Cerebral aneurysm (cerebral aneurysm, intracranial aneurysm) – is a pathological bundle of blood vessels that feed the brain. It is a common cause for non-traumatic subarachnoid haemorrhages. Most often arterial cerebral aneurysms rapture between the ages of 20-40. It is also more common for women than for men.
Etiology of cerebral aneurysms remains unclear. According to Dandy-Paget theory, the reason of this disease is the abnormal formation of arteries’ walls during fetal life. Common three-layer structure of the vessel is disrupted. There is no muscle layer on one of its parts and the elastic membrane is completely absent or underdeveloped.
Almost 80-90% of cases are congenital cerebral aneurysms, though they can be acquired as well.
Disease risk factors are:
Aneurysms are usually solitary, rarely - plural (10% of cases). They may vary in size from 2-3 mm to several centimetres. The larger brain aneurysm, the more likely it to rapture.
In most cases cerebral aneurysm is asymptomatic. Symptoms appear only after the vessel bursts and bleeds into the subarachnoid space. Clinical manifestations are based not only on the release of blood vessels, but also on the artery spasm that leads to ischemia (oxygen deficiency) of central nervous system structures.
In just a few days before the haemorrhage these symptoms may appear:
Rupture of the blood vessels can occur spontaneously, even with a perfectly healthy background. It can happen after exercise, after alcohol intake or viral infection. Rupture is also possible without any predisposing factors or previous symptoms, while resting or even during night sleep.
Symptoms of the cerebral aneurysm rapture:
In cases of small bleeding the symptoms are the same but mild. Usually, they regress by themselves in a couple days.
Depending on the symptoms, 5 stages of cerebral aneurysm are differentiated:
1 – No symptoms or low-grade symptoms.
2 – Mild symptoms – headache, stiff neck (a patient can not touch chest with the chin).
3 – Disordered consciousness of the patient, there may be difficulties in the movement of the limbs, facial muscles, speech, etc.
4 – Catatonic paralysis of one side of the body.
5 – A deep coma.
Other symptoms depending on the localization of the raptured aneurysm can also occur. Break the anterior cerebral and anterior communicating artery is largely characterized by mental disorders. Ophthalmic artery aneurysm break causes pain in the eye and excessive tearing. An aneurysm break of the adjustable ring circle of Willis causes impaired hearing, swallowing, and severe dizziness.
Diagnostics of the cerebral aneurysms is held with the help of the instrumental methods.
Cerebral angiography is an X-ray examination. The contrast agent is injected into the blood vessels and is the main way of detecting an aneurysm. Using the modern equipment, precision of the diagnostics reaches 95%. Theoretically, using cerebral angiography the aneurysm in the brain can be detected even before it will rapture. Practically it happens only after the aneurysm occurs as there was no need in diagnostic because of no symptoms.
Lumbar puncture is the method where the doctor inserts a needle into the subarachnoid space of the spinal cord at the lumbar level. It is held if the subarachnoid haemorrhage is suspected. It manifests itself in the increasing pressure of cerebrospinal fluid and blood in the cerebrospinal fluid.
Ultrasonic transcranial Doppler sonography helps to evaluate the brain blood flow and choose the best moment for performing the surgery after the bleeding occurred. In the case of decompensated ischemia caused by induced vascular spasm, surgery is contraindicated.
CAT (computed axial tomography) helps to detect the blood congestions. This method is used not only for diagnostics, but for the prognosis also.
Methods of treatment depend on the severity of patient’s condition after subarachnoid haemorrhage. Four stages are differentiated:
Extremely acute (first three days) – is the best time for the surgery in cases of the 1, 2 or 3 stage of severity. In case if 4-5 stages the conservative therapy is held.
Acute (up to two weeks) - phenomena of cerebral ischemia increase, so the surgery is not recommended and the patients are treated using conservative methods. Surgery is indicated if there is a repeated haemorrhage, but lethality after the surgery is 50%.
Subacute (up to four weeks) – is characterised by the regression of the ischemia and cerebral edema. Surgery is possible for the patients with 1, 2, 3 stages of severity and 4-5 stages also if the arteriopathy conditions are eliminated (due to the transcranial Doppler) under the influence of the conservative therapy.
Cold (after four weeks) – is the most desirable time for surgery, but it is usually performed earlier as the risk of the repeated aneurysm rapture is high during the subacute stage.
The point of the surgery is the removal of the blood and disabling the brain aneurysm from the blood flow in order to prevent another rapture. The procedure of clipping the blood vessels next to the aneurysm is performed for that (they put the clips).
In modern clinics the endovascular occlusion with the help of a spiral (closure of the vessel lumen) is possible. It is placed inside the artery causing its thrombosis. Main advantage of this kind of surgery is that no craniotomy is needed. A disadvantage is the impossibility of the blood removal. This surgery is performed in limited cases (if there is a little bleeding or the open surgery cannot be conducted).
The frequency of cases of spontaneous subarachnoid haemorrhage is 20 cases per 100,000 of population per year. 50-60% of cases from this number are caused by brain aneurysm.
In the case of bleeding from the aneurysm 60% of patients die within a week. In case of the repeated bleeding, which often takes place within the next month, mortality reaches 80%.
Timely and high quality surgery helps to prevent recurrent haemorrhage from an aneurysm, the probability of which is 40-60% percent with no treatment. Life prognosis is favorable after the surgery, but majority of patients have neurological disorders. Only 30% of survivors save performance capability.
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