Monthly Archives: February 2019

Brain Aneurysm: Treatment

Hope is what makes us believe in the promise of tomorrow

https://www.mayoclinic.org/diseases-conditions/brain-aneurysm/diagnosis-treatment/drc-20361595

There are two common treatment options for a ruptured brain aneurysm.

  • Surgical clipping is a procedure to close off an aneurysm. The neurosurgeon removes a section of your skull to access the aneurysm and locates the blood vessel that feeds the aneurysm. Then he or she places a tiny metal clip on the neck of the aneurysm to stop blood flow to it.
  • Endovascular coiling is a less invasive procedure than surgical clipping. The surgeon inserts a hollow plastic tube (catheter) into an artery, usually in your groin, and threads it through your body to the aneurysm. He or she then uses a guide wire to push a soft platinum wire through the catheter and into the aneurysm. The wire coils up inside the aneurysm, disrupts the blood flow and essentially seals off the aneurysm from the artery. This is what I had done.

Both procedures pose potential risks, particularly bleeding in the brain or loss of blood flow to the brain. The endovascular coil is less invasive and may be initially safer, but it may have a slightly higher risk of need for a repeat procedure in the future due to reopening of the aneurysm.

Flow diverters

Newer treatments available for brain aneurysm include flow diverters, tubular stent-like implants that work by diverting blood flow away from an aneurysm sac. The diversion stops blood movement within the aneurysm and so stimulates the body to heal the site, encouraging reconstruction of the parent artery. Flow diverters may be particularly useful in larger aneurysms that can’t be safely treated with other options.

Your neurosurgeon or interventional neuroradiologist, in collaboration with your neurologist, will make a recommendation based on the size, location and overall appearance of the brain aneurysm, your ability to undergo a procedure, and other factors.

Other treatments (ruptured aneurysms)

Other treatments for ruptured brain aneurysms are aimed at relieving symptoms and managing complications.

  • Pain relievers, such as acetaminophen (Tylenol, others), may be used to treat headache pain.
  • Calcium channel blockers prevent calcium from entering cells of the blood vessel walls. These medications may lessen the erratic narrowing of blood vessels (vasospasm) that may be a complication of a ruptured aneurysm. One of these medications, nimodipine (Nymalize, Nimotop), has been shown to reduce the risk of delayed brain injury caused by insufficient blood flow after subarachnoid hemorrhage from a ruptured aneurysm.
  • Interventions to prevent stroke from insufficient blood flow include intravenous injections of a drug called a vasopressor, which elevates blood pressure to overcome the resistance of narrowed blood vessels. An alternative intervention to prevent stroke is angioplasty. In this procedure, a surgeon uses a catheter to inflate a tiny balloon that expands a narrowed blood vessel in the brain. A drug known as a vasodilator also may be used to expand blood vessels in the affected area.
  • Anti-seizure medications may be used to treat seizures related to a ruptured aneurysm. These medications include levetiracetam (Keppra), phenytoin (Dilantin, Phenytek, others), valproic acid (Depakene) and others. Their use has been debated by several experts, and is generally subject to caregiver discretion, based on the medical needs of each patient.
  • Ventricular or lumbar draining catheters and shunt surgery can lessen pressure on the brain from excess cerebrospinal fluid (hydrocephalus) associated with a ruptured aneurysm. A catheter may be placed in the spaces filled with fluid inside of the brain (ventricles) or surrounding your brain and spinal cord to drain the excess fluid into an external bag. Sometimes it may then be necessary to introduce a shunt system — which consists of a flexible silicone rubber tube (shunt) and a valve — that creates a drainage channel starting in your brain and ending in your abdominal cavity.
  • Rehabilitative therapy. Damage to the brain from a subarachnoid hemorrhage may result in the need for physical, speech and occupational therapy to relearn skills.

Treating unruptured brain aneurysms

  • Aneurysm clip
  • Endovascular coiling

Surgical clipping or endovascular coiling or a flow diverter can be used to seal off an unruptured brain aneurysm and help prevent a future rupture. However, in some unruptured aneurysms, the known risks of the procedures may outweigh the potential benefit.

A neurologist, in collaboration with a neurosurgeon or interventional neuroradiologist, can help you determine whether the treatment is appropriate for you.

Factors to consider in making treatment recommendations include:

  • The size, location and overall appearance of the aneurysm
  • Your age and general health
  • Family history of ruptured aneurysm
  • Congenital conditions that increase the risk of a ruptured aneurysm

If you have high blood pressure, talk to your doctor about medication to manage the condition. If you have a brain aneurysm, proper control of blood pressure may lower the risk of rupture.

In addition, if you smoke cigarettes, talk with your provider about strategies to stop smoking since cigarette smoking is a risk factor for formation, growth and rupture of the aneurysm.

Mayo Clinic neurosurgeons are experts in each of these procedures and have pioneered many new techniques. They also regularly use advanced technology, such as 3D-printed models and computer simulations, to better understand the structure of the blood vessels and to plan surgery.

Mayo Clinic surgeons are trained in open vascular and endovascular neurosurgery, including minimally invasive techniques, such as the modified eyebrow incision, endoscopic skull base surgery and transnasal endoscopy. They are also experts in using computer-assisted technologies to navigate the brain during surgery and microvascular surgery.

Lifestyle changes to lower your risk

If you have an unruptured brain aneurysm, you may lower the risk of its rupture by making these lifestyle changes:

  • Don’t smoke or use recreational drugs. If you smoke or use recreational drugs, talk to your doctor about strategies or an appropriate treatment program to help you quit.
  • Eat a healthy diet and exercise. Changes in diet and exercise can help lower blood pressure. Talk to your doctor about changes appropriate for you.
Aneurysm clip
Endovascular coiling
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How did it happen? My brain aneurysm story: details unfolded Part II-Treatment

His story continues…

They decided to airlift you to Pretoria, South Africa, close enough to the medevac center for US Diplomats in the region. We all agreed that despite the risks involved with flying, it was the only best option to help save your life. AMREF air ambulance from Nairobi, Kenya, was organized and by 4pm on Saturday, about 15hours from when the aneurysm happened, you were on the tarmac in Entebbe airport ready to depart for South Africa.

The kids and I flew separate on a commercial airline after the plan to go with you in the air ambulance failed. We arrived in early Sunday morning and I had a lot of help from the Embassy. They helped organize for nannies, transportation, accommodation, and treatment for the kids.

You were send straight to Kloff Hospital where the neurosurgeons immediately started working on your case. Surgery was scheduled for Monday, August 1st. At that time, it was all up to God to guide everything. Almost all of the family members, friends, and relatives who were aware of your condition, were praying. Everything was being done by the hospital staff to keep you stable until the bleeding was stopped. I was anxious but hopeful.

The long awaited day came for the procedure to be done, I signed the papers and off they took you. I waited anxiously in the waiting room for the doctor to come out with good news. The procedure was to take 3-4hours. As I was gazing at the postings on the wall related to all types of aneurysms, the door opened and it was your neurosurgeon. It had only been 30minutes since they took you in. What could he be doing here right now? I asked myself as I starred at the disappointment look on his face. “Mr. Field, I am sorry to disappoint you, I know how anxious you are but things didn’t turn out the way we had planned. There has been a change of plan.” I don’t recall if I said anything to him or heard the rest of what he had to say. All I remember is feeling like somebody had just punched me right in the chest and removed my heart. I felt like I had stopped breathing. My whole body was shaking, my vision was blurry and my mind was blank all to the thought of having lost you. I must have fallen back or perhaps fainted but I recall the doctor calling a nurse to bring me some water and a cold wash cloth. After a few minutes, he explained to me that they had not lost me but rather cancelled the procedure after it was deemed to be more risky than previously assumed. He then added that he was going to consult with other neurosurgeons and the Embassy Doctor in order to come up with the safest yet most effective plan.

They brought you out of the surgery room looking a little bit drowsy from the anesthesia but still had your beautiful smile. I was so happy to see you even though I was dying inside from the anxiety. Your memory was still bad and you asked the same repetitive questions but every time I looked into your eyes, I saw hope, I saw life, I saw outstanding strength. One side of me was telling me that I shouldn’t sign the papers to give them authority to perform the procedure and accept all the complications, including death, which might occur. It was better to have you alive at that moment, bedridden, and confused than not to have you at all. I wished badly to freeze that moment in time because that was all I was sure of. The kids and I would wanted to see you and have your presence in our lives despite the disorientation. The thought of losing you especially after the procedure was stopped that day was impossible for me to accept and carry on with life. The other side of me was telling me to take the risk and have them do the procedure. Despite all the risks involved, somehow, I knew you were going to be fine. My heart was content with that decision. I tried to ask you what you wanted me to do but you were not able to answer. You did not respond to any questions that I asked other than the programed ones.

Later that day, the neurosurgeon came in and told me that they were going to transfer you to Netcare Unitas Hospital in Centurion where the other neurosurgeon would take lead on carrying out the procedure the following day. At this point, time was critical, every second was counting. The ambulance was organized and you were transferred to the ICU unit in Unitas Hospital. I went back to the hotel to organize for early checkout to another hotel that would be closer to Unitas Hospital and relieve the nanny from her job. At this point, all the kids were sick, the oldest one had refused to eat food insisting that he only wanted mama to feed him. Luckily, there was one nanny who agreed to stay for almost a week until your sister arrived. This nanny was so kind to the kids and was able to gain trust from our son, who later agreed to take food from her. This allowed me time to focus on you, the children’s medical needs, and my job.

The following day, I headed to the Hospital where you had been transferred to prepare for your procedure. I signed the documents as required and the two neurosurgeons together with the medical doctor informed me that after a careful review of the procedure, they decided to go ahead and do it using a different but safer approach. Both neurosurgeons were going to perform the coiling procedure. Well, that was enough to reassure me that God was in control and no matter what the outcome would be, the best available approach was being used. So, off you went. I kissed you softly and told you that I would see you shortly. You smiled back and that is all I needed.

Approximately three and half hours later, the lead neurosurgeon came to me in the waiting area. He seemed relaxed and content. Without wasting time, he told me “Mr. Field, your wife should be out shortly, the procedure went very well and she is expected to make full recovery in 2-8weeks but the memory should start improving as soon as the anesthesia wears off.” Tears of joy were dripping down my cheeks as I reached out to him and extended my gratitude. I was overjoyed, I wanted everyone to know that you were okay, I could not stopping smiling and thanking God. I did not mind waiting for an extra 30minutes while you were still in recovery room because I knew you were alright.

It was not too long before they brought you out on the stretcher and we started making our way to your room. As soon as we entered the elevator, however, you started coughing uncontrollably that the nurse started paging for help. She rushed you into your room where we found a team of care providers waiting. The physiotherapy took the lead to stabilize you. Fortunately, she was able to stabile you within 30minutes. I think she gave you a breathing treatment and bumped up your oxygen supply. After that, you started to verbalize more but you still complained of a severe headache. The nurse requested that I leave so she could give you some pain medicine and allow you time to rest. So, I left with a heart filled with joy ready to go and deliver the good news to the kids and our loved ones who had all been praying tirelessly and waiting anxiously to hear about the outcome of the procedure.

When I returned in the evening, you could talk to me, ask me different questions about the kids and what had happened to you and how we ended up in South Africa. You were able to follow a conversation although your memory, short term memory in particular, was not as sharp as it used to be.  When I came back the following morning, however, you had improved a lot. The focus was now on your recovery.

Brain Aneurysm: Diagnosis

Can you spot the 2 aneurysms? The big balloon was the largest and below it was the smallest one that is still intact. This is one of the pictures from my angio showing the aneurysm before the embolization. Zoom in close for details.
This scan compares the brain pre-embolization (top half) and post-embolization (bottom half). Zoom in close for a clear view and details.

Most brain aneurysms go unnoticed until they rupture or are detected during medical imaging tests for another condition. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Cerebral-Aneurysms-Fact-Sheet#5

If you have experienced a severe headache or have any other symptoms related to a ruptured aneurysm your doctor will order tests to determine if blood has leaked into the space between the skull bone and brain. 

Several tests are available to diagnose brain aneurysms and determine the best treatment. These include: 

  • Computed tomography (CT)This fast and painless scan is often the first test a physician will order to determine if blood has leaked into the brain.  CT uses x-rays to create two-dimensional images, or “slices,” of the brain and skull.  Occasionally a contrast dye is injected into the bloodstream prior to scanning to assess the arteries, and look for a possible aneurysm.  This process, called CT angiography (CTA), produces sharper, more detailed images of blood flow in the brain arteries.  CTA can show the size, location, and shape of an unruptured or a ruptured aneurysm. 
  • Magnetic resonance imaging (MRI).   An MRI uses computer-generated radio waves and a magnetic field to create two- and three-dimensional detailed images of the brain and can determine if there has been bleeding into the brain.  Magnetic resonance angiography (MRA) produces detailed images of the brain arteries and can show the size, location, and shape of an aneurysm. 
  • Cerebral angiography.  This imaging technique can find blockages in arteries in the brain or neck.  It also can identify weak spots in an artery, like an aneurysm.  The test is used to determine the cause of the bleeding in the brain and the exact location, size, and shape of an aneurysm.  Your doctor will pass a catheter (long, flexible tube) typically from the groin arteries to inject a small amount of contrast dye into your neck and brain arteries.  The contrast dye helps the X-ray create a detailed picture of the appearance of an aneurysm and a clear picture of any blockage in the arteries. 
  • Cerebrospinal fluid (CSF) analysis.  This test measures the chemicals in the fluid that cushions and protects the brain and spinal cord (cerebrospinal fluid).  Most often a doctor will collect the CSF by performing a spinal tap (lumbar puncture), in which a thin needle is inserted into the lower back (lumbar spine) and a small amount of fluid is removed and tested.   The results will help detect any bleeding around the brain.  If bleeding is detected, additional tests would be needed to identify the exact cause of the bleeding. 

In the next segment, I will talk about treatment.

Brain Aneurysm: Symptoms

From a Distance by Bette Midler.
https://www.youtube.com/watch?v=hLHE9jrb_N4

I remember having a constant headache for 2 days or so prior to the rapture. The pain wasn’t overwhelming and I could tolerate it. I would rate it a 2 on the scale of 1-10 with 10 being the worst. New mothers, me being one of them, tend to ignore little things that their bodies are trying to communicate. We give excuses in order to make ourselves feel better. It is very true we are tired most of the time with little to no adequate rest most of the time. We prioritize the needs of our children and our loved ones. The question that still ponders my mind is – ‘was the aneurysm ruptured already prior to my hospital admission and the bleeding just got worse or did it rapture on that hectic night?’ The doctors that I have met with haven’t given me a conclusive answer yet. They tend to say…..in so many words——“we just don’t know”

So what are the actual symptoms of a brain aneurysm?

Please do not sit and start guessing what could be wrong with you or your loved one. Get emergency care if you suddenly get an intensely painful headache, lose consciousness, or have some of these other symptoms of an aneurysm that has ruptured: I cannot emphasize enough to you how critical it is to get that medical care urgently. Get help if you think something is wrong with your body. DO NOT WAIT.

Although brain aneurysms usually don’t show symptoms, they can press on the brain and nerves as they get bigger. See a doctor at once if you’re having the following symptoms of an unruptured aneurysm:

  • Headache
  • Dilated pupils
  • Blurred or double vision
  • Pain above and behind an eye
  • Drooping eyelid
  • Hard time speaking
  • Weakness and numbness in one side of your face

Please remember that no matter what you are going through or how things turn out, you are not alone. God is with you and He has everything under control. He will lead you to where you need be at the right time. He will bring the right people to your case. God is watching us from a distance. You are a very special child of Him. Have faith and trust in nothing else but in Him. https://www.youtube.com/watch?v=hLHE9jrb_N4

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