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An aneurysm is an abnormal widening or ballooning of a portion of a blood vessel. A
cerebral aneurysm refers to a blood vessel within your brain that weakens over time and
undergoes such widening. This usually occurs at the junctions of the large arteries at the base of
your brain, in an area called the Circle of Willis. As the blood vessel weakens, it begins to bulge out
like a balloon. Often, as an aneurysm develops, it forms a neck with an associated dome, or balloon-
like structure. The larger the balloon becomes, the greater the risk it may burst. You would then
bleed into your brain.

Autopsy studies have revealed that 3-6% of adults in the United States have aneurysms
inside their brains. Fortunately, many of these aneurysms are small and not at risk to break. The
rates of aneurysms found by accident when other studies are performed suggest that 8-10 million
Americans have brain aneurysms. About 20-30% of people with an aneurysm will have more than
1. Each year, for every 100 people with an aneurysm, roughly 1 of them will suffer a rupture or
break-a condition known as subarachnoid hemorrhage.

Currently no one can predict which aneurysms will rupture. Data suggest that aneurysms
that rupture tend to be larger than 10 mm (0.4 in). About 25,000-30,000 cases of ruptured
aneurysms occur in the US each year. About 40% of the people who suffer bleeding from an
aneurysm die within the first month. Approximately another one third have residual major nervous
system problems but survive.

Many are left with long-term memory problems. They may have difficulty in the following:
thinking, perception, and performing simple daily activities. People who have survived a rupture of
a brain aneurysm are twice as likely as the general population to develop another aneurysm. If a
second aneurysm occurs, these people are 6 times more likely to have another ruptured aneurysm
and bleeding in their brain.



Brain aneurysms develop as a result of thinning and degeneration artery walls. Aneurysms
often form at forks or branches in arteries because those sections of the vessel are weaker.
Although aneurysms can appear anywhere in the brain, they are most common in arteries at the
base of the brain.

Aneurysms in the brain are considered to be acquired problems. They are not present at
birth. Rather, they develop over a lifetime.

Other evidence indicates that genetic factors make some people more likely to develop
brain aneurysms. The exact pattern of inheritance is not clear.

According to several studies, up to 20% of people with bleeding from an aneurysm have a
first- or second-degree relative with a brain aneurysm.
 

 

In most families with brain aneurysms, the condition affects only 2-3 members of the
extended family, and the method of inheritance is not apparent. Brain aneurysms are very rare in
children. The likelihood of having an aneurysm increases throughout life. 

Associated conditions - A number of conditions are associated with brain aneurysms, as

follows:

r| Polycystic kidney disease - A genetic disorder characterized by the growth of numerous

cysts in the kidneys.
r| Ehlers-Danlos syndrome - A group of inherited connective tissue disorders characterized by
extreme flexibility of joints, easily stretched skin and easily damaged tissue.
r| Marfan's syndrome - An inherited disorder of connective tissue, the glue and the scaffolding
of your body, which leads to tissue with less strength and that can rupture easier.
r| eurofibromatosis - A group of 8 genetic disorders of the nervous system that primarily
affect the development and growth of nerve cell tissues (These disorders cause tumors to
grow on nerves and produce other abnormalities such as skin changes and bone
deformities.)
r| Tobacco - Cigarette smoking is the only factor that has been consistently demonstrated to
increase the risk of ruptured aneurysm. Sustaining a rupture of a brain aneurysm is about
10 times more likely in a smoker than in a nonsmoker. The more cigarettes smoked, the
higher the risk.
r| Îigh blood pressure - Several studies have shown an increased risk for the development
and rupture of brain aneurysms in people with high blood pressure.
r| Îigh cholesterol - The effect of high cholesterol remains unclear. Three studies have looked
at high cholesterol as a risk factor for aneurysm and rupture. Two studies showed no
association and one study showed a relationship.
r| Alcohol consumption - A moderate to high level of alcohol use is considered a risk factor for
the rupture of a brain aneurysm. It is unclear if alcohol use increases the risk of developing
an aneurysm. Binge drinking appears to dramatically increase the risk of subarachnoid
hemorrhage from a ruptured aneurysm.
r| Older age

r| Îardening of the arteries (arteriosclerosis)

r| Îead injury

r| Certain blood infections

r| åower estrogen levels after menopause


   

‘
  

A sudden, severe headache is the key symptom of a ruptured aneurysm. This headache is often
described as the "worst headache" ever experienced. Common signs and symptoms of a ruptured
aneurysm include:

r| Sudden, extremely severe headache

r| ausea and vomiting
r| Stiff neck
r| Blurred or double vision
r| Sensitivity to light
r| Seizure
r| A drooping eyelid
r| åoss of consciousness
r| Confusion

å  

In some cases, an aneurysm may leak a slight amount of blood. This leaking, or sentinel bleed, is
likely to cause only a sudden, extremely severe headache. This bleeding is almost always followed
by a more severe rupture.


  

An unruptured brain aneurysm may produce no symptoms, particularly if it's small. Îowever, a
large unruptured aneurysm may press on brain tissues and nerves, possibly causing:

r| Pain above and behind an eye

r| A dilated pupil
r| Change in vision or double vision
r| umbness, weakness or paralysis of one side of the face
r| A drooping eyelid

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If you have a sudden, severe headache or other symptoms possibly related to a ruptured
aneurysm, you will undergo a test or series of tests to determine if you have had bleeding into the
space between your brain and surrounding tissues (subarachnoid hemorrhage) or another type
of stroke. If bleeding has occurred, then your emergency care team will determine if a ruptured
 aneurysm is the cause. If you have symptoms of an unruptured brain aneurysm Ȅ such as pain
behind the eye, changes in vision, and paralysis on one side of the face Ȅ you will likely undergo
the same tests.

Diagnostic tests include:

r| ° 
   
 °
 A CT scan, a specialized X-ray exam, is usually the first
test used to determine if you have bleeding in the brain. The test produces images that are
two-dimensional "slices" of the brain. With this test, you may also receive an injection of a
dye that makes it easier to observe blood flow in the brain and may indicate the site of a
ruptured aneurysm. This variation of the test is called CT angiography.
r| °

 
 If you've had a subarachnoid hemorrhage, there will mostly likely
be red blood cells in the fluid surrounding your brain and spine (cerebrospinal fluid). Your
doctor will order a test of the cerebrospinal fluid if you have symptoms of a ruptured
aneurysm but a CT scan hasn't shown evidence of bleeding. The procedure to draw
cerebrospinal fluid from your spine with a needle is called a lumbar puncture or spinal tap.
r| m 
  m‘ An MRI uses a magnetic field and radio waves to
create detailed images of the brain, either two-dimensional slices or three-dimensional
images. The use of a dye, MRI angiography, can enhance images of blood vessels and the site
of a ruptured aneurysm. This imaging test may provide a clearer picture than a CT scan.
r| °    During this procedure, your doctor inserts
a thin, flexible tube (catheter) into a large artery Ȅ usually in your groin Ȅ and threads it
past your heart to the arteries in your brain. A special dye injected into the catheter travels
to arteries throughout your brain. A series of X-ray images can then reveal details about the
conditions of your arteries and the site of a ruptured aneurysm. This test is more invasive
than others and is usually used when other diagnostic tests don't provide enough
information.

V    



The use of imaging tests to screen for unruptured brain aneurysms is generally not
recommended. Îowever, you may want to discuss with your doctor the potential benefit of a
screening test if you have:

r| A parent or sibling who has had a ruptured brain aneurysm, particularly if you have two
such first-degree family members with brain aneurysms
r| A congenital disorder that increases your risk of a brain aneurysm



 



When a brain aneurysm ruptures, the bleeding usually lasts only a few seconds. The blood can
cause direct damage to surrounding cells, and the bleeding can damage or kill other cells. It also
increases pressure inside the skull. If the pressure becomes too elevated, the blood and oxygen
supply to the brain may be disrupted to the point that loss of consciousness or even death may
occur.

Complications that can develop after the rupture of an aneurysm include:

r| ‘  An aneurysm that has ruptured or leaked is at risk of bleeding again. Re-
bleeding can cause further damage to brain cells.
r| o



 After a brain aneurysm ruptures, blood vessels in your brain may widen and
narrow erratically (vasospasm). This condition can limit blood flow to brain cells (ischemic
stroke) and cause additional cell damage and loss.
r| Î  

 When an aneurysm rupture results in bleeding in the space between the
brain and surrounding tissue (subarachnoid hemorrhage) Ȅ most often the case Ȅ the
blood can block circulation of the fluid surrounding the brain and spinal cord (cerebrospinal
fluid). This condition can result in hydrocephalus, an excess of cerebrospinal fluid that
increases pressure on the brain and can damage tissues.
r| Î
  Subarachnoid hemorrhage from a ruptured brain aneurysm can disrupt the
balance of sodium in the blood supply. This may occur from damage to the hypothalamus,
an area near the base of the brain. A drop in blood sodium levels (hyponatremia) can cause
swelling of brain cells and permanent damage.


 
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V  
There are two common treatment options for a ruptured brain aneurysm. 

r| V  

 is a procedure to close off an aneurysm. The neurosurgeon removes a

section of your skull to access the aneurysm and locates the blood vessel that feeds the
aneurysm. Then he or she places a tiny metal clip on the neck of the aneurysm to stop blood
flow to it.
r| Y 
    is a less invasive procedure than surgical clipping. The surgeon
inserts a hollow plastic tube (catheter) into an artery, usually in your groin, and threads it
through your body to the aneurysm. Îe or she then uses a guide wire to push a soft
 platinum wire through the catheter and into the aneurysm. The wire coils up inside the
aneurysm, disrupts the blood flow and causes blood to clot. This clotting essentially seals off
the aneurysm from the artery.

Both procedures pose risks, particularly bleeding in the brain or loss of blood flow to the brain. The
endovascular coil is less invasive and may be initially safer, but it also has a higher risk of
subsequent re-bleeding, and additional procedures may be necessary. Your neurosurgeon will
make a recommendation based on the size of the brain aneurysm, your ability to undergo surgery
and other factors.



Other treatments for ruptured brain aneurysms are aimed at relieving symptoms and managing
complications.

r| 

   such as acetaminophen (Tylenol, others), may be used to treat
headache pain.
r| °  
prevent calcium from entering cells of the blood vessel walls.
These medications may lessen vasospasm, the erratic widening and narrowing of blood
vessels that may be a complication of a ruptured aneurysm. One of these medications,
nimodipine, has been shown to reduce the risk of delayed brain injury caused by insufficient
blood flow after subarachnoid hemorrhage of a ruptured aneurysm.
r|  
 

   
     include intravenous
injections of a drug called a vasopressor, which elevates blood pressure to overcome the
resistance of narrowed blood vessels. An alternative intervention to prevent stroke is
angioplasty. In this procedure, a surgeon uses a catheter to inflate a tiny balloon that
expands a narrowed blood vessel in the brain. A catheter may also be used to deliver to the
brain a drug called a vasodilator, which causes blood vessels to expand.
r|  
     
may be used to treat seizures related to a ruptured aneurysm.
These medications include levetiracetam (Keppra), phenytoin (Dilantin, Phenytek, others)
and valproic acid (Depakene).
r| o  

 
 can lessen pressure on the brain from excess
cerebrospinal fluid (hydrocephalus) associated with a ruptured aneurysm. A catheter may
be placed in the spaces filled with fluid inside of the brain (ventricles) to drain the excess
fluid into an external bag. Sometimes, it may then be necessary to introduce a shunt system
Ȅ which consists of a flexible silicone rubber tube (shunt) and a valve Ȅ that creates a
drainage channel starting in your brain and ending in your abdominal cavity.
r| ‘   
 Damage to the brain from a subarachnoid hemorrhage usually
results in the need for physical, speech and occupational therapy to relearn skills.

  
   


Surgical clipping or endovascular coiling can be used to seal off an unruptured brain aneurysm and
help prevent a future rupture. Îowever, the known risks of the procedures may outweigh the
potential benefit.

A neurologist and a neurosurgeon can help you determine whether the treatment is appropriate for
you. Factors that they would consider in making a recommendation include:

r| The size and location of the aneurysm

r| Your age and general health
r| Family history of ruptured aneurysms
r| Congenital conditions that increase the risk of a ruptured aneurysm

If you have high blood pressure, talk to your doctor about medication to manage the condition. If
you have a brain aneurysm, proper control of blood pressure may lower the risk of rupture.



After you have been diagnosed with a cerebral aneurysm, your doctor will:

r| Advise you to modify any risk factors you may have. This may mean quitting the use of
alcohol and tobacco.
r| Follow your blood pressure closely.
r| Add medications to help control your blood pressure.
r| Recommend that you have regular physical examinations to monitor for symptoms of an
enlarging aneurysm.
r| Be particularly interested in changes in your vision, headache patterns, and examination of
your eyes.
r| Perform an examination of your nerve functions


  


r| If you have 1 close family member who has had a rupture of an aneurysm, your lifetime risk
of a ruptured aneurysm is about 1% at age 50 years and 2% at age 70 years.
r| The risk of surgery to repair an aneurysm that exists but has no symptoms is 2-5%, which is
clearly greater than the risk of hemorrhage into the brain for such people.
r| Screening is recommended for families who show no symptoms but who have 2 members
with a ruptured aneurysm. Siblings over age 30 years are at particularly high risk and
should be screened. Current recommendations are that family members have an MRI
angiography or helical CT angiography every 5 years.
r| Do not smoke cigarettes.
r| Control high blood pressure. The use of amphetamines (speed), cocaine, and even most
medications for the common cold can all dramatically increase blood pressure and increase
the risk of rupture in people with brain aneurysms.
r| Avoid binge drinking.

 

Unfortunately, the outcome is not very certain. When the cerebral artery bursts and causes
brain hemorrhage, sudden death can result. The mortality rate following a rupture is about 40
percent, and another 25 percent die from complications. Prognostication in this condition is
medically difficult since many variable factors come into play. When a window of opportunity
presents itself to allow institution of medical treatment, the prognosis becomes better. Once
definitive treatment, either with clipping or embolization, is initiated, the outlook significantly
improves. A healthy lifestyle, together with vigilance about health, is fundamental, not only in
dealing with aneurysms but with any other diseases, cardiovascular, metabolic, infectious, etc.
Îealth, after all is, indeed, wealth.