Can Cerebral Aneurysms be prevented?

Risk Factors and Complications of Cerebral Aneurysms (Brain Injury):

A Cerebral Aneurysm is a huge, weak area in the wall of an artery that supplies blood vessels to the mind. In most situations, a brain aneurysm causes no symptoms and goes unseen. In rare situations, the brain aneurysm bursts, launching blood vessels into the head and causing a heart stroke.

Risk Factors

• Atherosclerotic diseases
• Family history
• Polycystic Kidney Disease

Pathogenesis

The cause of aneurysm formation may be multifactorial with acquired factors combining with an underlying genetic susceptibility.

• Aneurysms were once thought to be ‘congenital’ due to the finding of developmental defects in the tunica media.
• Aneurysms often form at sites of haemodynamic stress where for example, a congenitally hypoplastic vessel leads to excessive flow in an adjacent artery.
• It is not known whether they form rapidly over the space of a few minutes, or more slowly over days, weeks, or months.

Clinical Presentation

Of those patients with intracranial aneurysms presenting acutely, most have had a subarachnoid haemorrhage. A few present with symptoms or signs due to compression of adjacent structures. Others present with an aneurysm found incidentally.

1. Rupture

The features of SAH have already been described in detail; they include sudden onset of headache, vomiting, neck stiffness, loss of consciousness, focal signs and epilepsy. Since the severity of the haemorrhage relates to the patients clinical state and this in turn relates to outcome, much emphasis has been placed on categorising patients into 5 level grading systems, e.g. Hunt and Hess.

2. Compression from Aneurysm

A large internal carotid artery aneurysm (or anterior communicating artery aneurysm) may compress.

3. Incidental Finding

The improved availability of sensitive high quality, non-invasive MR or CT imaging techniques has greatly increased the number of patients in whom an intracranial aneurysm is detected incidentally, during investigation for other disease.

Complications of Aneurysmal

INTRACRANIAL

• Rebleeding
• Cerebral ischaemia/infarction
• Hydrocephalus
• ‘Expanding’ haematoma
• Epilepsy

EXTRACRANIAL

• Myocardial infarction
• Cardiac arrhythmias
• Pulmonary oedema
• Gastric haemorrhage (stress ulcer)

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How to cure Chronic Subdural Haematoma (Head Injury)?

Clinical Features and Diagnosis of Subdural Haematoma (Head Injury):

Subdivision of subdural haematomas into acute and subacute forms serves no practical purpose. Chronic subdural haematoma however is best considered as a separate entity, differing both in presentation and management.

• Chronic subdural haematomas – fluid may range from a faint yellow to a dark brown colour.
• A membrane grows out from the dura to envelop the haematoma.
• Chronic subdural haematomas occur predominantly in infancy and in the elderly. Trauma is the likely cause, although a history of this is not always obtained.

Predisposing factors

• Cerebral atrophy
• Low CSF pressure (after a shunt or fistula)
• Alcoholism
• Coagulation disorder

Breakdown of protein within the haematoma and a subsequent rise in osmotic pressure was originally believed to account for the gradual enlargement of the untreated subdural haematoma. Studies showing equality of osmotic pressures in blood and haematoma fluid cast doubt on this theory and recurrent bleeding into the cavity is now known to play an important role.

Clinical Features

• Dementia.
• Deterioration in conscious level, occasionally with fluctuating course.
• Symptoms and signs of raised ICP.
• Focal signs occasionally occur, especially limb weakness. This may be ipsilateral to the side of the lesion, i.e. a false localising sign.

Diagnosis

• CT Scan appearances depend on the time between the injury and the scan.
• With injuries 1-3 weeks old, the subdural haematoma may be isodense with brain tissue. In this instance, i.v. contrast enhancement may delineate the cortical margin.
• Beyond 3 weeks subdural haematomas appear as a low density lesion.

Adult

• The haematoma is evacuated through two or three burr holes and the cavity is irrigated with saline. Drains may be left in the subdural space and nursing in the head-down position may help prevent recollection.
• Craniotomy with excision of the membrane is seldom required.
• In patients who have no depressed conscious level, conservative treatment with steroids over several weeks may result in resolution.

Infants

The haematoma is evacuated by repeated needle aspiration through the anterior fontanelle. Persistent subdural collections require a subdural peritoneal shunt. As in adults, craniotomy is seldom necessary.

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