most at risk for a hemorrhagic stroke? Being a cigarette smoker topped the list in the Finnish study. Compared with ex-smokers and nonsmokers, smokers had three times the risk. Since most of us don’t know if we are walking around with UIAs, the findings of this study make smoking even more of a game of Russian roulette. If warnings about lung cancer, heart disease and premature aging aren’t incentive enough to quit, the risk of brain damage or death from hemorrhagic stroke should be.

It also turns out that women, smokers or not, are more vulnerable than men when it comes to a bursting UIA. And age at diagnosis is also a big factor—men and women who were younger than 50 when the UIA was diagnosed were more than three times as likely to suffer a hemorrhagic stroke as people who were older than 50. If nothing else, these findings are clear—if you are a smoker or younger than 50 and told you have a UIA, you ought to have it removed no matter what the size, according to the researchers. If you are a nonsmoker and older than 40, especially if you are a man, you probably can safely take that watch-and-wait approach, they said.

GETTING RID OF UIAs

Microsurgical clipping and endovascular coiling are two common ways that UIA are surgically taken care of. In microsurgical clipping, a hole is drilled through the skull to get to the aneurysm. Then a small metal clip is permanently placed at the base of the aneurysm to stop blood flow into it. Endovascular coiling, on the other hand, doesn’t involve open brain surgery. Instead, a microcatheter is snaked through an artery in the groin to the site of the aneurysm in the brain. An x-ray technology called fluoroscopy is used to guide the microcatheter into place and make it release one or more tiny platinum coils attached to it into the aneurysm. The coils cause the blood in the aneurysm to clot, cutting off blood flow into the bulge.

The most serious complication of these procedures is rupture of the aneurysm. Luckily, incidence is not that common, occurring 2% to 3% of the time. And, naturally, recovery for microvascular clipping is longer than it is for endovascular coiling because microvascular clipping involves open brain surgery.

After clipping, most patients spend a night in the intensive care unit and then a few days in a private hospital room. Although patients will be able to be up and about after they leave the hospital, they do have to take it easy for the next four to six weeks to fully recover.

After endovascular coiling, patients also spend a night in the intensive care unit but get to go home the next day. Within a few days, they are fully back to all of their normal activities. One drawback to endovascular coiling, though, is that the UIA can come back. So patients having this procedure are required to visit their doctors for imaging tests on occasion to make sure all is well.

In any case, no matter what your health status, sex or age, there’s no guarantee that a brain aneurysm won’t burst, and it’s ultimately up to you to decide whether to have surgery. So I want you to understand just how the Finnish researchers came to their conclusions. They examined 118 people given a diagnosis of UIA before 1979 and followed them until they had hemorrhagic strokes or died of old age or other causes. The Finns were in a unique position to study what happens to people when UIAs, large or small, are just left alone. Up until 1979, instead of removing at least large UIAs, Finnish doctors just left them alone.

Their study found that women, especially women who smoke and have large UIAs (more than one-quarter of an inch in size) are most at risk for a hemorrhagic stroke. In fact, the risk of hemorrhagic stroke in women with large UIAs was 73%. If the woman also smoked, her risk increased to 100%. Meanwhile, men who smoked and had an aneurysm of this size had half the risk of their female counterparts…50%. Risk was virtually nil for men who didn’t smoke regardless of the size of their aneurysms…and nonsmoking women had a 31% risk.

Why women are more at risk than men wasn’t covered in the study, and it didn’t compare risk between current and former smokers to gauge risk of hemorrhage in the latter. Still, it makes an exceptionally strong case for kicking the habit whether or not you definitely know that you have a UIA—especially if you’re a woman—doesn’t it?

Importantly for those people who learn that they have a UIA, this information can help them and their doctors make crucial decisions about whether to go through a risky procedure to remove it. If you do not have any of the risky characteristics, your safest option may be to do nothing at all—be sure to have a thorough discussion about this with your doctor.