Wait and Watch
By the early 1990s, a general consensus had been achieved regarding best practice for unruptured aneurysms – that is, these lesions were felt to be quite dangerous and should be repaired by surgical means in most patients. Since that time, two events have challenged this treatment paradigm. First, the International Study for Unruptured Intracranial Aneurysms (ISUIA) suggested that the hemorrhage risk for unruptured aneurysms (particularly those < 7 mm in size) was less than previously reported. Second, the development and widespread application of endovascular therapy led to a marked increase in its use for the treatment of unruptured aneurysms. Because randomized controlled trials comparing surgery vs. endovascular therapy for unruptured aneurysms have not been completed to date, decisions regarding choice of treatment (surgery vs. endovascular therapy) remains at the discretion of the treating physician and the patient, and are based on a thorough evaluation of multiple factors that might affect hemorrhage and procedural risk, including aneurysm characteristics (e.g. aneurysm size, location, and neck width), patient factors (e.g. patient age and medical condition), and issues of local surgical and endovascular expertise.
Conservative management is also a reasonable option for some aneurysm patients – especially those that are elderly or medically infirm and those who harbor small aneurysms (especially those < 7 mm in size). If conservative management is pursued, the following is generally recommended: 1) stop or avoid smoking; 2) keep blood pressure under excellent control; and 3) avoid heavy alcohol intake. Each of these maneuvers likely reduces the risk of aneurysm progression or rupture. Also, many practitioners recommend repeat brain imaging via CT angiography (CTA), MR angiography (MRA), or catheter angiography in conservatively managed patients. If aneurysm progression is noted on repeat imaging, re-consideration of aneurysm treatment typically ensues.