A ruptured brain aneurysm is a life-threatening emergency. Patients who survive the immediate danger often face a challenging but important recovery journey. Our NNI healthcare team explains more.
In a group of 100 people, around two to three will be living with a brain aneurysm – a bulge or ballooning in the wall of an artery in the brain. Most people are unaware they have one because the aneurysm is small and causes no problem. But around 1 in 300 aneurysms burst, causing people to change rapidly from seemingly healthy to critically ill.
“About one in three people who suffer from a ruptured aneurysm die before they reach hospital, because the bleeding in the brain can be extensive. In other cases, a clot forms around the ruptured brain aneurysm which temporarily stops the bleeding. This creates a window of opportunity for emergency treatment,” says Dr Vincent Ng, Senior Consultant, Neurosurgery, NNI.
A sudden severe headache, often described as ‘the worst headache of your life’ is the most common symptom of a burst aneurysm and a signal to go straight to the Emergency Department.
On Arrival at A&E
If a ruptured aneurysm is suspected, a Computed Tomography (CT) head scan is done to check for an aneurysm, as well as bleeding and fluid build-up in the brain. The brain ventricle, a structure located in the middle of the brain, produces a clear liquid called cerebrospinal fluid (CSF) which normally flows over and within the brain to protect and nourish it.
The majority of brain aneurysms occur on arteries on the base of the brain. Blood from the rupture can spread and clot in the space between the brain and the skull (known as subarachnoid space – hence subarachnoid hemorrhage), covering areas of brain tissue and preventing CSF from circulating.
“As the fluid builds up, brain pressure increases. This can damage the brain. So our first priority is to identify fluid obstruction and to drain it by inserting a tube known as an external ventricular drain (EVD) into the brain ventricle,” says Dr Ng.
Within 24-48 Hours
Once the EVD is in place (if needed), the patient is monitored closely in the Intensive Care Unit and attention focuses on treating the aneurysm.
“The blood clot only stops the aneurysm bleeding temporarily so the aneurysm needs to be treated to prevent it from rupturing again. There are two main ways this can be done: via endovascular therapy or surgery. The team will determine which is best for the patient based on where the aneurysm is located in the brain, its size and appearance, if the patient has pre-existing illnesses and other factors,” says Dr Saravana Kumar, Consultant, Interventional Neuroradiologist, NNI.
4 – 14 Days After Rupture
The patient continues to be monitored in ICU and undergoes daily ultrasound scans of blood vessels in the brain to detect a possible serious complication known as vasospasm. This occurs when blood from the initial bleed (subarachnoid hemorrhage) triggers an inflammatory process and releases substances that cause the arteries to tighten and narrow. When there is significant narrowing, it restricts blood flow to the brain, and deprives the brain of oxygen and glucose resulting in brain injury.
“Vasospasm typically occurs in about 50-70% of patients after aneurysm rupture. About half of those affected will have clinical signs and symptoms within 4 to 14 days. Daily ultrasound scans are done on temples of patient’s head (near the ears) to detect changes in the speed of blood flow. There is no radiation and it is very safe. In general, the more the blood vessel narrows, the greater the severity of vasospasm, causing faster blood flow but lower volume,” says Phua Ziqun, Principal Sonographer, Neurodiagnostic Laboratory.
Treatment for Vasospasm
Medication to prevent vasospasm is given in the ICU for 21 days. If significant vasospasm is detected, additional treatment is started to increase the blood pressure to improve blood flow in the brain, but for some patients, this is not sufficient to treat the vasospasm.
“In such cases, medication will be injected directly into the blood vessels close to the vasospasm to ‘relax’ the tightened walls so that the blood can flow more smoothly. The medication is given via a fine tube that is inserted into an artery in the patient’s groin or wrist and passed through the blood vessels to the affected part of the brain,” explains Dr Saravana Kumar.
Removal of the EVD
When the patient has stabilised, the team will assess if the EVD is no longer needed for draining excess brain fluid.
“In 80% of the cases, the EVD can be removed successfully, but in about 20% of cases, the brain fluid circulation and absorption remain poor. A permanent brain shunt is inserted to divert the brain fluid to the abdomen where it is absorbed,” says Dr Ng.
2 weeks to 2 months
Once the risk of vasospasm has passed and the permanent shunt is inserted (if necessary), the focus switches to rehabilitation. This is an important stretch of a patient’s recovery journey and is coordinated by rehabilitation specialists. It can include treatment with a physiotherapist, occupational therapist, speech therapist, dietitian and/or psychologist, depending on the patient’s needs.
It starts with three weeks in the acute hospital followed by a further 6 to 8 weeks of inpatient rehabilitation, then the patient will return home.
Continuing recovery at home
Once discharged, the patient will continue to do rehabilitation at home and in the community for as long as needed. The patient also needs to attend review appointments in Specialist Outpatient Clinics with the neurosurgeon, interventional neuroradiologist and specialist nurses until the patient can be referred to their family doctor or polyclinic for long term follow-up.
