A ruptured cerebral aneurysm

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 can not function on a par with the undamaged one, so the rupture of a 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 lethal outcome due to delay is extremely high.

Epidemiology

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

A ruptured cerebral aneurysm is an age-related pathology. It is not detected in children 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. Predisposition in a child may exist, but the bulge itself is very likely to appear much later, when he grows up and accumulates diseases.

The propensity for the formation and rupture of cerebral aneurysms is somewhat higher in women. And the disease is diagnosed most often between 30 and 60 years of age, 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 in the place of the bulge occurs only in 0.01% of cases of the disease. And the cause is a spike in blood pressure. The sad fact is that in 70% of cases the rupture leads to the death of the patient.

Causes of the a ruptured cerebral aneurysm.

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

For "congenital" aneurysms, which can manifest themselves in adulthood, are characterized by the absence of the typical three-layer structure. Its wall is represented only by connective tissue. The lack of a muscular and elastic layer makes it less resistant to various kinds of loads. This is the reason for the formation of cerebral aneurysms. The wall of a blood vessel cannot withstand the pressure of blood and sags in the weakest place (most often in those places where the vessels bend, bifurcate or large branches branch off from them). [1]

Aneurysms can be detected in connective tissue dysfunction syndromes, hereditary disorder of collagen production. Congenital pathologies are characterized by combination with other intrauterine pathologies (PBBP, hypoplasia of renal arteries, heart defects, etc.).

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

Aneurysm is formed either due to improper 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 vasculature, as a result of which it is not able to withstand the constant or periodic impact exerted by blood. It is a question of blood pressure on the weakened vessel.

We have considered the risk factors that can lead (or not) 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] Yes and rupture of a cerebral aneurysm is predominantly the result of increased BP. Thinned stretched vessel wall, most often consisting of inelastic connective tissue, simply cannot withstand the pressure of blood. [4]

Symptoms of the a ruptured cerebral aneurysm.

We have already mentioned that cerebral aneurysms can remain hidden 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 when changing position abruptly. Everything depends on the localization, type of aneurysm (number of chambers), its size.

Large multichamber aneurysms are more prone to rupture. And the symptoms (clinical picture) appearing in this case have a direct dependence on the localization of the bulge and the form of hemorrhage, i.e. The area of the brain where the blood enters.

Brain aneurysm rupture results in intracerebral, intraventricular or subarachnoid hemorrhage. In the first case, the lethality is 40%. But most often blood enters the space between the cranial bone and the brain (subarachnoid space). Such bleeding is considered to be the most severe, because it can cause both death (with a high 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 a hemorrhage are considered to be:

• Sudden onset of severe shooting pains in the head in the form of a jolt.
• nausea and vomiting,
• An increase in body temperature (hyperthermia),
• photophobia,
• dilated pupils,
• impaired sensation of part of the face or extremities,
• hypersensitivity to noise,
• a stunned state of consciousness (from moderate stun to atonic coma), which may have different durations.

Many patients become restless and fidgety, talking and fidgeting a lot. They have weakness of the occipital muscles, Kernig's symptom (flexion of the legs at the knee and hip joints when pressure is applied to the pubis), which indicates irritation of the cerebral membranes by bleeding, and some other manifestations characteristic of meningitis.

The clinical picture of a ruptured cerebral aneurysm may differ depending on the localization of the pathological bulge:

• on the carotid artery: pain localized in the forehead and eye orbits, possible visual disturbances, paresis of the oculomotor nerve, sensory disturbances of the eye area and upper jaw;
• non anterior cerebral artery: mood swings, psychotic disorders, deterioration of memory and mental abilities in general, possible paresis of limbs, development of non-sugar diabetes, disorders of water and salt metabolism, affecting 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 speak, or vice versa), seizures, visual disturbances, often paresis of the hands;
• on the main artery: paresis of the oculomotor nerve, visual disturbances, up to loss of the ability to see with healthy eyes (cortical blindness), possible paresis of arms and legs, in severe cases respiratory disturbances, depressed consciousness, coma;
• on the vertebral artery: impaired innervation of the speech apparatus (dysarthria), resulting in slurred speech, hoarseness of voice, decreased sensitivity, and in severe cases, symptoms similar to aneurysms on the main 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, brain inflammation (meningitis). It also happens that doctors make a preliminary diagnosis of acute food poisoning or radiculitis. All this leads to the fact that patients are not provided with relevant help in time, while additional examinations and differential diagnosis 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. 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, there may be a sharp jump in pressure, the walls of the blood vessel in the pathologically altered area can not withstand, and then the blood pours out of the artery (less often a vein).

Depending on the type of aneurysm (billion, normal, large or giant), bleeding can be minor or quite severe. Clearly, if the bulge is up to 3 mm in size, a small hemorrhage can be expected when it ruptures. If the blood clotting is normal, the bleeding will not last long and its consequences will be less severe.

In the case of a giant aneurysm (2.5 cm or more), bleeding will be more severe, and the prognosis is less favorable. And the removal of such a neoplasm is very difficult and risky. [6]

The size and strength of the bleeding is largely determined by the severity (H-H scale) of the patient's condition, which in different periods of cerebral aneurysm rupture is determined by different factors. In the first 3 days (acute period), the decisive role is played by: the mass of hemorrhage, the presence of 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 vasospasm and its severity.

Rupture of a cerebral aneurysm is the most dangerous consequence of this disease, especially in the case of subarachnoid and intraventricular hemorrhage, which threatens disability or death of the patient. Any rupture of the vessel is a hemorrhage into the brain to a greater or lesser degree, and this is fraught with the development of hemorrhagic stroke (acute cerebral circulatory failure), CNS disorders, fatal outcome. 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 goes well the first time, you need to realize that where there is thin, there is tearing. There is always a high risk of aneurysm rupture again, so treatment is primarily aimed at preventing such a complication. And it should be started in any period after the first bleeding (taking into account the fact that patients often do not immediately go to the doctor, not realizing what happened), but the earlier the better.

In subarachnoid hemorrhage, there is a high risk of hydrocephalus (cerebral hydrocephalus or edema). The hemodynamic disorder causes cerebrospinal fluid to accumulate in the ventricles of the brain, they expand and begin to press on the brain matter.

One of the most dangerous complications is considered and vasospasm, which usually makes itself known, starting from 3 days for 2 weeks. As a result of a sharp narrowing of the cerebral vessels, blood circulation and blood supply to certain parts of the brain are disrupted. Hypoxia leads to impaired intellectual abilities, and in severe situations becomes the cause of damage to brain tissue, the dying off of its cells. Even if a person survives, there is a high risk of disability. [8]

Diagnostics of the a ruptured cerebral aneurysm.

Difficulties in diagnosing a ruptured brain aneurysm are due, firstly, to the localization of the neoplasm under the skull, which cannot be seen visually, and secondly, the absence in most cases of early symptoms of the disease. Patients come to the doctor with complaints of burning pain in the head or signs of acute stomach upset, but only a small proportion of them are diagnosed with an aneurysm. Others are not aware of their problem, and neither 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. Depending on the localization and strength of the hemorrhage, the symptoms may differ, but it is still a real chance to clarify the diagnosis and sooner begin a more complete examination and treatment.

For his part, the doctor examines the patient's medical records, listens to complaints, prescribes a neurological examination of the patient. Analyses in this situation are carried out only in connection with the need for surgical treatment. And to identify the pathological process, instrumental diagnostics is used.

The most popular and effective methods of instrumental diagnostics include:

• Lumbar puncture. It is this method with a high degree of accuracy allows to diagnose hemorrhage into the subarachnoid space, but it is not used with hematomas and extensive ischemia. The latter are detected by echoencephaloscopy or CT, which are performed before puncture.
• CT of the brain: the most common method of diagnosis, the most informative in the first day of the acute period. It allows to determine the fact of hemorrhage, its strength, localization and prevalence, the presence of hematoma, hemorrhage into the ventricular system and even the true cause of rupture. CT scan also provides an opportunity to assess the consequences of 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 aneurysm rupture. It makes it possible to detect both aneurysm and vasospasm. However, doctors are often limited to MRI, as a sufficiently informative method that does not require additional examinations. In addition, if there are contraindications to angiography, MRI is the most successful alternative.
• EEG. Encephalogram reveals disturbances in the electrical activity of the brain and helps to determine the possibility and timing of surgery, make surgical prognosis. It makes it possible to identify the source of hemorrhage in multiple aneurysms.
• Doppler helps to expand information about vascular spasm (blood flow velocity, localization of spasm, its severity and prognosis of development). The method allows to determine the possibility and volume of surgical intervention.

After the above studies, the patient is treated by a vascular surgeon, giving a great role to differential diagnosis. Stroke and ruptured aneurysm have the greatest clinical similarity. In both cases, there is hemorrhage into the brain with all the ensuing consequences.

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

Treatment of the a ruptured cerebral aneurysm.

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

If a vessel rupture has occurred, folk and drug treatment is of no use. It can be used only as a prevention of repeated arterial ruptures and to relieve symptoms. No drugs will restore the structure of the vessel and will not change what was formed in the fetal period.

Physiotherapeutic treatment is NOT used in this case either.

The only justified method of treatment is considered to be surgery, which is precisely the emergency treatment for a ruptured brain aneurysm. Pre-hospital care is only to help a person get to the hospital without straining his strength, to calm him down, because worries 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 suspected of rupture. If there is no rupture, it is not necessary to rush with surgery, because the probability of violating the integrity of the vessel wall is no more than 2%. In the case of rupture of the neoplasm, the operation should be tried in the first few days Surgical intervention is a prevention of repeated ruptures, the probability of which is especially high in the acute period.

During the first two weeks after cerebral aneurysm rupture, surgical intervention is indicated only in patients with uncomplicated course of the disease (1-3 severity of the condition), as well as those at high risk of recurrent rupture or clinically significant vasospasm.

Patients in serious condition doctors operate at their own risk in such cases:

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

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

In the case of complications, surgery after a cerebral vascular rupture is performed after the end of the acute period (after 2 weeks). All this time the person (4-5 degree of severity) is in the hospital under the care of doctors, whose task is to stabilize the patient's condition. [9]

Surgical treatment tactics 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 placed on the damaged vessel, cutting it off from blood flow.

If open surgery is not possible, as well as in the case of aneurysms that are difficult to access, endovascular embolization of the aneurysm (insertion of a balloon catheter that occludes the vessel and thereby disconnects it from the blood flow). This is a kind of prevention of recurrent 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 open surgery to clip the vessels.

Consequences after brain vascular surgery can be divided into 2 types: intraoperative and postoperative. The first includes vascular thrombosis and trauma to brain tissue during manipulation. The second group consists of neurologic symptoms, which may be transient or permanent, infectious complications (extremely rare). Neurologic 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 the re-rupture of the artery, the lower the earlier the surgery is performed, which minimizes the negative impact on the brain.

If the surgery is successful, much depends on the patient. Recovery and rehabilitation after the rupture of an aneurysm can take many months and even years, during which a person will have to completely change his or her lifestyle.

After surgery, a diet is indicated, which is recommended for all patients with aneurysms. This is a low-cholesterol diet with salt and fluid restriction. This will help to maintain normal blood pressure, which means that 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 a previously held position in favor of a job that does not require a lot of physical effort, more calm 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 this is a completely different living environment, to which a person can adapt only with the support of relatives and friends.

Medical treatment

We have already said that medications can not help with the rupture of a cerebral aneurysm. They are prescribed mainly as a prevention of complications, the most dangerous of which is considered a repeated rupture of the vessel, as well as to stabilize the patient's condition and relieve distressing symptoms.

Since the pain of a ruptured brain aneurysm is of a strong burning nature, it can only be relieved with potent drugs such as morphine, which is injected into the hospital.

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

The drug is not prescribed in severe CNS depression, coma, severe cardiovascular diseases, systemic brain diseases, impaired hematopoiesis, hepatic insufficiency. It is not used for treatment of pregnant women and nursing mothers, as well as in children.

Taking the drug may be accompanied by dry mouth, nasal congestion, visual disturbances, skin discoloration, reproductive system disorders, skin rashes. Possible heart rhythm disorders, vascular thrombosis, tremor of the extremities, insomnia and other unpleasant symptoms. That is why the drug should be taken under the supervision of a doctor.

Another symptom of impaired cerebral circulation may be seizures. Anticonvulsants (antiepileptics) can help prevent 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 BP. The drug promotes dilation of blood vessels, may cause brady 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 administered in a dosage of 60 mg 6 times a day with an interval of 4 hours. The treatment course is 1 week, after which the dosage is gradually reduced. The total course is exactly 3 weeks.

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

The most common side effects are considered to be: decreased BP, diarrhea, nausea, heart rhythm disturbances, hyperhidrosis, dizziness, sleep disturbance, 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 aneurysms, standard antihypertensive therapy is used. Labetalol, captopril, hydralazine are considered to be the most popular drugs of this plan for the prevention of aneurysm rupture.

The drug "Hydralazine" is administered after a meal orally. The initial dose is 10-25 mg 2-4 times a day. Gradually it is increased to 100-200 mg per day (not more than 300 mg per day).

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

Among the side effects are: attack-like pain in the heart, nausea with vomiting, weight loss, stool disorders, enlarged lymph nodes (lymphadenopathy), headaches, neuritis, facial hyperemia, shortness of breath, nasal congestion and some others.

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

Additionally prescribe vitamins as a general tonic, promoting rapid recovery.

Folk treatment and homeopathy

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

Folk medicine can offer many variants of recipes to normalize blood pressure, which is required in this case. In addition, many therapeutic compositions turn out to be an irreplaceable source of vitamins, so necessary weakened after surgery.

The most effective in this case is the treatment with herbs, or rather fruits of plants (currants, cranberries, hawthorn, rose hips, kalina, blackcurrant rowan). These tasty medicines can be consumed regularly without negative consequences for the body.

So rosehip is able not only to reduce blood pressure, but also to restore the elasticity of blood vessels. It is taken in the form of infusion (2 tbsp. Per 1 tbsp. Boiling water) twice a day half a cup.

You can also make an effective combined remedy recommended for high BP. Take 1 part each of aronia and cranberry and twice as much rosehip and hawthorn. 2 tbsp. Mixture brew 1 tbsp. Boiling water. Drink the infusion for 3 times. Take it half an hour before meals.

Black currants can be eaten throughout the year. In winter, a good infusion of dried berries (100 g to 1 liter of boiling water). It should be taken a quarter cup three times a day.

From the pressure is useful and beet juice with honey (3 times a day, 3 tbsp.).

Of the herbs for elevated BP can be used mistletoe, wheatgrass, cleanser, turfgrass.

Of modern homeopathic remedies to normalize blood pressure before and after the rupture of a cerebral aneurysm is well established drug "Homviotensin". It gently reduces pressure and stabilizes it, in parallel 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 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 in symptomatic hypertension.

All of these drugs are used purely for preventive purposes and can not replace surgical treatment.

Forecast

A ruptured brain aneurysm is a very dangerous complication with a poor prognosis. It is clear that people diagnosed with brain aneurysm are very concerned about the question, what is the chance 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 care. The least lethality is noted in the case of rupture of an aneurysm smaller than 5 mm. But it must be said that surgical intervention is a real chance for life. It is important that it was performed in a timely manner and preferably in a good clinic with an overall postoperative mortality rate of no more than 10-15%.

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

Brain aneurysm is an insidious pathology that leads a hidden "lifestyle". In most cases, it is detected accidentally, and most often in connection with a cerebral blood circulation disorder, including as a result of vessel rupture. But even if the diagnosis is known, there is nothing to change, the only thing left to do is not to aggravate the situation.

Measures to prevent conditions that provoke the rupture of a brain aneurysm can be considered a healthy lifestyle (moderate physical activity, proper diet, avoidance of bad habits), cholesterol control and, if necessary, normalization of blood pressure with the help of pharmacy drugs, folk medicine or homeopathic remedies. This is much easier than what patients with aneurysms have to go through, if you do not carry out prevention of rupture. But even following the above recommendations does not guarantee dangerous complications if the patient does not monitor his mental health.