Rupture of a brain aneurysm

An aneurysm is a protrusion of the wall of an artery or vein due to its thinning and loss of elasticity. This pathology in most cases is congenital. Most often, aneurysm is diagnosed in the vessels of the brain, which makes the disease potentially dangerous. The expanded part of the vessel cannot function on a par with the undamaged part, so the rupture of a brain aneurysm is a fairly common situation. The most unpleasant thing is that the patient may not even be aware of his diagnosis due to the absence of specific symptoms, so the risk of death due to delay is extremely high.

Epidemiology

We found that both the formation of an aneurysm and its rupture are the result of increased blood pressure. This means that patients with hypertension and drinkers are at risk. According to statistics, the likelihood of the formation and rupture of an aneurysm is higher in people with bad habits: smokers and drug addicts, especially those who "sat down" on cocaine.

Rupture of an aneurysm of the brain is an age-related pathology. In childhood, it is not detected due to the fact that arterial hypertension in children is a rare phenomenon. Yes, 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 likely to appear much later, when he grows up and accumulates diseases.

The tendency to form and rupture cerebral aneurysms is slightly higher in women. And the disease is diagnosed most often in the interval from 30 to 60 years, 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. Rupture of the artery at the site of protrusion occurs only in 0.01% of cases. And the reason is the pressure surge. The sad fact is that in 70% of cases, the rupture leads to the death of the patient.

Causes of the ruptured brain aneurysm

To understand what causes could lead to a rupture of a brain aneurysm, it is necessary to study the pathogenesis of the disease itself, which may have its onset even before the birth of the baby or cause injuries and illnesses. The cause of inadequate functioning of the vessels is most often metabolic and genetic disorders, which lead to a deviation in the formation of the vascular wall.

For "congenital" aneurysms, which can declare themselves 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 kinds of loads. This causes the formation of a cerebral aneurysm. The wall of a blood vessel cannot withstand blood pressure and bends in the weakest place (most often in those places where the vessels are bent, bifurcated, or large branches depart from them). [1]

Aneurysm can be detected in connective tissue dysfunction syndromes, hereditary disorders of collagen production. Congenital pathologies are characterized by a combination with other intrauterine pathologies (PBP, hypoplasia of the renal arteries, heart defects, etc.).

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

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

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

Symptoms of the ruptured brain 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 quite healthy. Others may complain of pain in the forehead and eye orbits, slight dizziness, especially with a sudden change in position. It all depends on the location, type of aneurysm (number of chambers), and its size.

Large multilocular aneurysms are more prone 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. In which area of the brain the blood goes.

A ruptured cerebral aneurysm results in intracerebral, intraventricular, or subarachnoid bleeding. In the first case, the mortality rate is 40%. But most often, blood enters the space between the cranial bone and the brain (subarachnoid space). Such 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 a non-traumatic subarachnoid hemorrhage. The first signs of such bleeding are:

• sudden onset of severe arching pains in the head in the form of a push.
• nausea and vomiting,
• increased body temperature (hyperthermia),
• photophobia,
• dilated pupils,
• loss of sensation in a part of the face or limbs,
• increased sensitivity to noise
• a stunned state of consciousness (from moderate stupor to atonic coma), which can have a different duration.

Many patients become restless and fidgety, talking and fussing a lot. They have weakness of the occipital muscles, Kernig's symptom (flexion of the legs at the knee and hip joints with pressure 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 orbits, visual disturbances, paresis of the oculomotor nerve, impaired sensitivity of the eye area and upper jaw are possible;
• not the anterior cerebral artery: mood swings, psychotic disorders, deterioration of memory and mental abilities in general, paresis of the limbs, the development of diabetes insipidus, disorders of water-salt metabolism that affect the work of the heart;
• on the middle cerebral artery: the development of motor or sensory aphasia (depending on the hemisphere of the brain, a person either understands speech, but cannot speak out himself, or vice versa), convulsions, visual disturbances, often paresis of the hands;
• on the main artery: paresis of the oculomotor nerve, visual disturbances, up to the loss of the ability to see with healthy eyes (cortical blindness), paresis of the arms and legs is possible, in severe cases, respiratory failure, depressed consciousness, coma;
• on the vertebral artery: a violation of the innervation of the speech apparatus (dysarthria), as a result of which speech becomes fuzzy, hoarseness, a decrease in various types of sensitivity, in severe cases, symptoms similar to an aneurysm on the main artery.

In a quarter of cases of ruptured brain aneurysm, 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 sciatica. All this leads to the fact that patients are not provided with timely assistance while additional examinations and differential diagnostics are being carried out. [5]

Complications and consequences

The fact that a person can live a completely happy life for many years without knowing about the disease does not mean at all that it is harmless. By itself, a cerebral aneurysm (and there may be several) 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 altered area may not withstand, and then the blood spills out of the artery (less often the vein).

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

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

The size and strength of bleeding is largely determined by the severity (on the H-H scale) of the patient's condition, which in different periods of rupture of the brain aneurysm is determined by different factors. In the first 3 days (acute period), a 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 vasospasm and what its severity was.

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

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

With subarachnoid hemorrhage, the risk of developing hydrocephalus (dropsy or swelling of the brain) is high. Violation of hemodynamics leads to the fact that cerebrospinal fluid accumulates in the ventricles of the brain, they expand and begin to put pressure on the medulla.

One of the most dangerous complications is considered to be vasospasm, which usually manifests itself, starting from 3 days for 2 weeks. As a result of a sharp narrowing of the vessels of the brain, blood circulation and blood supply to individual parts of the brain are disturbed. Hypoxia leads to a violation of intellectual abilities, and in difficult 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 the ruptured brain aneurysm

Difficulties in diagnosing a ruptured cerebral aneurysm are associated, firstly, with the localization of the neoplasm under the cranium, which cannot be seen visually, and secondly, with the absence in most cases of early symptoms of the disease. Patients come to the doctor with complaints of a burning pain in the head or signs of acute indigestion, but only a small proportion of them are diagnosed with an aneurysm. Others do not know about their problem, however, like 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, depending on the location and strength of the hemorrhage, may differ, but still this is a real chance to clarify the diagnosis and start a more complete examination and treatment as soon as possible.

The doctor, for his part, studies the data of the patient's medical record, listens to complaints, and prescribes a neurological examination of the patient. Analyzes in such a situation 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. It is this method with a high degree of accuracy that makes it possible to diagnose hemorrhage in the subarachnoid space, but it is not used for hematomas and extensive ischemia. The latter are detected as a result of echoencephaloscopy or CT, which are performed before puncture.
• CT scan of the brain. The most common diagnostic method, the most informative on the first day of the acute period. It allows you to determine the very fact of hemorrhage, its strength, localization and prevalence, the presence of a hematoma, hemorrhage into the ventricular system, and even the true cause of the rupture. CT makes it possible to assess the consequences of an aneurysm rupture.
• MRI of the brain. Gives maximum information in the subacute and chronic period. It has a high probability of detecting cerebral ischemia, helps to determine its nature.
• Cerebral angiography. It is considered the "gold standard" for diagnosing ruptured aneurysms. It makes it possible to identify both aneurysm and vasospasm. True, doctors often limit themselves to MRI, as a fairly informative method that does not require additional examinations. In addition, in the presence of contraindications to angiography, MRI is the most successful alternative.
• EEG. The encephalogram reveals disturbances in the electrical activity of the brain and helps to determine the possibility and timing of the operation, to make predictions 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 extent of surgical intervention.

After carrying out the above studies, a vascular surgeon deals with the patient, assigning a large role to differential diagnosis. Stroke and aneurysm rupture have the greatest similarity of the clinical picture. In both cases, a cerebral hemorrhage occurs with all the ensuing consequences.

But in some cases, the disease is more like a migraine, acute poisoning, sciatica, and only differential diagnosis makes it possible to see the danger in time and, possibly, save a person's life.

Treatment of the ruptured brain aneurysm

Brain aneurysm is a disease for which effective treatment has not been developed by doctors. Moreover, some experts believe that drug therapy can only aggravate the situation, so they take a wait-and-see attitude, recommending that patients rest, avoid heavy physical exertion and worries, and, if necessary, maintain normal pressure using alternative means.

If there is a rupture of the vessel, alternative and drug treatment does not make sense. It can only be used as a prophylaxis for repeated ruptures of the arteries and to relieve symptoms. No drugs will restore the structure of the vessel and will not change what was formed in the prenatal period.

In this case, physiotherapy treatment is also NOT applicable.

The only justified method of treatment is surgery, which is precisely the emergency care for a ruptured brain aneurysm. First aid consists only in helping a person get to the hospital, without straining his strength, to calm him down, because experiences will only aggravate the situation. It is better not to give any drugs to the patient without consulting a doctor.

In principle, surgical treatment, as the only correct tactic, is indicated for all patients with a brain aneurysm if it is suspected to rupture. If there was no rupture, it is not necessary to rush with the operation, because the probability of violating the integrity of the vessel wall is not more than 2%. In case of rupture of the neoplasm, the operation should be carried out in the very first days. Surgical intervention is the prevention of repeated ruptures, the likelihood of which is especially high in the acute period.

During the first two weeks after a rupture of a cerebral aneurysm, surgery is indicated only for patients with an uncomplicated course of the disease (1-3 severity of the condition), as well as for those who are at high risk of repeated ruptures, or there is a clinically significant vasospasm.

Doctors operate on patients in serious condition at their own peril and risk in such cases:

• the formation of a large hematoma, squeezing the brain,
• the formation of dropsy of the brain, 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, surgery after rupture of cerebral vessels is carried out after the end of the acute period (after 2 weeks). All this time, a person (grade 4-5) is in the hospital under the supervision of doctors, whose task is to stabilize the patient's condition. [9]

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

If it is impossible to conduct an open operation, as well as in the case of hard-to-reach aneurysms, endovascular aneurysm embolization (insertion of a balloon-catheter that clogs the vessel and thereby turns it off from the bloodstream). This is a kind of prevention of rebleeding, which is somewhat inferior in efficiency to open surgery. Quite often, doctors prefer a combined intervention: first, a balloon is inserted, and when the patient's condition improves, an open vascular clipping operation is performed.

Consequences after operations on the vessels of the brain can be divided into 2 types: intraoperative and postoperative. The former include vascular thrombosis and trauma to brain tissue 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 a deterioration in speech, motor, and intellectual functions.

It must be said that the risk of all kinds of complications, including re-rupture of the artery, is lower, the earlier the operation is performed, which minimizes the negative impact on the brain.

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

After surgery, a diet is indicated, which is recommended for all patients with aneurysm. This is a low-cholesterol diet with limited salt and fluids. 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 his previous position in favor of a job that does not require a lot of physical strength, is more calm in a psycho-emotional sense. Sometimes neurological symptoms appearing after a rupture or an operation that affect intellectual abilities, motor and speech activity, lead to disability. And these are already completely different living conditions, to which a person can adapt only with the support of relatives and friends.

Medical treatment

We have already said that drugs can do nothing to help with a ruptured brain aneurysm. They are prescribed mainly as a prevention of complications, the most dangerous of which is considered to be a repeated rupture of the vessel, as well as to stabilize the patient's condition and relieve painful symptoms.

Since pain during rupture of a brain aneurysm has a strong burning character, then they can be removed only with potent drugs, such as morphine, which is injected in a hospital.

Patients very often experience nausea and exhausting vomiting. In this case, antiemetics may be prescribed. For example, prochlorperazine is an antipsychotic that relieves symptoms of nausea. Take it after meals at a dosage of 12.5 - 25 mg (maximum 300 mg per day).

The drug is not prescribed for severe CNS depression, coma, severe cardiovascular diseases, systemic brain diseases, hematopoietic disorders, liver failure. It is not used for the treatment of pregnant women and nursing mothers, as well as in childhood.

Taking the drug may be accompanied by the appearance of dry mouth, nasal congestion, disorders of the organs of vision, discoloration of the skin, disorders of the reproductive system, skin rashes. Possible heart rhythm disturbances, vascular thrombosis, tremor of the limbs, insomnia and other unpleasant symptoms. That is why the medicine must be taken under medical supervision.

Seizures can be another symptom of cerebrovascular accident. Anticonvulsant (antiepileptic) drugs help prevent the occurrence of such seizures. 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 so as not to provoke a sharp drop in blood pressure. The drug promotes the expansion of blood vessels, can cause bradycardia or tachycardia, drowsiness.

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

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

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

The most common side effects are: lowering blood pressure, diarrhea, nausea, heart rhythm disturbances, hyperhidrosis, dizziness, sleep disturbance, irritability. Gastric bleeding, headaches, vein 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 aneurysms, standard antihypertensive therapy is used. The most popular drugs of this kind for the prevention of aneurysm rupture are labetalol, captopril, hydralazine.

The drug "Hydralazine" is prescribed after ingestion of food inside. The initial dose is 10-25 mg 2-4 times a day. Gradually it is increased to 100-200 mg per day (no more than 300 mg per day).

Do not prescribe a medicine for severe atherosclerosis of the vessels, defects of the mitral valve of the heart. Caution must be observed in cerebrovascular insufficiency and aortic aneurysm, severe kidney disease, acute autoimmune processes.

Among the side effects are: paroxysmal pain in the heart, nausea with vomiting, weight loss, stool disorders, swollen lymph nodes (lymphodenopathy), headaches, neuritis, facial flushing, shortness of breath, nasal congestion and some others.

Any of the above drugs cannot be prescribed for hypersensitivity to its components.

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

Alternative medicine and homeopathy

We have already mentioned that some of the doctors with a certain degree of doubt refer to drug therapy, offering to use the services of alternative medicine. But such advice is more justified as a measure to prevent aneurysm rupture (first or subsequent). Without surgery for a ruptured brain aneurysm, it is impossible to restore blood supply and brain function by any means.

Alternative medicine can offer many options for prescriptions for normalizing blood pressure, which is what is required in this case. In addition, many therapeutic formulations are an indispensable source of vitamins, which are so necessary for the body weakened after surgery.

The most effective in this case is the treatment with herbs, or rather the fruits of plants (currant, cranberry, hawthorn, wild rose, viburnum, chokeberry). These tasty medicines can be consumed regularly without negative consequences for the body.

So rosehip is 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 tablespoon of boiling water) twice a day for half a cup.

You can also make an effective combination medicine recommended for high blood pressure. We take 1 part of chokeberry and cranberry and twice as much wild rose and hawthorn. 2 tbsp mixture brew 1 tbsp. Boiling water. We drink the infusion for 3 times. It should be taken half an hour before meals.

Blackcurrant can be eaten throughout the year. In winter, an infusion of dry berries is good (100 g per 1 liter of boiling water). You need to take it in a quarter cup three times a day.

From pressure, beetroot juice with honey is also useful (3 times a day, 3 tablespoons).

From herbs with increased blood pressure, mistletoe, cudweed, stonecrop, sweet clover can be used.

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

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

"Aurum plus" normalizes the work of the heart, 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 of these drugs are used purely for prophylactic purposes and cannot replace surgical treatment.

Forecast

Rupture of a brain aneurysm is a very dangerous complication with a not the best prognosis. It is clear that people diagnosed with cerebral aneurysm are very worried about the question, what is the chance to survive? There are no exact statistics on the number of deaths, but the risk is clearly high.

Much depends on the size of the aneurysm and the timeliness of assistance. The smallest lethality is noted in case of aneurysm rupture, less than 5 mm in size. But I must say that surgery is a real chance for life. It is important that it be carried out in a timely manner and preferably in a good clinic with an overall postoperative mortality rate of no more than 10-15%.

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

Cerebral aneurysm 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, incl. And as a result of rupture of the vessel. But even if the diagnosis is known, nothing can be changed, it remains only to do so as not to aggravate the situation.

Measures to prevent conditions that provoke a rupture of a brain aneurysm can be considered a healthy lifestyle (moderate physical activity, proper nutrition, giving up bad habits), cholesterol control and, if necessary, normalization of blood pressure with the help of pharmaceutical preparations, alternative medicine or homeopathic remedies. This is much easier than what an aneurysm patient has to go through if the rupture is not prevented. But even following these recommendations does not guarantee dangerous complications if the patient does not monitor their mental health.