What is cerebral aneurysm?
An aneurysm is a ballooning of the arterial wall in the brain caused by a weakening of the artery wall and is most commonly seen in the aneurysm areas of the arteries. This ballooning structure is less resilient than a normal vessel and under certain conditions can rupture and cause bleeding into the brain. Aneurysms can be caused by congenital malformation of the blood vessel, high blood pressure, arteriosclerosis (atherosclerosis), infections or head trauma. Aneurysms are often located at the base of the brain, where they cause bleeding into the cerebrospinal fluid. The annual risk of bleeding from aneurysms is approximately 1%.
There are 4 equal aneurysms.
1)Saccular aneurysms: The most common type of aneurysm, they occur at the base of the brain in areas where large blood vessels branch off. The vessel wall is exposed to more pressure at these atal points. This constant pressure causes ballooning as a result of damage to the vessel wall over time. Saccular aneurysms develop over many years. The risk of aneurysm rupture increases with age. Loss of elasticity of the vessel wall as a result of deterioration of the vascular structure in advanced ages is another important reason for aneurysm formation.
2) Fusiform (spindle-shaped) aneurysms: This aneurysm appears as a spindle-shaped dilatation involving a long segment of the vessel. These types of aneurysms can also rupture and bleed, enlarge to a severe degree and cause pressure on the brain tissue in the brain tissue or develop clotting in it and cause a blockage (embolism) in the normal brain vessels, leading to stroke-like symptoms.
3) Mycotic (inflammatory) aneurysms: are rare and develop as a result of dilation of the vessel. They are usually sac-shaped. Inflammation causes damage to the blood vessel wall, weakening it and increasing the risk of aneurysm formation and rupture. It is often a complication of subacute bacterial endocarditis (commonly known as rheumatism of the heart).
4) Traumatic (accidental) aneurysms: This is an aneurysm that develops in the blood vessels of the brain after an accident. In the area of trauma, the damaged vessel wall weakens and may subsequently rupture.
Prevalence and Frequency in Society
The incidence of cerebral hemorrhage due to brain aneurysm is around 10-15 per 100,000 people per year. In our country, an average of 10,000 people can be considered to be at risk of cerebral hemorrhage due to aneurysm every year. The survival rate is between 25-40% in patients with bleeding who can be admitted to a health institution. Therefore, almost half of the patients with a bleeding aneurysm die. An important point here is the early diagnosis and treatment of brain aneurysms that have not yet bled but still put the patient at risk.
Aneurysms can occur in any age group. However, the frequency increases gradually at the age of 25 and above. It is most common between the ages of 50 and 60 and is 3 times more common in women than in men. A family history of aneurysms increases the risk of aneurysms in other family members. The presence of multiple aneurysms in one person at the same time increases this risk even more.
Although the exact cause of aneurysm formation is unknown, many factors are known to play a role in its development;
These;
Hypertension
Smoking
Sugar disease
Excessive alcohol consumption
Inborn genetic predisposition
Damage to blood vessels
Some infections
SIGNs (WARNING SIGNS)
Patients with aneurysm rupture/bleeding may have some warning signs:
Nausea and vomiting
Headache that persists in any one area
Hardness in the back
Blank or cloudy vision
Sensitivity to light
Sense flaws
People with unruptured aneurysms may have no symptoms at all. Few patients may experience some or all of the following symptoms
Paralysis of the optic nerve (e.g., drooping of the eyelid, inability to move the eyelid comfortably)
Unilaterally enlarged göz baby
Çift vision, pain in the back of the eyes, behind the eyes, or at the top of the eyes
Headache that persists in one area
Progressive weakness and lethargy
RISKS AND COMPLICATIONS
When aneurysms rupture, subarachnoid hemorrhage (sac) often develops. Blood passing through the vessel with high pressure into the subarachnoid space can accumulate there and compress the brain; blood elements can also reach the spinal cord with lower pressure. Bleeding from the aneurysm can sometimes be oozing, in which case a small clot can form at the point of oozing and stop the bleeding and the patient can live. However, this process caused by the clot does not prevent the risk of rebleeding; with each additional bleeding, life becomes more endangered and survival becomes less likely. Most spontaneous SAHs are caused by an aneurysm.
The precise localization of the aneurysm, its size, size, size and structure is a critical point in its treatment and therefore in the prevention of rebleeding. The chance of rebleeding after a hemorrhage is around 20% in the first 14 days. Aneurysm hemorrhage progresses at rates up to 50%. It also causes permanent neurologic disorders in 25% of living patients. Impairment of all vücut functions (e.g. partial paralysis) may also occur. In more serious cases, the bleeding can cause severe damage to the brain cells and can put the patient into a coma. If the aneurysm is large, it can also cause damage by causing pressure on the brain tissue even without bleeding. In addition, clots can develop in large aneurysms. And fragments that break off can cause a large number of strokes.
Blood leaking into the brain can cause narrowing of the blood vessels (vasospasm). This can lead to a decrease in blood flow to brain tissue, which can cause a stroke. Vasospasm usually develops 5-8 days after bleeding and is very difficult to treat. It can jeopardize the patient's life. Blood leaking from a bleeding aneurysm may cause hydrocephalus (excessive fluid accumulation in the brain) by preventing the circulation of cerebrospinal fluid (CSF). In this case, excess fluid may accumulate in the cavities of the brain called ventricles, causing an increase in cranial pressure. In order to prevent this fluid increase, drains should be placed in these cavities to remove the accumulated fluid and leaking blood. Aneurysm bleeding can also cause brain hemorrhage or swelling. This can affect brain function and cause serious problems. Swelling and increased pressure of the brain tissue damages the brain tissue. Brain ödemi can cause compression of blood vessels, slowing the blood supply to the brain.
Diagnostic Methods
According to the current medical regulations in our country, patients with brain aneurysms can only be hospitalized under the supervision of neurosurgeons (neurosurgeons). The most important diagnostic method is brain angiography. This test cannot be performed in patients who are prone to bleeding. An important advantage of computed tomography angiography (CTA) is that there is no need to transport the patient to the angiography suite and no need for additional staff. The procedure is completed in less than a minute and carries no risk of stroke. Magnetic resonance angiography (MR angiography) is a diagnostic test that uses magnetic fields and computer technology to provide a dimensional image of the brain vessels. It is a harmless test for the patient, but some people may experience claustrophobia (fear of being indoors) because the device is narrow. In addition, people who are not allowed to enter the magnetic field cannot be planted.
THERAPY SEÇENTEKS
There are significant treatment options for patients diagnosed with aneurysms in our day and age.
- Observation and/or non-surgical treatment (follow-up)
2) Surgical treatment and closure (clipping) of the aneurysm
3) Stenting and/or occlusion with intravascular (endovascular) treatment
As with all diseases, the treatment of an aneurysm should be decided by the patient and the physician together. If the situation is urgent or the patient is unconscious as a result of an aneurysm bleeding, this decision should be made together with the patient's next of kin. Depending on the patient's condition, the physician should provide the patient with the appropriate treatment from these options.
The best way to treat aneurysms in our day and age is still a matter of debate. However, it should be kept in mind that treatment should be performed as soon as possible. The size of the aneurysm, its location, the age and general condition of the patient affect the choice and success of treatment.
GÖIMPLICATIONS AND/OR NON-SURGICAL TREATMENT
If the aneurysm carries less risk of enlargement and bleeding due to its location, follow-up alone may be a good option. Diagnostic tests should be repeated in the follow-up of these patients. In these people, the annual risk of bleeding persists, albeit to a lesser extent. Patients on follow-up should stop smoking and control their blood pressure. These factors are important in aneurysm formation and growth. If high blood pressure is an important complaint, antihypertensive treatment and/or diet and exercise program can reduce blood pressure. Radiologic examination (cerebral angiography, MRI or CT angiography) at regular intervals can detect changes in aneurysm size and enlargement. The following factors should be questioned in patients with non-bleeding aneurysms:
1) Size and layout
2) Age and health status of the patient
3) Family story
4) Treatment risks
Surgical Treatment and Clipping (Latch Closure)
Açlary surgery is a long-standing and still very important intervention for patients with aneurysms. It is an operation to close the aneurysm and is performed under general anesthesia by opening a small window in the skull. The aneurysm is peeled away from the surrounding brain tissue and vessels and the neck of the aneurysm is closed with a small metal clip (a kind of metal clip), usually made of titanium. Normal blood flow is maintained in the vessel where the aneurysm is clipped. The clips are permanent, left in place and do not cause any damage to the body. People who undergo this surgery can have an MRI. Normally, after aneurysm surgery, the patient is hospitalized in the hospital for 3 to 5 days and then 3-4 weeks of home rest is appropriate. For bleeding aneurysms, the length of hospital stay is 7 or more days. After surgical closure of the aneurysm, follow-up angiography may be required 5 years after surgery.
Advantages and Disadvantages of Surgical Treatment and Clipping
Advantages of clipping;
The treatment is often permanent and does not require reoperation on the same aneurysm. The aneurysm can be directly visualized (this is important for complex aneurysms), the aneurysm can be removed after clip application and the compression of the aneurysm on the brain tissue can be surgically removed, and if there are other aneurysm(s) during surgery, they can be directly visualized and treated. In those who have bled, the aneurysm phase and blood elements and clots in the brain tissue can be removed during surgery; this removal is important in the rapid recovery of some patients. In addition, a craniectomy (a procedure to remove some bone from the skull) can remove part of the skull during surgery and prevent increased intracranial pressure (such as brain infarction), which can cause patients to become dull.
The disadvantages of surgery are that it is invasive, the skull needs to be opened and complications can occur. Damage to surrounding structures and moist vessels can occur during clip application.
Vascular Içi Treatment - Blockage
Intravascular therapy is a method developed over the last 15 years and is similar to the procedures used by cardiologists to remove blocked vessels in the heart or large vessels of the body. Especially in the last 5 years, it has become an acceptable alternative to surgical clipping. Intravascular treatment may be a viable option in patients with a high surgical risk and in patients with a clinical and neurologic picture, or in some difficultly located aneurysms such as the basilar artery (a large cerebral artery supplying the brain stem and deep brain regions). A recent study found that in hemorrhagic aneurysms amenable to both clipping and intravascular therapy, if intravascular occlusion was used, better outcomes were obtained, at least in the early stages (23.5% for those who underwent occlusion and 30% for those who underwent surgical clipping at 1 year). Vascular occlusion can be performed under general anesthesia or sedation. The arterial system is accessed through a large vessel in the groin (femoral artery in the thigh). A needle is inserted into the artery. A small catheter is inserted through the artery and, under the guidance of x-rays, the dört main artery supplying the brain is accessed. Through this, a smaller catheter (microcatheter) is used to reach the aneurysm. The catheter is positioned in the aneurysm and a thin wire (coil) is inserted into the aneurysm. A clot forms in the aneurysm and in the long term, new tissue growth is expected to fill the base of the coils at the base of the aneurysm and complete healing is expected. Balloon-assisted coil placement is another method in which a balloon is inflated in the neck of the aneurysm with the help of another catheter during the procedure, preventing the coils from entering the vessel and keeping them in the aneurysm. In a similar fashion, stent-assisted coil placement uses a highly flexible cylindrical cage that acts as a scaffold for coiling.
Vascular Içi Therapy - Advantages and Disadvantages of Coiling
The advantages of intravenous treatment are first and foremost that it is minimally invasive (few side effects related to the procedure), does not require opening the skull, and has fewer early post-procedure complications. Patients with non-bleeding aneurysms can be discharged home in a day or two and back to work in a week or two. The disadvantages of coiling are that the aneurysm is less likely to close at an early stage and there is a higher likelihood of nüks görülür. During the procedure, the aneurysm (bubble) may bleed and require immediate surgery. Therefore, an additional intervention may be required and a longer follow-up may be necessary for a complete cure.
Recovery and Follow-up
Although recovery varies from patient to patient, the type of aneurysm, its location, the presence of bleeding, the type of treatment and the general condition of the patient are among the most important factors. In patients who have had a brain hemorrhage, the neurologic deficits are more severe and pronounced, and these patients require a longer recovery period. Although each patient has unique findings, some of the side effects that may occur after surgery are listed below:
Headaches
Lethargy and fatigue
Pain at the operation site
Çene pain
Clock ticking sound in the head
Görsel disorders
Partial or complete disability
Loss of visual field
Fine motor movement disorders
Emotional problems
Depression
Conceptual güçlüks
Speech problems
Perceptual problems
Behavioral changes
Disorders of balance and coordination
Concentration güçlüks
Short-term memory problems
As in stroke patients, the recovery and rehabilitation period is an important part of aneurysm treatment. In some cases, functions lost when the aneurysm bleeds or is treated can be restored by undamaged brain areas. Rehabilitation may include physical therapy, speech therapy and vocational training.
