Aneurysm of the cerebral vessels

Aneurysm is a localized dilation of the arterial lumen caused by pathological change or damage to the vascular wall. Aneurysm of cerebral vessels can cause the development of subarachnoid hemorrhage of nontraumatic etiology, which occurs in more than 80% of all intracranial hemorrhages. The origin of such pathology can be different: there is no single cause. Since cerebral aneurysm carries a direct threat to the life of the patient, the treatment is predominantly radical - surgical. [1]

Epidemiology

Specialists point out that it is impossible to keep complete statistics on the development of cerebral vascular aneurysms. First of all, this is due to the fact that the disease is not always diagnosed: many patients live without knowing about the problem. In some people, the pathology is asymptomatic.

There is evidence that in the majority of cases the disease only reveals itself with the development of a complication - in particular, hemorrhage. The fatal outcome after this most common complication is estimated at 65%. In surviving patients, the risks of repeated rupture of the vessel are significantly increased - such an unfavorable outcome is diagnosed in 60-90% of patients.

Brain aneurysms are referred to as intracranial, intracranial, or cerebral aneurysms. Pathologic expansions of this type are more often saccular, lacking a muscular layer. The problem is more often found in patients 30-50 years old. The incidence is 1.5-5% in the entire world population. In our country, cerebral vascular aneurysms affect up to 2 million people, with 5 to 10 thousand new patients added annually. On average, 17-18% of patients have multiple aneurysms. Men and women are sick with approximately the same frequency, but women are more likely to have giant pathologic bulges. Pathology is considered the most dangerous when it comes to a pregnant woman.

The disease is more common in countries such as Finland and Japan.

The risks of aneurysmal hemorrhage from the pathologic focus are approximately 1% per year. At the same time, the risks of recurrent hemorrhage increase and are between 15 and 25% during the first 14 days and about 50% at six months.

The larger the size of the aneurysm, the greater the risk of hemorrhage. Small dilations up to 5 mm are complicated by hemorrhage in 2.5% of cases, bulges between 6 and 10 mm rupture in more than 40% of cases, and foci larger than 11 mm and smaller than 15 mm rupture in almost 90% of cases. Large aneurysms with a diameter of more than 15 mm rupture less frequently due to massive thrombus formation in them.

The risks of patient death in case of repeated rupture of the pathologic focus during the first 7 days after the development of the complication are estimated at 32%, during 14 days - 43%, and during the first 12 months after rupture - up to 63%. Repeated hemorrhages almost always have a more severe course, in contrast to the first episode. [2]

Causes of the cerebral aneurysms

Specialists cannot identify a single theory of the origin of cerebral vascular aneurysms. Apparently, there are several causes, and the main ones are considered to be degenerative changes in the vessel wall, or damaging effects of certain factors.

Cerebral vascular aneurysm formation occurs in the presence of these wall defects:

• damage to the muscular layer of the blood vessels;
• a defect in the inner elastic layer;
• hyperplasic processes in the intima, atheromas;
• damage to the collagen fibers;
• increasing stiffness of the arterial vessel against the background of its thinning.

Aneurysms of cerebral vessels are most often found at the branching site of the arterial trunk or at the bend of the artery. This is due to the large hemodynamic impact on the vascular walls in these areas.

Brain aneurysms are often found against the background of such pathologies as hypertension, renal polycystosis, coarctation of the aorta, connective tissue diseases, brain tumors, arteriovenous malformation. [3]

• Is a brain aneurysm hereditary?

Aneurysms can be congenital or acquired. In most cases, we are talking about acquired aneurysms of the brain vessels: such a disease is usually caused by pathological intravascular processes, such as atherosclerosis, infectious processes, or trauma and mechanical damage.

The aneurysm itself is not inherited. However, certain provoking factors can be transmitted, such as hereditary connective tissue pathologies, genetic defects of the cerebral vessels. In particular, inherited Marfan syndrome, which is accompanied by mutations in the gene fibrillin - the most important component of connective tissue. As a result of such mutations, there is an increase in the content of specific protein structures that provoke the appearance of characteristic pathological changes, resulting in a significantly increased risk of cerebral aneurysm formation. The degree of inheritance of Marfan syndrome from a sick parent is 50/50.

Specialists say that hereditary inheritance can also be a tendency to early atherosclerosis and hypertension. In such a situation, a person has additional risk factors that can provoke the development of cerebral vascular aneurysms. If such factors are present, it is important to regularly visit your doctor, to conduct diagnostics, which allows timely detection of disorders of the cerebral vessels.

Risk factors

The main root cause of cerebral aneurysm formation is a structural disorder of any of the layers of the vascular wall. If the adventitia, media or intima are intact and undamaged, there will be no formation of a pathological bulge in them. Factors that contribute to the appearance of an aneurysm include:

• inflammatory processes in the brain (in particular, meningitis in the anamnesis);
• craniocerebral injuries that can cause dissection of the walls of the cerebral blood vessels;
• systemic diseases, endocarditis, syphilis, mycoses, etc.;
• congenital pathologies (mainly connective tissue disorders and vascular defects);
• hypertension;
• autoimmune pathologies;
• atherosclerotic processes;
• Other factors (oncology, cerebral amyloid angiopathy, etc.).

Pathogenesis

A cerebral aneurysm is the result of a structural disorder in the vessel wall. In a healthy person, the vessel has an inner layer - intima, a layer of muscle fibers and an outer layer called adventitia. Degeneration processes, improper development, or damage to any of their layers entails loss of elasticity and thinning of the corresponding vascular segment. Subsequently, under the influence of blood flow, a localized bulge is formed in the wall of an artery or vein: the resulting enlarged cavity is an aneurysm. Most often, the problem occurs in the area of a vascular branch, which is caused by high pressure on the vessel wall. [4]

Congenital pathology may be the result of any developmental defects associated with improper structural organization of the arterial wall. This problem often occurs against the background of other congenital diseases - for example, renal polycystic disease, aortic coarctation, connective tissue dysplasia, venous-arterial cerebral malformation, etc. [5]

Acquired cerebral vascular aneurysms usually develop due to abnormalities caused by head injuries, prolonged high blood pressure, marked atherosclerotic changes, and vascular hyalinosis. In some patients, dilation of cerebral vessels is provoked by the entry of emboli into them - in particular, mycotic emboli.

Other possible causes include irregular blood flow. [6]

Symptoms of the cerebral aneurysms

For a long time - years, decades - cerebral vascular aneurysms are asymptomatic. Since the cerebral vascular network consists of fairly small vessels, pathological dilations are rarely large. As a result, the pressure on nearby structures is weak, which entails scarce symptomatology.

However, sometimes an aneurysm does present with individual symptoms or a combination of symptoms. This happens:

• if the bulge is so large that it starts to press on certain brain structures;
• if the abnormal enlargement is near an area of the brain responsible for vital functions;
• if a dissection and/or rupture of the dilated segment occurs;
• if the bulge is present against the background of hypertension or other chronic pathologies.

The first signs may be as follows:

• Headache, constant or intermittent, non-intense or severe.
• Insomnia at night, drowsiness during the day, or a constant feeling of sleepiness.
• Digestive disorders, often - nausea (up to vomiting).
• Meningeal signs (characteristic of aneurysms localized near the cerebral membranes).
• Seizures.
• Skin sensitivity disorders, visual or hearing impairment, vestibular disorders.
• Malfunction of the nerves responsible for fine facial motor skills.

Symptomatology develops over time, depending on events. When an aneurysmal bulge is significantly enlarged, symptoms such as pain in the head and/or eyes, pupil dilation (more often in one eye), visual impairment such as double vision or blurred vision, numbness of certain muscles in the face, neck. Speech and hearing may be impaired.

If the aneurysmal extension ruptures, the picture worsens dramatically:

• the pain in his head is dramatically increasing;
• nausea (to the point of vomiting), photosensitivity;
• blurred consciousness, dizzy;
• The eyelid may droop, half of the face or even half of the body may go numb (limbs on one side, like a stroke).

If medical attention is not rendered at the moment of rupture of the affected vessel, irreversible changes occur in the affected area within a few hours. In most cases, the patient soon dies.

If the aneurysm is complicated by thrombosis, blood flow within the vessel is inhibited or completely stops. A dissection of the damaged vascular segment is also possible, when blood penetrates between the layers of the artery.

Vascular pathology negatively affects the quality of life, especially in the case of a significant bulge that presses on a certain part of the brain. The resulting neurological symptoms become an obstacle not only to professional duties, but also to household chores. [7]

Psychosomatics

According to the theory of the influence of psycho-emotional mood on the development of pathological conditions, cerebral aneurysm is able to occur in people who have experienced great grief, loss of loved ones. As a rule, it is about some strong rupture, shock, for which a person feels guilty.

Such a diagnosis indicates that the patient should seriously think about and free himself from all negative emotions. The optimal solution will be to establish a dialog with loved ones (relatives or friends) about their worries and problems.

Experts warn: you can't keep emotions and thoughts inside. If you do not let the grief go out, it will simply kill the body from the inside. You should not indulge in bad thoughts and actions, because they are usually provoked by stubbornness and pain living inside a person. The problem will cease to be hopeless and growing if you spill it out, get rid of it forever.

It is known that brain aneurysms are more likely to develop in people who are malleable, overly sensitive, and devoid of their own opinions.

Headache with a brain aneurysm

Pain in the head is a vivid and characteristic symptom accompanying cerebral aneurysm. The pain syndrome may occur both in the frontal, occipital, temporal regions and throughout the head, with irradiation to the neck.

As the affected vascular segment stretches, the surrounding structures - tissues and nerve endings that are present in them - are compressed. Appears quite severe pain in the head, often reminiscent of migraine attacks. In addition, neurological disorders may also occur: deterioration of vision, blurring, color distortion, etc.

If the aneurysm is located in the temporal lobe, then, in addition to pain in the temples, there may be sudden hearing loss (usually on one side), changes in speech perception or speech activity. Dizziness, blood pressure fluctuations, unevenness of pressure and pulse rates on the left and right arm are possible.

Any of these signs is a reason to consult a doctor. Constant or frequent headache is also an indication for medical consultation. [8]

High blood pressure with a brain aneurysm

High blood pressure acts as a cause of intracranial cerebral aneurysm, as well as a symptom that aggravates the course of the pathology and worsens its prognosis.

The danger of increases and fluctuations in blood pressure is that they have an extremely unfavorable effect on the condition of the arteries. In some patients, hypertension in general proceeds without certain symptoms, without pain and dizziness. As a result, a person does not know about high blood pressure, does not take any measures, which can end very badly: the walls of cerebral arteries are even more damaged, the risk of rupture of the vessel and the development of hemorrhagic stroke increases.

In patients with arterial hypertension, aneurysms occur predominantly in small arteries less than 500-800 μm in diameter that supply blood to the deeper parts of the cerebral hemispheres (internal capsule, white matter, subcortical ganglia). Due to anatomical peculiarities, the walls of small arterial vessels experience the greatest pressure and the most intense structural changes occur.

Stages

The danger of pathology is often hidden in the initial, hidden stage of development, when pathological changes are already occurring, and the patient is not even aware of them. Clinical manifestations are detected at later stages, when the formation begins to press on nearby brain structures. The sequence of the appearance of symptomatology is determined by the following stages:

• an increase in the bulge;
• the appearance of a defect in the muscle layer;
• stage of damage to the inner elastic membrane;
• processes of hyperplasia of the inner lining of the vessel;
• appearance of a defect in collagen fibers, delamination of the vessel wall;
• increasing stiffness of the arterial wall, a decrease in its thickness;
• a tear in the wall of a cerebral vessel.

Forms

Depending on the localization, the following types of aneurysms are divided:

• aneurysm of the internal carotid artery;
• an aneurysm of the anterior or middle cerebral artery;
• vertebrobasilar aneurysm.

In general, many criteria form the basis of classification. In addition to localization, this includes the configuration of the pathological segment, belonging of the affected vessel, causative factor, peculiarities of course, etc.

Thus, cerebral artery aneurysms can be saccular (more common) or spindle-shaped, miliary, common, large, giant (more than 25 mm in diameter), and multichamber or single-chamber, multiple or single, acquired or congenital.

Aneurysm of the carotid artery of the brain is particularly dangerous, since it is through this vessel that the cerebral blood supply is carried out, and any complication of the pathology can provoke a stroke. Pathological bulging can occur in the cervical carotid artery or in its intracerebral section. All parts of the vessel are considered life-threatening. Rupture of the cervical section is quite rare, but there is a possibility of the formation of a thrombus that can block blood flow through the artery. Sometimes the thrombus particles cause the development of ischemic stroke. Intracerebral bulges in many cases are complicated by rupture and the development of hemorrhagic stroke. Pathology can develop in the bifurcation zone, in the internal or external carotid artery, in the intracranial section of the internal carotid artery.

More than 85% of aneurysmal pathologies form in the carotid or anterior cerebral artery. Up to 30% of bulges are found on or near the intracranial portion of the internal carotid artery. Up to 30% more form in the anterior portion of the vessel. More than 20% develop in the basal branch of the middle cerebral artery.

The pathology can affect any cerebral region, but most commonly involves the sites of branching off from the arteries, between the lower brain and the cranial base.

Aneurysm of the cerebral basilar artery is more often found in the more proximal parts of the vessel. Less often, segments localized along the course of the upper vascular portion are affected. Often the problem is detected in the region of the exit of the posterior inferior cerebellar artery.

Aneurysms can appear on almost any vessel. But most often they are diagnosed on the arterial trunks at the cranial base. This is due to anatomical and physiological features: in this place, blood pressure is higher than in other areas, so the risks of stretching the vascular walls are increased. If one layer is damaged, the bulge quickly worsens under the influence of pressurizing blood flow.

All vascular pathological enlargements are conditionally divided into acquired and congenital. Congenital cerebral aneurysm is provoked by defects in the development of the vascular network, genetic diseases associated with changes and weakening of connective tissue. If there is unfavorable heredity, the problem manifests itself already at a young age. In early childhood, pathology very rarely makes itself known.

The vast majority of aneurysmal dilatations are acquired diseases. The causes are craniocerebral trauma, tumor and infectious processes, hypertension and atherosclerosis, diabetes mellitus and bad habits.

Multiple cerebral aneurysms are often a consequence of inflammatory processes caused by fungal or streptococcal infection. Pathology can occur in patients with tuberculosis, syphilis.

A saccular cerebral aneurysm is the most common configuration of pathologic enlargement. It has the appearance of a small thin-walled sac with structural parts such as the bottom, middle part and neck. Such formations can be single or multichambered.

Fusiform cerebral aneurysm, otherwise called spindle-shaped (because the shape resembles a spindle), is somewhat less common than the baggy form.

According to the size, the pathology is classified as follows:

• less than 3 millimeters is miliary;
• 4 to 15 millimeters - regular;
• 16 to 25 millimeters is large;
• over 25 millimeters is a giant brain aneurysm.

According to the type of the affected vessel, pathology can be arterial, venous, and combined. Arteriovenous aneurysms of the brain are a tangle of dilated vessels with different diameters and irregular structure.

Inoperable cerebral aneurysm

The only radical way to eliminate pathologic dilation is surgical intervention. This is a complex neurosurgical operation, often involving the opening of the skull and resection of the damaged vascular segment. Rehabilitation after such intervention is complex and long.

Despite the continuous improvement of microsurgical techniques, modern equipment and other innovations, the procedure to remove a vascular bulge is not always successful. If the pathological focus is located deep in the brain, access to it may be difficult, so such aneurysms are recognized as inoperable - that is, those that cannot be operated on.

The doctor performs angiography, neuronavigation, electrocorticography, computerized tomography or magnetic resonance imaging to find out the possibilities of surgery.

Symptoms of cerebral aneurysms in women

It is known that the prevalence of aneurysmal lesions of cerebral vessels in the female population is somewhat higher, and the pathological enlargements themselves are more often larger than in men. A special role in the development of "female" aneurysms is played by hormonal fluctuations, pregnancy and bad habits - in particular, smoking.

The most common complaint of female patients, with which they turn to doctors, is headache - frequent, prolonged, not controlled by conventional medicinal analgesics. Other possible symptoms include:

• pain in the eye (or behind the eyeball, usually on one side);
• changes in visual function, double vision;
• Numbness on one side of the face, unilateral hearing impairment or pupil dilation.

As the pathology worsens, the clinical picture expands and the condition worsens. Severe headaches, vestibular disorders, nausea and vomiting, blurred or double vision, increased light sensitivity, eyelid drooping, neck numbness, emotional instability and disorders of consciousness are possible.

As complications develop, a corresponding clinical symptomatology is noted.

Symptoms of cerebral aneurysms in men

Men more often suffer from asymptomatic variant of the pathology: the problem is discovered by chance, during MRI or CT scan of the brain for some other indications. Less common are variants accompanied by symptomatology similar to the picture of a tumor process in the brain. Patients complain of pain and noise in the head, nausea and dizziness, photophobia, speech, auditory and visual disturbances, deterioration of sensitivity on one side of the trunk. There may be weakening of some mimic muscles, limb muscles on one side of the body, sometimes - convulsions.

When an aneurysm ruptures, subarachnoid hemorrhage occurs. Blood pours into the subarachnoid brain space, which is accompanied by increased symptomatology. In most cases, the picture worsens suddenly: there is a sharp pain in the head, nausea to vomiting. Some patients note a feeling of "boiling water spilling into the head". There may be a moderate to comatose state of consciousness.

The acute period is often accompanied by psychomotor agitation, increased body temperature and blood pressure.

A brain aneurysm in children

The development of vascular bulges in the brain is rare in children (slightly more than 2% of the total number of diagnosed aneurysmal dilatations). Moreover, scientists cannot explain why children develop this disease at all, which is more typical for patients over 40-50 years old. In pediatrics, there are no such risk factors as smoking, hypertension, atherosclerosis and so on.

For a long time, the opinion about the congenital origin of the pathology has been voiced. At the same time, no cases of aneurysms have been identified so far in the study of fetal intrauterine development - for example, in screening ultrasound.

It has been observed that in children cerebral pathologic bulges have a particular tendency to enlarge and become large in a relatively short period of time. Given the above, the theory of the acquired nature of all cerebral aneurysms is currently dominant. Sometimes infectious diseases and head injuries are considered as probable root causes. Nevertheless, in most situations, the origin of this disease in childhood remains unclear.

In children, the problem occurs more often in the region of the internal carotid artery: lesions of the distal and proximal intracranial portions of the bifurcation zone and the cavernous section are common, whereas in adult patients, dilatations of the middle segments (supraclinoid and paraclinoid sections) predominate.

In almost 70% of cases, the pathology in children is manifested by intracranial hemorrhage. Less often tumor-like and ischemic types of aneurysmal course are registered. [9]

Complications and consequences

In most patients, the pathology is detected accidentally, during routine examination, or diagnostic measures carried out for other diseases. Usually the problem does not detect itself clinically, only a small number of patients may indicate the occasional occurrence of headaches, dizziness, unsteadiness. The real visible symptomatology often occurs only when complications develop.

The rupture of a cerebral aneurysm manifests itself as a sharp blow, as a sudden headache. The patient feels a rush of heat to the upper half of the body and, especially, to the head, there is severe weakness in the extremities. Hemorrhage can have a different localization, depending on this, the symptoms differ:

• vascular rupture in the frontal lobe is accompanied by severe psychomotor agitation;
• rupture of the middle cerebral artery occurs with hemiparesis or hemiplegia, there is difficulty in making movements of one side of the trunk;
• rupture of a vessel in the posterior cranial fossa is noted loss of consciousness, coma, spikes in blood pressure, respiratory distress;
• A vascular rupture in a section of the anterior communicating artery can lead to the development of partial blindness.

Quite often the rupture entails subarachnoid hemorrhage - the escape of blood into the cavity that lies between the brain and the cranial bone. A threatening consequence of such bleeding can be hydrocephalus, characterized by excessive accumulation of cerebrospinal fluid in the cerebral ventricles, which increase in size and press on nearby brain structures.

Another possible complication is vasospasm, a narrowing of the blood vessels resulting in restricted blood flow. Vasospasm, in turn, can cause stroke or tissue damage.

A thrombosed cerebral aneurysm is a dangerous condition in which the blood channels become clogged with a blood clot, resulting in impaired microcirculation and further development of ischemia. Increased blood volume inside the skull leads to an increase in intracranial pressure. As a result, the patient has severe headaches, epileptic seizures. Seizures with a brain aneurysm are not uncommon. The problem occurs along with neurological disorders - such as paralysis, visual and sensory disturbances. If the cerebral edema is significant, disturbances of consciousness up to the development of coma are often noted.

Temperature in brain aneurysm can be one of the signs of mycotic infection, or arise from damage to the brain stem, when the dilated section of the vessel begins to press on the centers of thermoregulation. Stem stroke is considered the most unfavorable complication: the structures of the brain stem are responsible for providing vital functions of the body, including blood circulation, respiration, cardiac activity, and vital reflexes.

Can a brain aneurysm go away on its own?

Independent "resorption" of the aneurysmal focus is impossible. In some cases, it is possible to achieve a slowdown in the dynamics of pathologic enlargement, but it is not possible to completely get rid of the problem by conservative means.

The root of the danger lies in the fact that the patient can "procrastinate", postpone the operation and hope for an independent disappearance of pathology - and this, of course, does not happen. Meanwhile, the problem worsens, the risk of rupture increases. Often it ends in the death of the patient.

With cerebral aneurysms do not joke, expect them to "resorb", or try to cure by folk methods in no case can not. Pathology can seriously damage the central nervous system, provoke the development of hemorrhagic stroke. In addition, there are often recurrences of the disease, which in many cases also occur covertly and end with cerebral hemorrhage.

Diagnostics of the cerebral aneurysms

It is impossible to determine the presence of pathological vascular dilation in the brain based on the patient's complaints and present symptoms. Moreover, pathology is often asymptomatic. Therefore, the diagnosis is made on the basis of a set of measures, including history taking, neurological examination, tomographic and radiological studies, and tests (including cerebrospinal fluid).

During the neurological examination, the presence of focal and meningeal signs is assessed, which allows to orient and suggest the possible localization of the pathological focus.

In addition to the standard general clinical blood and urine tests, the patient is prescribed a lumbar puncture. If blood particles are found in the extracted cerebrospinal fluid, it indicates subarachnoid or intracerebral hemorrhage. [10]

Instrumental diagnosis involves the following tests:

• X-ray of the skull - allows you to identify areas of calcification in the vessels, as well as destructive processes in the bone system.
• MRI visualizes an aneurysm even without the use of contrast. During the procedure, it is possible to determine the size and localization of the affected vascular segment, identify signs of lack of blood flow in the aneurysmal zone, and detect the presence of complications.

Major MRI signs of cerebral aneurysm:

1. the characteristic "emptiness of flow";
2. High-intensity, hyperintense, or isointense signal during the acute phase in magnetic resonance angiography.

• CT is a method used along with MRI, but requires the use of contrast. Radiologic diagnostics is most often prescribed for patients who are in a serious condition, which is due to the high speed of image acquisition (3-5 minutes). The resulting three-dimensional image helps to consider the location of the feeding vessels, the zone of arteriovenous malformation. The disadvantage of the method is the poor viewing of the vascular network near bony structures, as well as in the radiation load. The main contraindication to the study is hypersensitivity to the contrast agent used in CT.
• Angiography - helps to clarify the localization, configuration and size of the aneurysm site. Radiologic angiography requires the use of contrast agents. Magnetic resonance angiography is performed without contrast administration and allows to display a two-dimensional picture of a cross-sectional vascular section or a three-dimensional volumetric picture.
• Ultrasound of the cerebral vessels can be represented by ultrasound Doppler, duplex and triplex ultrasound. Which procedure to choose is decided by the doctor.

Differential diagnosis

Aneurysms of cerebral vessels are differentiated with the following diseases (depending on clinical manifestations):

• cerebral circulation disorders (hypertensive crisis, transient ischemic attacks);
• Strokes (embolic, thrombotic, hemodynamic, etc.);
• acute hypertensive encephalopathy.

In the course of diagnostic measures, attention should be paid to all possible acute and chronic disorders of blood circulation in the brain. These may be transient disorders of cerebral circulation, strokes (cerebral or mixed), transient ischemic attacks, hypertensive crises.

The range of diagnostics should be as extensive as possible and include a wide range of laboratory and instrumental studies. It should be taken into account that a similar clinical picture is often given by such pathologies as tumor processes in the brain, arteriovenous malformations.

Treatment of the cerebral aneurysms

Patients with small vascular bulges can be treated with conservative methods with regular monitoring by neurologists and neurosurgeons. Therapeutic measures are aimed at preventing further aggravation of the pathology. They include stabilization of blood pressure and heart function, reduction of blood cholesterol levels, and general strengthening of blood vessels.

If there are risks of bulge enlargement or rupture, the patient is prepared for surgical treatment. The main surgical techniques are considered to be clipping of the aneurysmal neck and endovascular embolization. It is also possible to use stereotactic coagulation, creating an artificial thrombus with the help of coagulants. Vascular malformations are removed by radiosurgical or transcranial methods.

In case of aneurysm rupture, measures are performed similar to hemorrhagic stroke. Some patients with ruptured vessels undergo surgical intervention: removal of the hemorrhage, stereotactic aspiration of the hematoma, or endoscopic evacuation of the spilled blood. Ventricular hemorrhage may require ventricular drainage. [11]

Drugs for cerebral aneurysms

The use of conservative methods aims to prevent further progression and rupture of the aneurysmal enlargement. It is possible to prescribe such drugs:

• Nimodipine is a selective calcium channel blocker, actively used to eliminate ischemic disorders caused by cerebral vasospasm. After a 1-2 week course of infusion treatment, the drug is prescribed for another week at 60 mg six times a day. Treatment is adjusted by a doctor on an individual basis. Possible side effects: nausea, decreased blood pressure, headache.
• Labetalol, Captopril - drugs that reduce blood pressure. They are prescribed in tablets in individual dosages. Use may be accompanied by dizziness, headache, nausea, a feeling of brokenness and fatigue, skin itching.
• Picamilon is a nootropic drug that improves cerebral blood circulation, reducing vascular resistance. The standard dosage of the drug is 0.02-0.05 g up to three times a day, for several months. The dose can be adjusted by the doctor according to indications. Picamilon is not recommended for use in severe acute cerebral circulation disorder.
• Fosphenytoin is an anticonvulsant drug, prescribed for epileptic seizures in individually adjusted dosages. Often causes dizziness and drowsiness, so during the treatment course patients should not drive vehicles.
• Prochlorperazine is a neuroleptic, antiemetic drug, prescribed 5-10 mg up to 4 times a day. Restrictions to administration: acute periods of brain injury, pregnancy, impaired hematopoiesis, acute infections, renal and hepatic insufficiency.
• Mexidol is an antioxidant drug, improves metabolic processes and blood supply to the brain, reduces platelet aggregation. Mexidol is taken orally at 125-250 mg, gradually increasing the dosage until the required therapeutic effect is achieved. The maximum daily dose is 800 mg. The duration of the treatment course - from two to six weeks. The drug is canceled gradually. Among the common side effects: digestive disorders and drowsiness.

Surgical treatment

The cardinal way to eliminate aneurysmal pathology of the brain is surgical "disconnection" of it from the blood flow. Despite the only true method of treatment, not every pathological bulge of a cerebral vessel is considered operable. When recommending surgery, the doctor takes into account:

• peculiarities of individual clinical course of pathology;
• the degree of risk of vessel rupture;
• the location of the pathologic focus;
• the size and number of aneurysmal bulges;
• overall cerebral vascular tone;
• other existing individual risks of the operation.

In some cases, with a small size of the bulge and in the absence of negative dynamics, the doctor establishes surveillance of the pathological segment, performs regular diagnostics: prescribes repeated control MRI or CT - for example, annually.

If the risk of rupture of the vessel is high, surgical intervention is inevitable, and its tactics are determined by the surgeon. Usually one of two common methods is used:

• Clipping (open craniotomy);
• method of endovascular embolization (coiling).

Clipping is a traditional technique in which the surgeon makes a hole in the skull, exposes the arterial vessel with the aneurysm through it, and clamps its neck with a special titanium clip. The procedure results in "switching off" the affected area from the blood flow and preventing its further expansion and rupture.

Open intervention is rarely practiced, mainly in case of impending or already occurred rupture and intense bleeding. The operation is quite risky, in many cases leading to disability of the patient.

Coiling, another variant of surgery, is a minimally invasive intervention. The vascular bulge is "turned off" from the inside using minispirals: no opening of the skull is required. Access is performed by puncturing the femoral artery with the introduction of a conductor into it - a special cannula with a diameter of 2 to 4 mm. A catheter is inserted through the cannula, which helps to monitor the vessel and control the course of the operation. Additionally, a minicatheter with a thickness of up to 0.5 mm is also inserted. It is he who allows to approach the aneurysm and install in it coiling - a platinum spiral with a diameter of up to 0.25 mm. Depending on the size of the aneurysmal expansion, several such spirals can be used: the dilated lumen is filled from the inside until the vessel is "turned off". The "eliminated" vascular segment is gradually replaced by connective tissue.

If the lumen of the bulge is too wide, the surgeon first places a stent and only then proceeds to the placement of the spiral. As a result, the dangerous segment is strengthened, which reduces the risk of its damage during coiling. The operation is completed by removing all the instruments and closing the inguinal artery. [12], [13]

Nutrition in brain aneurysms

Changes in nutrition will help prevent the development of complications from cerebral aneurysms, prevent the aggravation of pathology. Rational nutritional regimen implies full satisfaction of the physiological needs of a person in nutrients and energy. Food should be varied, healthy, taking into account age, sex, body weight. Dishes are prepared with a minimum amount of table salt, with the exclusion of animal fat, with normal or low calories. At the same time, the diet should include enough products rich in dietary fiber, magnesium and potassium, polyunsaturated fatty acids. Such changes in diet will help slow the development of atherosclerotic changes, stabilize blood pressure, reduce the risk of complications.

Special emphasis should be placed on the consumption of fish oil, fish, seafood, herbs, fruits and vegetables. It is strongly recommended to regularly add seaweed, raisins, zucchini and pumpkin, buckwheat, beets, bananas and apricots to the diet.

Diet for cerebral aneurysms

Nutritional correction for cerebral vascular pathology should help improve blood circulation and cardiovascular function, as well as normalize cholesterol levels.

Nutrition should be physiologically complete, with a reduced amount of salt (up to 3 g / day), with the exclusion of food containing animal fats and extractive components that affect the nervous and cardiovascular systems. Under the ban fall strong coffee and tea, broths based on meat and fish, lard, offal, smoked, fried and spicy foods. Food should contain a sufficient amount of magnesium and alkaline. In the diet should necessarily add fermented milk products, different types of cabbage, carrots and beets, citrus fruits, apples. Dishes are allowed to be steamed, baked, boiled. Optimal mode of eating: 5-6 times a day.

The list of allowed and undesirable products is presented in the table:

Food products	Authorized	Unwanted
Bakery products	Unleavened and salt-free bread from dark wheat varieties, diet breads, unsweetened cookies, galette cookies.	White bread, muffins, saltine crackers, puff pastry, pancakes and fritters, pies.
First courses	Vegetarian (potato and vegetable, dairy).	Meat, fish, mushroom broths.
Meat dishes	Lean white meat (boiled or baked).	Red meat, fat and lard, smoked meat, sausages, offal, canned meat.
Fish	Preferably seafood, boiled, stewed or baked.	Smoked and salted fish, caviar, canned food.
Dairy products	Low-fat whole milk (up to 1%), fermented milk products, cottage cheese, low-fat sour cream (up to 10% and in small quantities).	Salty cheeses, fatty types of cheese (more than 45% fat content).
Eggs	Up to a couple of chicken eggs per week (including as part of meals).	Fried eggs.
Grains	Any cereals cooked on water or milk, pasta from durum wheat.
Vegetables	Potatoes and other root vegetables, zucchini, pumpkin, tomatoes, herbs, cucumbers. Onions and garlic - as part of dishes that undergo heat treatment.	Pickles and pickles, sauerkraut, sorrel, radishes, raw onions and garlic, mushrooms.
Carbohydrate food	Any fruit, dried fruits, soursels, compotes, jellies, honey, jam.	Chocolate, brownies, cakes, candy.
Beverages	Lightly brewed tea, coffee substitutes with milk, self-made juices (vegetable or fruit), rosehip decoction and herbal teas (chamomile, mint, calendula, linden).	Strong tea or coffee, cocoa.
Fats	Vegetable oil (any).	Any animal fat, butter, spreads and margarines.
Sauces, condiments	Homemade tomato and sour cream sauces, fruit pours, vanillin, citric acid, cinnamon, bay leaf.	Horseradish, mustard, mayonnaise, any sauces based on meat, fish or mushroom broth.

Vaccination for cerebral vascular aneurysm

Most experts believe that localized cerebral vasodilation, as well as other chronic cardiovascular diseases, are not contraindications to coronavirus vaccination. Stroke is also not considered a contraindication. Experts point out that COVID-19 disease carries a much greater threat to vascular health and condition than vaccination. Moreover, in people who have experienced a rupture of a cerebral vessel, the additional load in the form of coronavirus infection can cause repeated hemorrhage. Therefore, it is mandatory to vaccinate such people.

Important: vaccination is not administered:

• in the acute phase of any disease;
• in a period of severe weakening of immunity (for example, against the background of treatment with immunosuppressors, hormones, etc.).

Limitations of cerebral aneurysms

After the diagnosis of a brain aneurysm, most patients are confused and bewildered. Few of them realize how their life should change due to the presence of the disease. Often patients simply "give up", losing precious time for treatment. Meanwhile, doctors strongly advise against this: aneurysm itself will not dissolve and disappear. It is important not to allow the problem to worsen, so all recommended restrictions should be aimed at preventing the emergence of complications and preventing aneurysmal enlargement.

In no case should you take any medications on your own, unless they are prescribed by your doctor. We are talking about pills, injections, and even dietary supplements. If a person has to take any medication for other diseases, he or she should consult his or her doctor beforehand.

The presence of an aneurysm is not a reason to exclude all activity. The patient must remain active within a certain volume, which is determined during the medical consultation.

What should I not do if I have a brain aneurysm?

Patients with a diagnosed cerebral aneurysm, regardless of the size and localization of the pathological focus, can not:

• to smoke;
• drinking alcohol;
• eat too salty and spicy food, lard, fatty meat, butter;
• drink coffee and strong tea;
• allow for intense physical and nervous strain;
• to gain weight;
• ignoring doctor's orders.

It is strictly forbidden to stay in the sun for a long time, to visit steam rooms and saunas, to allow sudden temperature changes, to take any medications not approved by the attending physician. It is also desirable to exclude air travel, which is often not easily tolerated even by healthy people. For people with aneurysms, high altitude pressure fluctuations, reduced oxygen in the cabin during takeoff, staying in the turbulent zone are particularly dangerous. However, for each specific case the question "to fly or not to fly" is discussed with the attending physician.

The following can be said about the possibility of driving. With adequate visual acuity, speed of reactions and thought processes, preserved muscle function, if the patient is able to react quickly to any situation on the road, he is allowed to drive. If driving can lead to additional stress, increased blood pressure, general overexcitation, it is better to refuse it.

Prevention

Competent preventive measures can protect a person from the formation of brain aneurysms. This is especially true for people in risk groups:

• who are overweight;
• abusing alcohol and smoking;
• who lead passive and sedentary lifestyles;
• who are over the age of 45;
• with a genetic predisposition;
• Suffering from diabetes and/or hypertension;
• who are exposed to frequent physical and stressful activities.

Doctors advise:

• avoid foods high in cholesterol;
• practice moderate motor activity (physical education, hardening, long walks);
• to control your body weight;
• consult doctors in case of systematic pain in the head, dizziness, sudden deterioration of vision.

If you are prone to high blood pressure, it is important to measure your blood pressure daily. Once or twice a year, it is recommended to take blood tests for cholesterol, undergo an ECG, and regularly measure blood sugar levels. You should also drink plenty of water, avoid animal fats and high salt intake, and keep physically and intellectually active.

It is also necessary to protect your head from injury: use protective equipment (helmet and other equipment) during sports, and follow safety procedures.

Forecast

Many patients with cerebral aneurysms are unaware of their dangerous pathology throughout their lives, as it is not complicated - in particular, by rupture. Nevertheless, the risk of complications is always present at any moment.

When an aneurysm ruptures, the chances of life significantly decrease: according to statistics, only about 30% of patients survive. However, even among them, about every second patient dies within 4 weeks after rupture, and only 10% of patients live for more than two years.

Lack of timely and adequate medical care in the development of complications in the vast majority of cases leads to death. [14]

Can the question of how long people live with a brain aneurysm be answered?

The fact is that the vascular wall normally has three layers - a muscle layer, an elastic membrane and connective tissue. The segment affected by an aneurysm is only a connective tissue layer, thin enough to rupture at any moment. Exactly when the rupture will occur, and whether it will ever occur at all, depends on many factors. Risk states can be:

• physical exertion (even relatively minor);
• nervous tension, stress, fright, anger, anxiety;
• drinking coffee, drinking alcohol, taking drugs, smoking;
• prolonged or short-term increase in blood pressure.

A rupture can even occur when a person bends forward, or when lifting a bucket of water or a heavy bag, or in women during pregnancy and childbirth. Sometimes the causes are even more trivial, such as constipation and excessive straining to empty the bowels. [15]

So, it is impossible to name the exact amount of time a person with a cerebral vascular aneurysm has to live. This term is absolutely individual. Moreover, the probability of complications and life expectancy practically do not depend on whether a person has symptoms or not.

Disability

Aneurysm of cerebral vessels can cause severe changes in the body that lead to permanent disability. The possibility of assigning a degree of disability is assessed by specialists, taking into account the type of pathology (venous, arterial), its location, as well as other characteristics - including the presence and degree of cerebral and local disorders, the presence of seizure syndrome, mental disorders. The doctor determines the functionality and degree of compensation of hemodynamic mechanisms by conducting a comprehensive diagnosis. In some cases, it is necessary to speak only about temporary disability, the recovery of which occurs against the background of inpatient therapy for 8-16 weeks.

Patients who suffered hemorrhagic stroke, with preserved body functions and after treatment measures can be classified as able-bodied population. It is possible to provide them with more favorable professional conditions.

• Consideration of awarding disability to patients with a brain aneurysm is possible in the following situations:
• for repeated subarachnoid hemorrhages;
• in intense psychopathologies and localized neurological disorders;
• in the presence of epilepsy;
• if the patient's professional activity is associated with pronounced neuropsychic or physical stress.

1. The first disability group is assigned if a person has complex organic mental disorders, complete paralysis, hemiparesis, aphasia.
2. The second disability group is assigned in the presence of mental disorders of astheno-organic or psycho-organic type, intellectual and motor disorders, aphasia, severe deterioration of visual function, recurrent epileptic seizures. Disability certificate is issued to patients who have suffered repeated hemorrhages or who have stable decompensation of cerebral hemodynamics.
3. The third group is assigned to individuals with relatively small residual manifestations of subarachnoid hemorrhage.

Aneurysm of cerebral vessels is a pathology in which excessive physical and mental strain is contraindicated, and trauma and intoxication can lead to the development of fatal complications. Any unfavorable influence is capable of causing rupture of the damaged vascular segment. Therefore, an important link in the social and labor rehabilitation of patients should be vocational training, retraining, vocational selection and reorientation.