What is a cerebral aneurysm?
A cerebral aneurysm is not a tumor, but an abnormal localized bulge in the wall of a cerebral artery. Its occurrence is mainly related to defects in the middle layer of the cerebral artery wall, cerebral artery atherosclerosis, as well as abnormal impact of cerebral blood flow and increased blood pressure. Under long-term blood flow impact, the weak part of the vessel wall gradually swells outward, forming a small balloon-like hemangioma. The incidence of cerebral aneurysms is high, accounting for about 2-5% of the population. Although only a small percentage of aneurysms will rupture, the consequences of subarachnoid hemorrhage caused by a sudden rupture of a cerebral aneurysm will seriously threaten the life and health of the patient. The mortality rate of the first ruptured cerebral aneurysm is 15% to 20%. If the patient does not die after the first hemorrhage and is not treated in time, a second hemorrhage will occur soon, and the mortality rate will be as high as 80% at that time.
What are the clinical manifestations of cerebral aneurysm?
Brain aneurysm may not cause any symptoms until it ruptures, but about half of the patients have warning symptoms before the aneurysm bleeds heavily. Secondly, the aneurysm may cause symptoms such as drooping eyelids, inability to open one eye, double vision, partial blindness, loss of vision and facial pain. In addition, ischemic symptoms such as dizziness may also occur due to vasospasm. The best way to reduce mortality and disability is to treat cerebral aneurysms before they bleed.
Once the cerebral aneurysm ruptures, there is usually a sudden and severe headache, which is an instant and unexperienced severe head pain like splitting on a clear sky, instead of a slow headache little by little; this headache can extend to the neck, shoulder, waist and back and lower limbs, accompanied by nausea, vomiting, pale face, cold sweat, and more than half of them have different degrees of consciousness impairment, the lighter ones have a short period of confusion, the heavier ones In severe cases, the patient may die due to brain herniation.
It should be noted that some patients may have sudden onset of severe headache as the only symptom, so further examination is necessary to exclude bleeding from ruptured cerebral aneurysm.
What are the causes of cerebral aneurysm?
According to the theory of congenital defect of arterial wall, there is a congenital lack of smooth muscle layer in the arterial bifurcation of Willis ring in the skull. The theory of acquired degeneration of the arterial wall suggests that intracranial atherosclerosis and hypertension. It causes the destruction of the elastic plate in the artery and gradually expands to form a cystic aneurysm.
2, In addition, infectious lesions in the body such as bacterial endocarditis and lung infection, infectious emboli are shed and erode the wall of cerebral artery to form infected aneurysm; head trauma can also lead to aneurysm formation. However, they are rare in clinical practice.
3. The following causes may lead to aneurysm.
Hypertension or intracerebral arteriosclerosis.
Cerebral thrombosis.
Certain types of infections.
Trauma to the head.
Heredity.
Drug use such as cocaine.
Other, such as smoking.
What are the clinical manifestations of a cerebral aneurysm?
Bleeding symptoms: Aneurysms that do not rupture and bleed can be clinically asymptomatic. Some of them are severe subarachnoid hemorrhage, with a sharp onset and severe headache, described as “head exploding”. Frequent vomiting, profuse sweating, elevated body temperature, neck stiffness, and a positive Creutzfeldt-Jakob sign. There may also be impaired consciousness and even coma. Some patients have a trigger such as exertion and emotional stress before bleeding, while others have no obvious trigger or have the attack during sleep. In about 1/3 of patients, aneurysm rupture is not treated promptly and death occurs. Most aneurysm ruptures are closed by clotting and the bleeding stops, and the disease gradually stabilizes. As the clot around the aneurysm dissolves, the aneurysm may rupture and bleed again. The second bleed occurs within 2 weeks of the first bleed. In some patients, hemorrhage may invade the vitreous through the optic nerve sheath and cause visual disturbances.
Focal symptoms: Depending on the location of the aneurysm, the adjacent anatomy, and the size of the aneurysm. Arteriovenous nerve palsy is commonly seen in internal carotid artery-posterior communicating artery aneurysms and aneurysms of the posterior cerebral artery and presents with unilateral eyelid ptosis, pupil dilation, inversion, inability to see up or down, and loss of direct and indirect light responses. Sometimes focal symptoms appear before subarachnoid hemorrhage and are considered precursors to aneurysm hemorrhage, such as mild migraine and orbital pain followed by articular nerve palsy, which should alert the patient to the ensuing subarachnoid hemorrhage. If an aneurysm in the middle cerebral artery bleeds and a hematoma is formed, or if an aneurysm bleeds elsewhere and cerebral vasospasm is followed by cerebral infarction, the patient may develop hemiparesis, motor or sensory aphasia. If a giant aneurysm affects the visual pathway, the patient may have visual field impairment.
What are the diagnostic tests for cerebral aneurysm?
If an aneurysm is suspected or a subarachnoid hemorrhage occurs, you should be hospitalized immediately and first undergo a CT examination to determine whether there is bleeding in the brain. If you confirm that there is bleeding in the brain, you should strive to undergo a CTA, MRA or DSA examination as soon as possible within the scope of permission, of which DSA examination is currently the gold standard for diagnosing aneurysms and is the most definitive diagnostic method.
1.CT scan: A special kind of X-ray examination that can see the blood flowing into the brain tissue.
2.Lumbar puncture: For those with normal CT scans, lumbar puncture is recommended. First, an anesthetic is injected into the lumbar region, and then a fine needle is inserted into the spinal canal to extract the cerebrospinal fluid from it for laboratory testing. This procedure is usually performed at the bedside and takes 15 minutes. After the puncture is accepted, the patient should lie flat on his or her back with the pillow removed for 4 to 6 hours to prevent the occurrence of headache.
3.Angiography (DSA): It is an important test for the diagnosis of aneurysm. It is performed in a special x-ray room and takes about 1 hour. The contrast is injected into the cerebral vessels through a special catheter, and then the contrast can be seen under the X-ray as the blood circulates in the brain, thus showing the shape of the cerebral vessels and whether there is an aneurysm or bleeding in the brain. Cerebral angiography is a necessary test to confirm the diagnosis of intracranial aneurysm, and it is very important to determine the exact location, shape, internal diameter, number of aneurysms, vascular spasm and determine the surgical plan.
4.MRA and CTA are non-invasive examination methods that can be used to diagnose aneurysm.
What are the common treatment methods for cerebral aneurysm?
The aim of surgical treatment of cerebral aneurysm is to prevent the aneurysm from rupture and bleeding or re-rupture. There are now two main types of treatment: craniotomy and endovascular intervention.
Craniotomy is performed by a surgeon using a V-shaped metal clamp on the neck of the internal carotid aneurysm. The procedure is performed by removing a portion of the skull at the appropriate site, probing the brain and blood vessels, carefully separating the aneurysm from the surrounding brain tissue, and then clamping the aneurysm to the neck of the aneurysm to isolate it from the blood supplying artery. With the invention of the operating microscope, the development of microsurgical techniques, and the use of new aneurysm clips, clamping has gradually become the standard treatment for aneurysms; however, it is still an invasive and relatively technically complex procedure.
Endovascular interventions use a special catheter to pass through the blood vessel to the site of the aneurysm and place a small metal screw ring or inject ONXY gel to treat the aneurysm. First, a small incision is made in the groin, a catheter is inserted into the femoral artery, which is passed along the vessel to the site of the cerebral aneurysm, and a metal coil is inserted through the catheter into the aneurysm cavity. At this point, the blood flow in the aneurysm cavity is significantly slowed and stagnated, gradually forming a thrombus and blocking the aneurysm cavity, a technique that is now well established.
The procedure may be performed within the first few days after the onset of the disease, or it may be delayed until the patient is stable enough to tolerate a more extensive procedure. The choice between craniotomy clamping or endovascular embolization is determined by the specific circumstances of the aneurysm. The physician will discuss the details of the situation with the patient and family, and choose a different treatment option depending on the specific condition. The location of the aneurysm, the presence of bleeding, the severity of the bleeding, and the patient’s overall physical condition determine the timing, risks, recovery time, and prognosis of the procedure.
Do asymptomatic aneurysms need to be treated?
Whether asymptomatic aneurysms need to be treated is a concern for many physicians and patients alike, and is still controversial. Some believe that because the thinning and bulging cerebral artery wall is prone to rupture and bleeding, which can be life-threatening, treatment is needed even if it does not rupture. Others believe that the incidence of aneurysms in the population is 2-5% higher, but the annual rupture rate is 0.5-2%, or that the risk of natural progression of asymptomatic aneurysms may be lower than the risk of surgical management, and thus asymptomatic intracranial aneurysms found incidentally can be left untreated, or can be dynamically observed by means of noninvasive tests such as MRA and CTA. The principles we have mastered in clinical practice are: (1) aneurysm diameter over 5 mm; (2) irregular morphology; (3) low expected risk and difficulty of treatment; (4) patient’s age and physical condition. However, in the specific case of patients, their incidentally discovered asymptomatic aneurysms have the potential risk of distant bleeding after all, so whether to perform interventional treatment or not requires comprehensive clinical consideration, including adequate communication between doctors and patients.
Selection of the timing of intracranial aneurysm surgery
Although there are some controversies, there is basically a consensus: for ruptured intracranial aneurysms, they should be treated urgently once they are diagnosed; for nonruptured aneurysms, if there are symptoms of compression or precursors of rupture, they should be operated in a limited period of time, and for ruptured aneurysms, interventional treatment during the chronic phase of bleeding or absorption is definitely less risky than treatment during the acute phase of bleeding. However, according to statistics, the rebleeding rate of intracranial aneurysm within 2 weeks after rupture and bleeding is as high as 20%, because many patients often die of secondary bleeding before the first bleeding is absorbed, thus losing the opportunity of surgery.
Is it better to treat intracranial aneurysms with traditional craniotomy or interventional treatment?
In this field, it is also the focus of controversy among many scholars. Most scholars believe that the effectiveness of the treatment depends on the specific condition of the aneurysm, which is suitable for both craniotomy and interventional embolization. The posterior circulation aneurysms and aneurysms of the cavernous sinus and internal carotid segments are easier to embolize. In my personal opinion, not all aneurysms are suitable for embolization, and surgical clamping cannot solve all aneurysms. The choice of treatment is based on a combination of patient, aneurysm and medical provider. Advantages of interventional treatment: Less invasive, faster recovery and other advantages. Disadvantages: There is a certain recurrence rate and expensive. Patients who are older, weaker, have serious organic diseases, and cannot tolerate open-heart surgery tend to choose interventional treatment. Advantages of surgical treatment: treatment is more thorough, intraoperative rupture is relatively straightforward to deal with, and the cost is relatively less. For aneurysms with wide necks and complex pathways, vascular variants, and difficult catheter delivery by contrast, craniotomy is more appropriate.
What are the common surgical methods of aneurysm craniotomy?
1.Direct clamping of aneurysm neck, which is the most ideal method in aneurysm surgery.
2.Aneurysm electrocoagulation, for small (1~2mm) aneurysm without aneurysm neck or abnormal bulge of arterial wall, the aneurysm can be coagulated and crumpled by electrocoagulation with bipolar electrocoagulation forceps under low current.
3.Aneurysm isolation.
4.Aneurysm wrapping reinforcement.
5.Other, aneurysm resection revascularization.
Post-operative rehabilitation of cerebral aneurysm
The treatment of aneurysm rupture subarachnoid hemorrhage is a comprehensive treatment, of which surgical treatment is a part but not the whole. These treatments include dehydration to lower cranial pressure, antispasmodic, volume expansion, fluid replacement, functional rehabilitation, etc. Sometimes ventriculocentesis, lumbar puncture, or lumbar pool drainage to release bloody cerebrospinal fluid is also necessary, and some patients may develop delayed hydrocephalus 3 to 4 weeks after hemorrhage, which may require surgical ventriculo-abdominal shunt This may require a surgical ventriculo-abdominal shunt to resolve.
What is the best way for the family to care for the patient after discharge? First of all, the patient should be kept psychologically optimistic and avoid agitation. Secondly, blood pressure should be controlled. In addition, postoperative review of whole brain angiography and regular outpatient follow-up are required.
The following points should be done in daily diet.
1.Control the intake of caloric energy.
2.Limit the intake of fat.
3, moderate intake of protein.
4.Eat more foods rich in potassium and calcium and low in sodium ……
5, meals should be light.
6, eat more green vegetables and fresh fruit, which is conducive to myocardial metabolism, improve myocardial function and blood circulation, promote the excretion of cholesterol, and prevent the development of hypertension.
7, avoid eating foods that excite the nervous system, such as wine, strong tea and coffee, etc. Smokers should quit smoking.