Aneurysm rupture : what are the warning signs?

Aneurysm

About 5,000 people rupture an aneurysm each year. It is a brutal and very violent occurrence, and must be treated quickly to avoid death. What are the signs to recognize it? What happens in the brain? Treatments and consequences?

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Definition: What is an aneurysm rupture?

A brain aneurysm is a small pocket that forms in an artery in the brain. "It's a bit like a hernia in an internal tube," explains Professor Emmanuel Houdart, a neuroradiologist at the Lariboisière Hospital in Paris.

This aneurysm develops over time.

The pocket, which is initially small, grows. As it stretches, the artery becomes fatally thinner at the site of the aneurysm and therefore more fragile.

Sometimes this small bag, full of blood, can break or rupture, causing internal bleeding: this is called an aneurysm rupture.

"It is always a characteristic, sudden and serious event," says Emmanuel Houdart. The wall breaks suddenly, causing a small and very brief hemorrhage, which does not last more than a second". The risk of rupture of this aneurysm is all the more important because the aneurysm is bulky.

Types of aneurysm ruptures: Not only in the brain

Aneurysms can occur in any of the arterial pathways, either in the form of a pocket or an arterial widening. There are three main types of aneurysms that can rupture:

• Brain Aneurysms: These are the most common aneurysms. They are normally found at the base of the brain and cause intracranial bleeding when they rupture.
• Aortic Aneurysms: The aorta is the largest artery leading from the heart muscle to the spine.
• Cardiac aneurysms, often located in the left ventricle. This type of aneurysm usually forms after a heart attack.

What is the difference between a stroke and an aneurysm rupture?

Stroke is caused by the blockage of a blood vessel in the brain due to a clot or rupture of a vessel.

In the latter case, it may be related to the rupture of an aneurysm and cause a brain hemorrhage.

What causes an aneurysm to rupture?

"The origin of the aneurysm is not very well known," says Professor Jacques Moret, head of the department of neuroradiology at the Rothschild Foundation.

All that is known is that sometimes they are the result of a congenital anomaly that turns into an aneurysm over time.

In children (for whom aneurysm rupture is extremely rare) and in young adults more often.

In other cases, they are acquired: a pathology such as hypertension or diabetes has caused a weakening of the arterial walls, thus favoring the appearance of an aneurysm".

Tobacco also plays an almost certain role, although its effects cannot yet be accurately described. "The products contained in tobacco and inhaled cause the oxidation of the arterial walls.

This oxidation causes inflammation and therefore weakening of the walls.

Therefore, a more favorable terrain for the development of deformation.

Doctors tell their surviving patients that they should stop smoking. Smoking is one of the main factors contributing to the development of atheroma (deposits of lipids that form whitish plaques on the internal walls of the arteries), which could also play a detrimental role in aneurysms.

Finally, specialists cite oral contraceptives and excessive alcohol consumption as factors influencing the development of aneurysms.

Prevalence and age of maximum aneurysm rupture

It is estimated that between 2% and 3% of the population has an aneurysm without knowing it most of the time. The peak of aneurysm ruptures is observed around the age of 45. Women are slightly more affected than men.

Diagnosis: how to know?

The prevalence of aneurysm rupture increases with age, but it is impossible to give an exact figure because most patients do not realize they have the disease until they rupture.

Others may be diagnosed by an MRI or CT scan, but if you have not had an MRI or CT scan, you may have an aneurysm and not know it for the rest of your life.

"In the vast majority of cases, an uninterrupted aneurysm is asymptomatic," adds Professor Houdart.

A common characteristic that should alert in all cases: the appearance of symptoms is always extremely abrupt.

Warning signs: a very violent headache.

The first symptom of a ruptured brain aneurysm, common to the vast majority of patients, is an unprecedented headache of violence, which appears instantly.

"Nothing to do with a migraine," says Emmanuel Houdart. All patients describe this extremely intense headache as a kind of explosion in the skull.

On the other hand, this rash is so sudden that they are able to tell precisely what they were doing when it happened. A patient told me the other day that he was turning the key in his door lock when he felt the first symptoms. And also:

This pain is often accompanied by nausea and vomiting.

The patient becomes sensitive to light and noise, which increases his symptoms tenfold.

It is not uncommon for the person with the ruptured aneurysm to lose consciousness for a few moments. In the most severe cases, they may even go into a coma or die suddenly.

Other disorders, more rare, may be associated with aneurysm rupture: some people are partially paralyzed (particularly at the level of the eyeballs), others suffer an epileptic seizure ...

"There are also some surprising psychological manifestations," says Professor Houdart. It is very rare, but the patient may have no more symptoms than extremely strange and sudden behavior.

For example, I have a patient, a businessman, who suddenly got naked on the Eurostar. He was found lost in the Gare du Nord. In these cases, one does not immediately think of a ruptured aneurysm!"

Treatment: as soon as possible

When an aneurysm ruptures, the prognosis depends largely on how quickly it can be treated. The blood that is lost leaves the artery and flows into the fluid spaces around the brain.

The amount of blood spilled is very small (more than 30 ml is immediate death), but because the skull is inextensible, it causes an instantaneous acute reaction: the brain begins to swell.

This swelling is very dangerous, but it also saves lives because it blocks the flow of blood.

"The brain starts to swell.

At the same time, a small plug is formed, which allows the damaged artery to be blocked very quickly. "But this closure is precarious. If the person is a little hypertensive, the blockage will burst.

The same happens if the brain gradually deflates: the crack can reopen and cause a second bleeding, which will inevitably be more severe.

A third hemorrhage would be fatal. That's why we have to act very quickly. We have to call emergency.

Do not be afraid to insist on the violence and intensity of the symptoms, otherwise some doctors will think of a less serious pathology first and prescribe painkillers, which will cause a loss of a few hours to a few precious days before the treatment.

"After that, our job is to prevent the aneurysm from bleeding again.

At the same time, we will treat the consequences of the bleeding in the brain," explains Emmanuel Houdart.

This usually involves taking cerebral antiedematous drugs to reduce swelling of the brain and sometimes by draining the spinal fluid.

Embolization

The technique used in 70% of the cases is embolization, which is much less cumbersome than conventional surgery. "It involves crossing the interior of the arteries, not the exterior, to cover the aneurysm with small platinum coils.

These small wires are inserted through a small catheter that slides into the arteries. It is inserted into the femoral artery in the thigh. The operation is performed by a neuroradiologist.

It leaves no scars and is much easier to recover than surgery.

After embolization, the patient will be monitored regularly for the first few years to make sure that the platinum wires do not "settle". This occurs very rarely, but if it does, it should be repeated to rule out any risk of additional bleeding.

Classic surgery

In about 30% of cases, embolization is not possible or desirable for various reasons and physicians then resort to conventional surgery.

The technique then consists of cutting the aneurysm: it is thus separated from the rest of the circulation and the blood is drained. The surgery requires opening the skull, which always carries risks and creates additional trauma to the brain.

Why do people die from a ruptured aneurysm?

Often the bleeding has caused a kind of clot that prevents the fluid from coming out. Because it occurs all the time, there can be a buildup of this fluid around the brain, which then compresses.

"If no intervention is performed and the brain is actually compressed, death occurs within minutes," says Professor Houdart.

One third of patients die before reaching the hospital.

Consequences of a ruptured aneurysm: the risk of sequelae

The consequences of an aneurysm rupture vary greatly from one individual to another. While about a third of patients die before reaching the hospital, another third leave the hospital with much fear, temporary fatigue, but no lasting signs. Another third survive, with various sequelae.

"It can vary from memory problems to a vegetative state, including hemiplegia," explains Emmanuel Houdart.

These sequels are usually related to vasospasm (contraction of the arteries) and cerebral infarction that can be induced. The extension of the hemorrhage also comes into play.

Even for those who get away with it, a long rest will be necessary before they can return to work.

"At least 3 months, but I often prescribe 6, so that they can resume work in the best possible conditions".

The patient can also request a part-time therapy for one year: the company pays him/her for his/her work time and the Health Insurance compensates the loss of salary.

What is the follow-up after an aneurysm?

The rupture of an aneurysm is recognized as a long-term disorder (LDA). "It can even be an accident at work if the rupture occurred during working hours," says Professor Houdart.

A follow-up control must be ensured, with a CT scan after three months and a control arteriography after one year. "There is no risk of recurrence in the strict sense.

Once treated, it is definitive and life expectancy does not decrease. But in some rare cases, aneurysm coils may settle.

We may have to intervene again. If after one year nothing has changed, a new MRI is prescribed after three years. Follow-up can be offered thereafter, depending on the patient. "If it is causing anxiety, it is better to drop it.

Thanks to Professor Emmanuel Houdart, neuroradiologist at the Lariboisière Hospital in Paris and Professor Jacques Moret, head of the neuroradiology department at the Rothschild Foundation.

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