By: Atul Behll (From SPS Hospital in Ludhiana, India
Mildly Edited By: Jonathan Noble
Headaches are a very common problem and people usually don’t take it seriously. For example, a 60 year old female had a severe headache around midnight. She complained about it to her husband and he gave her some painkillers. She slept after that but did not wake up in the morning. She was then brought to our hospital and was found to be hemorrhaging due to a rupture of brain aneurysm.
A few years back the only treatment available for brain aneurysm was surgery but endovascular coiling has now revolutionised its treatment.
But what is a brain aneurysm?
A brain aneurysm, also referred to as a cerebral aneurysm, is a weak bulging spot on the wall of a brain artery. Over time, the artery wall becomes gradually thinner from the dilation and this may cause the aneurysm to rupture and allow blood to escape into the space around the brain.
What is the problem associated with brain aneurysm?
There is a brain aneurysm rupturing every 18 minutes. Ruptured brain aneurysms are fatal in about 40% of cases. Of those who survive, about 66% suffer some permanent neurological deficit. Approximately 15% of patients with aneurysmal subarachnoid hemorrhage (SAH) die before reaching the hospital.
What are the risk factors for aneurysm?
People who smoke, people who have high blood pressure are at higher risk than general population. Apart from this, female sex, drug abuse, and infections also increase the risk of having an aneurysm.
What are the symptoms associated with brain aneurysm?
Unfortunately, most aneurysms are detected when they rupture. An unruptured brain aneurysm usually produces no symptoms, particularly if it’s small. However, a large unruptured aneurysm may press on brain tissues and nerves, possibly causing pain above and behind an eye, a dilated pupil or a drooping eyelid.
In few patients there may be warning headaches (sentinel headaches) before the actual rupture of the aneurysm. A sentinel headache is due to the leakage of blood from the aneurysm. This produces a very sudden and very severe headache. If recognised, this could lead to diagnosis of the aneurysm prior to rupture. This is why a sudden, severe headache should be taken seriously and never be ignored.
A ruptured aneurysm present with a sudden, extremely severe headache that the patient describes as the “worst headache of their life,” particularly along with vomiting, stiff neck, sensitivity to light, seizure, unconsciousness etc. is possible
Can the aneurysm be detected before it ruptures?
Individuals at high risk of harboring a brain aneurysm can be identified easily with non-invasive imaging tests such as MR angiography or CT angiography. In Western countries persons who are at high risk of having an aneurysm are regularly screened and thus aneurysms are detected before they rupture.
What are the treatment options available for cerebral aneurysms?
A few years back the only treatment available for brain aneurysms was surgical. It involved opening the skull and stopping the blood flow into the aneurysm by closing communication to the artery with a clip.
During the last twenty years, however, endovascular treatment of brain aneurysms with tiny platinum coils has revolutionized treatment of both ruptured aneurysms and intact aneurysms.
What is meant by the term endovascular?
Endovascular is combination of two words: “Endo,” meaning inside and “vascular,” meaning blood vessel. Endovascular procedure is a minimally invasive procedure in which a catheter or a miniature instrument is inserted through the skin into a blood vessel for the treatment of vascular disease.
For treating aneurysm a plastic catheter is inserted into the femoral artery in the leg and is navigated through the vasculature to the site of brain aneurysm. Coils are then packed into the aneurysm up to the point where it arises from the blood vessel. A clot forms around the coils, stopping the flow of blood into the aneurysm, thus preventing rupture.
What are the advantages of endovascular coiling over surgery?
Since it is a minimally invasive procedure, there is no incision given thus avoiding scarring, there is less blood loss, less risk of infection etc. Most elective patients will go home the next day after coiling and are back to normal activities the following day.
According to a recent international study comparing the safety and efficacy of endovascular coil treatment versus surgical clipping for treatment of ruptured brain aneurysms, patients with a ruptured aneurysm tend to do better in the long term after a coiling procedure.
What are the other disorder/diseases in which endovascular therapy is useful?
Endovascular neurosurgery is also used in treatment of patients who have had strokes. Stroke is the third-leading cause of death behind heart disease and cancer.
Patients who suffer an ischemic stroke have blood vessels that become obstructed by a clot preventing normal blood flow to the brain. As a stroke could cause permanent brain damage and even death, it is classified as a medical emergency. During the first three hours after onset, a clot-busting drug called TPA can be administered intravenously with good success. After the three-hour window, endovascular removal of the clot is recommended.
Clot removal through endovascular route has become the treatment of choice for stroke. Clot removal using mechanical thrombolytic devices make it a matter of minutes, whereas pharmaceutical thrombolytic may take as long as two hours for dissolution of the clot. Thus mechanical thrombectomy establishes the blood flow early and this provides superior results. Other diseases like brain and spine AVM can also be treated endovascularly.
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