A ruptured cerebral aneurysm

An aneurysm is a bulge in the wall of an artery or vein due to its thinning and loss of elasticity. In most cases, this pathology is congenital. Most often, an aneurysm is diagnosed in the vessels of the brain, which makes the disease potentially dangerous. The dilated part of the vessel cannot function on par with the intact one, so a ruptured cerebral aneurysm is a fairly common situation. The most unpleasant thing is that the patient may not even suspect his diagnosis due to the lack of specific symptoms, so the risk of a fatal outcome due to delay is extremely high.

Epidemiology

We found out that both the formation of an aneurysm and its rupture are the result of high blood pressure. This means that the risk group includes patients with hypertension and drinkers. According to statistics, the probability of an aneurysm formation and rupture is higher in people with bad habits: smokers and drug addicts, especially those who are hooked on cocaine.

A ruptured cerebral aneurysm is an age-related pathology. It is not detected in childhood due to the fact that arterial hypertension in children is a rare phenomenon. And cholesterol on the walls of blood vessels, making them less elastic, settles only over time. A child may have a predisposition, but the protrusion itself is very likely to appear much later, when he grows up and accumulates diseases.

The tendency for cerebral aneurysms to form and rupture is somewhat higher in women. And the disease is most often diagnosed between the ages of 30 and 60, although there are exceptions.

It must be said that many people live with an aneurysm for many years and die of old age. But at the same time, they are constantly at risk. Arterial rupture at the site of the protrusion occurs only in 0.01% of cases of the disease. And the cause is a jump in pressure. The sad fact is that in 70% of cases, the rupture leads to the death of the patient.

Causes of a ruptured cerebral aneurysm.

To understand what causes could lead to a ruptured cerebral aneurysm, it is necessary to study the pathogenesis of the disease itself, which can begin before the baby is born or become the cause of injuries and diseases. The cause of inadequate functioning of blood vessels is most often metabolic and genetic disorders, which lead to deviations in the formation of the vascular wall.

For "congenital" aneurysms, which can make themselves known already in adulthood, the absence of a typical three-layer structure is characteristic. Its wall is represented only by connective tissue. The absence of a muscular and elastic layer makes it less resistant to various types of loads. This is the reason for the formation of a cerebral aneurysm. The wall of the blood vessel cannot withstand the pressure of the blood and bends at the weakest point (most often in those places where the vessels bend, bifurcate, or large branches depart from them). [ 1 ]

An aneurysm can be detected in connective tissue dysfunction syndromes, hereditary collagen production disorder. Congenital pathologies are typically combined with other intrauterine pathologies (PBP, renal artery hypoplasia, heart defects, etc.).

Less often, blood vessels change their properties under the influence of external (trauma, gunshot wounds to the head, radiation, infectious brain damage) or internal (vascular atherosclerosis, protein dystrophy of arterial walls, tumor formation) causes. [ 2 ]

An aneurysm is formed either as a result of the incorrect formation of the vessel walls or as a result of human activity. But in both cases, there is a violation of the functionality of the vascular membrane, as a result of which it is not able to withstand the constant or periodic impact of blood. We are talking about blood pressure on a weakened vessel.

We have considered the risk factors that may or may not lead to the formation of an intracranial aneurysm. It all depends on whether a person has pathologies or certain situations in life that affect blood pressure. [ 3 ] And a ruptured cerebral aneurysm is mainly the result of increased blood pressure. The thinned, stretched wall of the vessel, most often consisting of inelastic connective tissue, simply cannot withstand the pressure of the blood. [ 4 ]

Symptoms of a ruptured cerebral aneurysm.

We have already said that a cerebral aneurysm can exist in a latent state for a long time. In some cases, patients do not notice any suspicious symptoms at all, feeling completely healthy. Others may complain of pain in the forehead and eye sockets, slight dizziness, especially with a sharp change in position. Everything depends on the localization, type of aneurysm (number of chambers), its size.

Large multi-chamber aneurysms are more susceptible to rupture. And the symptoms that appear in this case (clinical picture) are directly dependent on the localization of the protrusion and the form of hemorrhage, i.e., which area of the brain the blood enters.

The result of a ruptured cerebral aneurysm is intracerebral, intraventricular or subarachnoid bleeding. In the first case, the mortality rate is 40%. But most often, blood gets into the space between the cranial bone and the brain (subarachnoid space). This type of bleeding is considered the most severe, since it can cause both the death of the patient (with a high degree of probability) and severe complications associated with impaired blood circulation in the brain.

In 75% of cases, the clinical picture of a ruptured brain aneurysm resembles the symptoms of non-traumatic subarachnoid hemorrhage. The first signs of such bleeding are:

• sudden, severe, bursting pain in the head in the form of a jolt.
• nausea and vomiting,
• increased body temperature (hyperthermia),
• photophobia,
• dilated pupils,
• impaired sensitivity of part of the face or limbs,
• increased sensitivity to noise,
• a stunned state of consciousness (from moderate stupor to atonic coma), which can have varying duration.

Many patients become restless and fidgety, talk a lot and fuss. They have weakness of the occipital muscles, Kernig's sign (bending of the legs at the knee and hip joints when pressing on the pubis), which indicates irritation of the meninges during bleeding, and some other manifestations characteristic of meningitis.

The clinical picture of a ruptured cerebral aneurysm may differ depending on the location of the pathological protrusion:

• on the carotid artery: pain is localized in the forehead and eye sockets, visual disturbances, paresis of the oculomotor nerve, impaired sensitivity in the eye area and upper jaw are possible;
• not of the anterior cerebral artery: mood swings, psychotic disorders, deterioration of memory and mental abilities in general, possible paresis of the limbs, development of diabetes insipidus, disturbances of water-salt metabolism affecting the work of the heart;
• on the middle cerebral artery: development of motor or sensory aphasia (depending on the hemisphere of the brain, a person either understands speech but cannot express himself, or vice versa), convulsions, visual impairment, often paresis of the hands;
• on the main artery: paresis of the oculomotor nerve, visual impairment, up to and including loss of the ability to see with healthy eyes (cortical blindness), possible paresis of the arms and legs, in severe cases respiratory failure, depressed consciousness, coma;
• on the vertebral artery: disruption of the innervation of the speech apparatus (dysarthria), as a result of which speech becomes unclear, hoarseness, decreased sensitivity of various types, in severe cases symptoms similar to an aneurysm on the basilar artery.

In a quarter of cases of cerebral aneurysm rupture, doctors diagnose an atypical course of the disease, the symptoms of which resemble other pathologies: hypertensive crisis, migraine, psychotic disorders, inflammation of the brain (meningitis). It also happens that doctors make a preliminary diagnosis of acute food poisoning or radiculitis. All this leads to the fact that patients do not receive timely urgent help while additional examinations and differential diagnostics are carried out. [ 5 ]

Complications and consequences

The fact that a person can live a happy life for many years without knowing about the disease does not mean that it is harmless. A cerebral aneurysm itself (and there may be several of them) may not remind of itself. But with a strong nervous shock, high physical exertion and in other situations, a sharp jump in pressure is possible, the walls of the blood vessel in the pathologically changed area may not withstand, and then the blood spills out of the artery (less often the vein).

Depending on the type of aneurysm (million, ordinary, large or giant), bleeding may be minor or quite severe. It is clear that if the protrusion is up to 3 mm in size, then a small hemorrhage can be expected when it ruptures. With normal blood clotting, bleeding will be short-lived and its consequences less severe.

In the case of a giant aneurysm (2.5 cm or more), the bleeding will be more severe and the prognosis less favorable. And the removal of such a neoplasm is associated with great difficulties and a certain risk. [ 6 ]

The size and strength of the bleeding largely determine the severity (on the H-H scale) of the patient's condition, which is determined by different factors at different periods of the rupture of the cerebral aneurysm. In the first 3 days (the acute period), the decisive role is played by: the massiveness of the hemorrhage, the presence of an intracerebral hematoma, and whether there was a breakthrough of blood into the ventricular system of the brain. In the following days, everything depended on whether there was a vascular spasm and how severe it was.

A ruptured cerebral aneurysm is the most dangerous consequence of this disease, especially in the case of subarachnoid and intraventricular hemorrhage, which threaten disability or death of the patient. Any ruptured vessel is a hemorrhage into the brain to one degree or another, and this is fraught with the development of a hemorrhagic stroke (acute cerebrovascular accident), CNS disorders, and death. But subarachnoid hemorrhage due to an aneurysm rupture is considered the most common and severe complication with a high percentage of mortality and disability. [ 7 ]

And even if everything goes well the first time, you need to understand that where it is thin, there it breaks. There is always a high risk of a repeated rupture of the aneurysm, so treatment is primarily aimed at preventing such a complication. And it is worth starting it at any time after the first bleeding (considering the fact that patients often do not immediately consult a doctor, not understanding what happened), but the sooner the better.

With subarachnoid hemorrhage, there is a high risk of developing hydrocephalus (dropsy or cerebral edema). Disruption of hemodynamics leads to the fact that cerebrospinal fluid accumulates in the ventricles of the brain, they expand and begin to press on the brain matter.

One of the most dangerous complications is considered to be vasospasm, which usually manifests itself starting from the 3rd day for 2 weeks. As a result of a sharp narrowing of the brain vessels, blood circulation and blood supply to individual areas of the brain are disrupted. Hypoxia leads to a violation of intellectual abilities, and in severe situations it causes damage to brain tissue, the death of its cells. Even if a person survives, there is a high risk of disability. [ 8 ]

Diagnostics of a ruptured cerebral aneurysm.

The difficulties in diagnosing a ruptured cerebral aneurysm are related, firstly, to the localization of the neoplasm under the cranium, which cannot be seen visually, and secondly, to the absence of early symptoms of the disease in most cases. Patients come to the doctor with complaints of a burning pain in the head or signs of acute stomach upset, but only a small part of them are diagnosed with aneurysm. Others are unaware of their problem, as is the doctor at the first appointment.

That is why it is very important to describe all the symptoms that have appeared and the moments that preceded them. Symptoms may differ depending on the location and strength of the hemorrhage, but this is still a real chance to clarify the diagnosis and begin a more complete examination and treatment sooner.

The doctor, for his part, studies the patient's medical record, listens to complaints, and orders a neurological examination of the patient. In such a situation, tests are carried out only in connection with the need for surgical treatment. And to identify the pathological process, instrumental diagnostics are used.

The most popular and effective methods of instrumental diagnostics include:

• Lumbar puncture. This method allows for a high degree of accuracy in diagnosing hemorrhage into the subarachnoid space, but it is not used for hematomas and extensive ischemia. The latter are detected by echoencephaloscopy or CT, which are performed before the puncture.
• CT of the brain. The most common diagnostic method, the most informative in the first day of the acute period. It allows you to determine the fact of hemorrhage, its strength, localization and prevalence, the presence of a hematoma, hemorrhage in the ventricular system and even the true cause of the rupture. CT also allows you to assess the consequences of an aneurysm rupture.
• MRI of the brain. Provides maximum information in the subacute and chronic periods. Has a high probability of detecting cerebral ischemia, helps to determine its nature.
• Cerebral angiography. It is considered the "gold standard" for diagnosing aneurysm rupture. It allows detecting both aneurysm and vasospasm. However, doctors often limit themselves to MRI, as a fairly informative method that does not require additional examinations. In addition, if there are contraindications to angiography, MRI is the most successful alternative.
• EEG. An encephalogram reveals disturbances in the electrical activity of the brain and helps to determine the possibility and timing of surgery, and to make prognoses for surgical intervention. It makes it possible to identify the source of hemorrhage in multiple aneurysms.
• Dopplerography helps to expand information about vascular spasm (blood flow velocity, spasm localization, its severity and development prognosis). The method allows to determine the possibility and scope of surgical intervention.

After the above-described studies, the patient is treated by a vascular surgeon, who gives a major role to differential diagnostics. The greatest similarity in clinical picture is between a stroke and an aneurysm rupture. In both cases, there is a hemorrhage into the brain with all the ensuing consequences.

But in some cases the disease is more reminiscent of a migraine, acute poisoning, radiculitis, and only differential diagnostics makes it possible to see the danger in time and, possibly, save a person’s life.

Treatment of a ruptured cerebral aneurysm.

Aneurysm of the brain is a disease for which doctors have not developed an effective treatment. Moreover, some specialists believe that drug therapy can only worsen the situation, so they take a wait-and-see attitude, recommending patients to rest, avoid heavy physical exertion and stress, and, if necessary, maintain normal blood pressure using folk remedies.

If a vessel has ruptured, folk and medicinal treatments are useless. They can only be used as a preventative measure against repeated arterial ruptures and to relieve symptoms. No medications will restore the vessel structure or change what was formed in the prenatal period.

Physiotherapy treatment is NOT used in this case.

The only justified method of treatment is considered to be surgery, which is an emergency aid for a ruptured brain aneurysm. Pre-hospital care consists only of helping the person get to the hospital without straining their strength, calming them down, because worrying will only make the situation worse. It is better not to give the patient any medications without consulting a doctor.

In principle, surgical treatment, as the only correct tactic, is indicated for all patients with a brain aneurysm with a suspected rupture. If there was no rupture, there is no need to rush with the operation, because the probability of a violation of the integrity of the vessel wall is no more than 2%. In case of a rupture of the neoplasm, the operation should be carried out in the first days. Surgical intervention is a preventive measure against repeated ruptures, the probability of which is especially high in the acute period.

During the first two weeks after a cerebral aneurysm rupture, surgical intervention is indicated only for patients with an uncomplicated course of the disease (grades 1-3 severity of the condition), as well as for those who have a high risk of repeated ruptures or clinically significant vascular spasm.

Doctors operate on patients in serious condition at their own risk in the following cases:

• the formation of a large hematoma compressing the brain,
• the formation of hydrocephalus, leading to dislocation of the brain stem,
• multiple or widespread foci of cerebral ischemia.

In these cases, the operation is part of the resuscitation procedures.

In case of complications, operations after rupture of cerebral vessels are performed after the acute period is over (after 2 weeks). All this time, the person (4-5 severity level) is in the hospital under the supervision of doctors, whose task is to stabilize the patient's condition. [ 9 ]

The tactics of surgical treatment are chosen based on the localization of the aneurysm, its size, the presence of hematomas, angiospasm and other nuances. One of the most popular methods of treatment is open microsurgery, during which clips are applied to the damaged vessel, turning it off from the bloodstream.

If open surgery is not possible, as well as in the case of hard-to-reach aneurysms, endovascular embolization of the aneurysm (insertion of a balloon catheter that occludes the vessel and thus excludes it from the bloodstream). This is a kind of prevention of repeated bleeding, which is somewhat inferior in effectiveness to open surgery. Quite often, doctors prefer a combined intervention: first, they insert a balloon, and when the patient's condition improves, they perform an open operation to clip the vessels.

The consequences of cerebral vascular surgery can be divided into 2 types: intraoperative and postoperative. The first includes vascular thrombosis and brain tissue injuries during manipulations. The second group consists of neurological symptoms, which can be transient or permanent, infectious complications (extremely rare). Neurological symptoms are usually associated with cerebral disorders, but do not always lead to deterioration of speech, motor, and intellectual functions.

It must be said that the risk of all sorts of complications, including repeated rupture of the artery, is lower the sooner the operation is performed, which minimizes the negative impact on the brain.

If the operation was successful, much depends on the patient. Recovery and rehabilitation after an aneurysm rupture can last many months and even years, during which a person will have to completely change their lifestyle.

After the operation, a diet is recommended for all patients with aneurysms. This is a low-cholesterol diet with limited salt and liquid. This will help maintain normal blood pressure, which means the risk of repeated ruptures will be lower.

Life after an aneurysm rupture will change even in the sense that a person may have to give up their previous position in favor of work that does not require a lot of physical effort, and is calmer in psycho-emotional terms. Sometimes neurological symptoms that appear after a rupture or surgery, affecting intellectual abilities, motor and speech activity, lead to disability. And these are completely different living conditions, to which a person can adapt only with the support of family and friends.

Drug treatment

We have already said that medications cannot help in any way with a ruptured cerebral aneurysm. They are prescribed mainly as a preventative measure against complications, the most dangerous of which is a repeated rupture of the vessel, as well as to stabilize the patient's condition and relieve painful symptoms.

Since the pain from a ruptured brain aneurysm is of a strong, burning nature, it can only be relieved with potent drugs, such as morphine, which is administered by injection in a hospital setting.

Patients very often experience nausea and debilitating vomiting. In such cases, antiemetics may be prescribed. For example, prochlorperazine is a neuroleptic that relieves nausea symptoms. It is taken after meals in a dosage of 12.5 - 25 mg (maximum 300 mg per day).

The drug is not prescribed for severe CNS depression, comatose states, severe cardiovascular diseases, systemic brain diseases, hematopoiesis disorders, liver failure. It is not used to treat pregnant women and nursing mothers, as well as in childhood.

Taking the drug may be accompanied by dry mouth, nasal congestion, visual disturbances, skin discoloration, reproductive system disturbances, skin rashes. Heart rhythm disturbances, vascular thrombosis, limb tremors, insomnia and other unpleasant symptoms are possible. That is why the drug should be taken under the supervision of a doctor.

Another symptom of cerebrovascular accident may be seizures. Anticonvulsants (antiepileptics) help prevent such attacks. For example, fosphenytoin.

This drug is administered intravenously or intramuscularly: during an attack at a dosage of 15-20 mg PE/kg, maintenance (prophylactic) dose – 4-8 mg PE/kg every 24 hours.

The drug should be administered slowly to avoid a sharp drop in blood pressure. The drug promotes dilation of blood vessels and can cause brady- or tachycardia, drowsiness.

Calcium channel blockers are prescribed to prevent vasospasm, dilate blood vessels and improve cerebral circulation. For example, nimodipine.

After subarachnoid hemorrhage, the drug is prescribed in a dosage of 60 mg 6 times a day at intervals of 4 hours. The course of treatment is 1 week, after which the dosage is gradually reduced. The total course is exactly 3 weeks.

The drug is not prescribed for severe liver diseases with impaired organ functionality, unstable angina, in childhood, such treatment is allowed for pregnant women only in extreme cases, and when breastfeeding the child, it is recommended to transfer to another type of nutrition. The drug is not allowed for myocardial infarction and within a month after it.

The most common side effects are: decreased blood pressure, diarrhea, nausea, heart rhythm disturbances, hyperhidrosis, dizziness, sleep disturbances, irritability. Gastric bleeding, headaches, venous thrombosis, skin rashes are possible.

The drug should not be used in combination with anticonvulsants due to a decrease in the expected effect.

To maintain normal blood pressure, which is vital in aneurysm, standard antihypertensive therapy is used. The most popular drugs of this type for the prevention of aneurysm rupture are labetalol, captopril, hydralazine.

The drug "Hydralazine" is prescribed after meals orally. The initial dose is 10-25 mg 2-4 times a day. It is gradually increased to 100-200 mg per day (no more than 300 mg per day).

The drug is not prescribed for severe vascular atherosclerosis, mitral valve defects. Caution should be exercised in cerebrovascular insufficiency and aortic aneurysm, severe kidney disease, acute autoimmune processes.

Side effects include: paroxysmal pain in the heart, nausea with vomiting, weight loss, bowel disturbances, enlarged lymph nodes (lymphadenopathy), headaches, neuritis, facial flushing, shortness of breath, nasal congestion and some others.

Any of the above mentioned drugs cannot be prescribed in case of hypersensitivity to its components.

Additionally, vitamins are prescribed as a general tonic that promotes rapid recovery.

Traditional medicine and homeopathy

We have already mentioned that some doctors have a certain degree of doubt about drug therapy, suggesting using traditional medicine. But such advice is justified more as a preventive measure for aneurysm rupture (first or subsequent). Without surgery for a ruptured cerebral aneurysm, it is impossible to restore blood supply and brain function by any means.

Traditional medicine can offer many recipe options for normalizing blood pressure, which is what is needed in this case. In addition, many medicinal compositions are an irreplaceable source of vitamins, which are so necessary for an organism weakened after surgery.

The most effective treatment in this case is herbal treatment, or rather plant fruits (currant, cranberry, hawthorn, rose hip, viburnum, chokeberry). These tasty medicines can be taken regularly without negative consequences for the body.

Thus, rose hips are able not only to reduce pressure, but also to restore the elasticity of blood vessels. It is taken as an infusion (2 tablespoons per 1 cup of boiling water) twice a day, half a glass.

You can also make an effective combination medicine recommended for high blood pressure. Take 1 part of chokeberry and cranberry and twice as much rose hips and hawthorn. Brew 2 tbsp of the mixture with 1 tbsp of boiling water. Drink the infusion 3 times. It should be taken half an hour before meals.

Blackcurrant can be eaten all year round. In winter, an infusion of dried berries is good (100 g per 1 liter of boiling water). It should be taken a quarter of a glass three times a day.

Beetroot juice with honey is also useful for blood pressure (3 tablespoons 3 times a day).

For high blood pressure, herbs that can be used include mistletoe, immortelle, sedum, and sweet clover.

Of the modern homeopathic remedies for normalizing blood pressure before and after a ruptured cerebral aneurysm, the drug "Homviotensin" has proven itself well. It gently reduces blood pressure and stabilizes it, while normalizing the work of the heart and kidneys.

The drug "Aneurosan" not only normalizes blood pressure, but also relieves headaches and nervous excitement.

"Aurum Plus" normalizes heart function, improves the condition of blood vessels in atherosclerosis and is its prevention, relieves symptoms of dizziness, improves brain function.

"Edas 137" is used for symptomatic hypertension.

All the above mentioned drugs are used strictly for preventive purposes and cannot replace surgical treatment.

Forecast

A ruptured cerebral aneurysm is a very dangerous complication with a not very good prognosis. It is clear that people diagnosed with "cerebral aneurysm" are very concerned about the chances of survival. There are no exact statistics on the number of fatalities, but the risk is definitely high.

Much depends on the size of the aneurysm and the timeliness of the assistance. The lowest mortality is observed with a ruptured aneurysm smaller than 5 mm. But it must be said that surgical intervention is a real chance for life. It is important that it is carried out in a timely manner and preferably in a good clinic with a general postoperative mortality rate of no more than 10-15%.

If the patient refuses hospitalization, his chances of survival and preservation of brain functions drop sharply. This means that you need to be more attentive to your health and not ignore alarming symptoms, making conclusions about the presence of a migraine or poisoning.

Aneurysm of the cerebral vessels is an insidious pathology, leading a hidden "lifestyle". In most cases, it is discovered by chance, and most often in connection with a violation of cerebral circulation, including as a result of a ruptured vessel. But even if the diagnosis is known, nothing can be changed, all that remains is to do so as not to aggravate the situation.

Measures for preventing conditions that provoke a rupture of a cerebral aneurysm include a healthy lifestyle (moderate physical activity, proper nutrition, giving up bad habits), monitoring cholesterol levels and, if necessary, normalizing blood pressure using pharmaceutical drugs, traditional medicine or homeopathic remedies. This is much easier than what patients with an aneurysm have to go through if they do not take preventive measures against rupture. But even following these recommendations does not guarantee dangerous complications if the patient does not monitor his or her mental health.