What is an Aneurysm?
The word aneurysm is derived from the Greek word “aneurusma”, which means to dilate. Most commonly located in a specific part of the brain, heart or abdomen, aneurysms are caused by a pouch or balloon in the blood vessel, which becomes filled with blood causing it to bulge. The increased amount of blood puts stress on the walls of the artery and can potentially cause it to burst. When this occurs, the blood flows into the brain, abdominal or heart cavity and can potentially cause severe hemorrhage, stroke and paralysis or death. Individuals ages 35-60 are more at risk for developing aneurysms and suffering from the results of an arterial rupture.
Types of Aneurysms
There are many types of aneurysms, however the vast majority of cases fall into the categories below:
- Cerebral/Intracranial – Involving the arteries of the brain
- Aortic – ccurs in the abdominal region below the spleen) and Theocratic Aortic (located in the upper chest area and affecting the heart)
- Peripheral arterial aneurysms – occur less often. These are found behind the knees (Popliteal) and another region from the lower pelvis to upper leg (Femoral)
Because of their nature, an aneurysm may not be easy to detect. Below is an examination of each major type of aneurysm, along with common symptoms, risk factors and treatment options. Aneurysms are extremely serious in nature and immediate medical attention should be sought if one is suspected.
A cerebral aneurysm is the type most people imagine when hearing of a burst vessel. Diagnosed more in women by a ratio of 3:2, Aneurysms of the brain account for the majority of aneurysms overall. Of those, eighty five percent of all cerebral aneurysms are isolated in the “Circle of Willis”, a network of arteries on the base of the brain that supply it with blood. The major arteries usually affected are the internal and external carotid arteries, which extend downwards into the neck. Depending on the exact location of the aneurysm as well as size, the rupture rate can vary between 1 and 12 percent of diagnosed cases per year.
Early detection of an aneurysm is critical. Knowing the symptoms of a swollen blood vessel can help mitigate the serious outcomes that result from it rupturing. However, it is often possible to go months or years with an aneurysm without being aware. A person may not become aware of a possible problem until the aneurysm becomes large enough to cause discomfort. Also, symptoms present differently depending on whether the blood vessel has burst or not. Another factor is the location of the enlarged vessel.
Unruptured Cerebral (Brain) Aneurysm Symptoms
- Localized pain/throbbing
- Low blood pressure
- Feeling lightheaded
- Problems in the peripheral vision
- Changes in balance and amount of coordination
- Paralysis of one side of the face
- Problems with short-term memory and concentration
Ruptured Cerebral (Brain) Aneurysm Symptoms
- Sudden sharp or hammer-like pain in the head or behind the eyes
- Intense headache
- Drooping eyelids
- Vomiting or intense nausea
- Loss of feeling in the limbs
- Loss of mental clarity
- Pain in the neck
- Loss of consciousness
Cerebral Aneurysm Causes
An aneurysm in the brain can develop for a number of reasons. The most common causes are:
- Trauma to the head
- Genetically or congenitally weakness of the artery walls
- Previous aneurysm
- Blocked arteries (fat buildup)
- Uncontrolled high blood pressure
- Cancer in the head or neck
- Congenital or genetic abnormalities of the cardiovascular system
- Connective tissue disorders
- Tangled arteries
- Drug use
- Advanced age
- Cigarette Smoke
- Family history of aneurysm
Video of What Causes cerebral Aneurysm
Cerebral aneurysms are normally what are considered “true aneurysms”, meaning they involve all three of the arteries layers. Cerebral aneurysms are classified in three ways:
- Saccular or berry-like aneurysms are those that look like a small sac attached to one side of the artery. A saccular aneurysm is called berry-like if it has a berry like stem by which it is attached to the artery.
- Fusiform aneurysms encompass the entire circumference of the artery. A blood vessel affected in this way looks like a balloon that is being blown up and is expanding equally on every side.
- Mycotic (infectious) aneurysms are much less prevalent and is the result of an infection from another part of the body entering the artery. This manifests as a saccular aneurysm.
An enlarged blood vessel in the brain is extremely dangerous, with rupture leading to bleeding into the brain or meninges- the membrane that protects the central nervous system. Continued bleeding into the cavity between the brain and scull can lead to subarachnoid hemorrhage, a form of stroke which carries a fifty percent fatality rate, with up to fifteen percent expiring before reaching the hospital. Even with early identification and treatment, hemorrhaging can cause severe cognitive and neurological impairment.
The Aorta is the body’s largest blood vessel, which runs through the center of the body from the heart, down through the abdominal cavity. The job of the aorta is to carry oxygen rich blood from the heart to other organs throughout the body. Because of its vital role, a rupture of the Aortic Artery can be life threatening. An aneurysm can occur at various points along this artery and the location is the determining factor in classification. Aortic Aneurysms are of two types:
Abdominal Aortic Aneurysm
Located in the stomach, abdominal aortic aneurysms (AAA) make up the majority of aortic aneurysms. They occur when a portion of the aorta which resides in the stomach becomes weak or swollen. The area may remain swollen, but not rupture. However, there can also be a small tear in the artery, or a full rupture, which is the most serious.
It is estimated that 15,000 people die a year as a result of abdominal aortic aneurysms, making it the tenth highest cause of adult mortality in the U. S. The senior citizen population is especially prone to abdominal aneurysms, with an estimated 2.7 unruptured cases. If detected early, ninety five percent of abdominal aortic aneurysms can be successfully treated.
Unruptured Abdominal Aortic Aneurysm Symptom
- Chronic Abdominal or back pain
- A tender feeling in your stomach, near the navel
- A pulsing or vibrating feeling in the abdomen
Ruptured Abdominal Aortic Aneurysm Symptoms
- Sudden and severe pain in the middle of the stomach
- Loss of consciousness
- Accelerated heartbeat
Abdominal Aortic Aneurysm Causes
- High Blood Pressure
- Males of advanced age
It is critical to treat an abdominal aneurysm as early as possible to avoid rupture. If an aneurysm does rupture in the abdomen, possible side affects include:
- Heart Attack
- Kidney Failure
- Arterial Embolism
Thoracic Aortic Aneurysm
A Thoracic aortic aneurysm occurs in the upper portion of the aorta above the diaphragm, near the heart. In this case, only fifty percent of individuals who have a thoracic aneurysm experience any tangible symptoms, even though the blood vessel may be very swollen. In fact, an aneurysm in the chest area is usually discovered during a cat scan for another problem and documented as a secondary diagnosis. A clearly identifiable bulge of at least 50 percent of the width of the aorta is classified as a Thoracic aortic aneurysm. Approximately 25 percent of aortic aneurysms are theoracic, with 15,000 Americans suffering from this ailment per year. Fifty percent of individuals who experience a thoracic aneurysm rupture do not survive long enough to get to the hospital for treatment.
The section of the aorta that lies in the chest can be divided into three parts, which are often used to segment and label the aneurysm. They are:
- Ascending Thoracic Aorta- the part of the aortic artery which extends upward from the heart’s left ventricle, before curving downwards.
- Aortic Arch- the portion of the aortic artery which curves downwards from the ascending aorta in an arch-like shape and continues down into the stomach.
- Descending Aorta- The straight portion on the aorta, which descends downwards towards the stomach cavity.
A theoracic aortic aneurysm can occur at any of these points in the aorta, or even consist of one large aneurysm that spans the majority of the aorta, called a thoracoabdominal aneurysm. The majority of theoracic aneurysms are located in descending theoracic aorta. This is followed in frequency by the ascending aorta and finally the arch. However, even with three places for these types of aneurysms to occur, they are still less prevalent than abdominal aortic aneurysms.
Unruptured Theoracic Aortic Aneurysm Symptoms
- Heart failure from ongoing pressure on the hearts valves
- Coughing up blood
- Extreme pressure, resulting in a swollen and painful head, arms and neck
- Pressure on the windpipe, which causes wheezing and problems swallowing
- Strained or total loss of voice
- Pain in the neck, back or chest
Ruptured Theoracic Aortic Aneurysm Symptoms
- Severe pain or tearing sensation in the upper chest area
- Coughing up blood
- Immediate lowering of blood pressure
- Internal bleeding, resulting in shock and loss of consciousness
- Death, if not treated immediately
Thoracic Aortic Aneurysm Causes
- A breakdown in the outer collagen layers of the aorta, known as idiopathic cystic medial degeneration, which leaves the artery weakened.
- Atherosclerosis is a hardening of the arteries, which blocks normal blood flow to the heart, legs and brain. This irregularity causes damage to the walls of the blood vessel, increasing the risk of aneurysm. Atherosclerosis is caused by a variety of factors, including high blood pressure, high cholesterol and smoking tobacco.
- Marfan Syndrome is also a contributor to aortic aneurysms. Marfan syndrome is a genetic connective tissue disorder. In this disease, the gene fibrillin, is defective, and does not adequately support the production of connective tissue. Because the layers of the aorta are partly made up of connective fibers, sufferers are more likely to experience weakened blood vessels and aneurysms. Marfan syndrome causes aortic aneurysms, dissections and mitrial valve prolapses.
Left untreated, this condition can cause serious problems. The aneurysm will usually continue to grow and the patient may eventually experience a dissection- a tear in one or more layers of the artery wall. This tear allows blood to flow into and pool into the layers of the artery. At some point, the aneurysm may rupture completely. The most common ramifications of a Thoracic Aortic Aneurysm rupture are:
- Leaky heart valve- In this condition, the artery has swollen to the point where it expands and presses against the heart valve that lies between the aorta and the heart. When this happens, the valve is unable to close entirely and allows blood to flow back into the heart.
- Thrombus formations- the formation of blood clots in the abdominal cavity that can travel to other areas of the body.
- Pulmonary embolism- blood clots that can enter the lungs and block the flow of blood or oxygen, resulting in damaged organs or possibly death.
Peripheral aneurysms are aneurysms that are found in veins and arteries other than the aortic artery. These types of aneurysms do not often rupture, however they can swell to a considerable size. Because of the swelling, adjacent arteries and tissues are compressed, causing pain and lack of mobility.
Another major concern with a peripheral aneurysm is that there is the possibility for blood clots to develop. These clots can break off and travel to other parts of the body, blocking blood flow. Clots can also enter into the body’s organs and can cause damage. Besides the aortic artery, aneurysms can also occur in the following areas:
Popliteal Artery Aneurysm
The Popliteal artery is a large vein that runs the length of the back of the leg in the area known as the popliteal fossa. Aneurysms of this artery are most often true aneurysms, which encompass the entire circumference of the artery. Of all peripheral aneurysms, eighty five percent are in the leg.
As with most peripheral aneurysms, they rarely rupture, but the risk of thrombosis (blood clots) and peripheral embolism (clots traveling to other areas and clogging arteries). This has caused approximately thirty percent of thrombosis cases to require amputation, with 50,000 leg amputations performed in the US. yearly. Symptoms of a popliteal aneurysm can include:
- A pulsing, painful lump on the back of the knee, arm, neck and groin area.
- Constant pain in the arm or leg
- Swelling or sores in your feet and hands
- Numbness in your extremities
Popliteal aneurysms are most common in men over fifty years of age and also in individuals who have been diagnosed with a prior aortic aneurysm.
Popliteal Aneurysm Causes
There are a number of risk factors for developing popliteal aneurysms. They include the following:
- Blocked arteries, known as atherosclerosis
- Genetically weak arteries resulting from Marfan Syndrome
- Increased weight and blood flow from pregnancy
- Smoking cigarettes
- Type 2 Diabetes
- Advanced age
Femoral Arterial Aneurysm
A second, less common type of peripheral aneurysm is found in the femoral artery. This artery extends from the pelvic area down through the thigh. It is connected to the main aortic artery by the iliac artery, which branches off in the lower abdomen and travels down towards the pelvis.
The femoral artery is in fact a collection of arteries, each of which feed blood to a different part of the leg. They are:
- The Common Femoral artery, which is the main artery behind the femur
- The Deep Femoral Artery, which branches off of the common femoral artery and sends blood to the thigh
- The Superficial Femoral Artery, which also branches off of the common femoral artery and supplies blood to the knee and foot
Femoral Arterial Aneurysm Symptoms
While it is common not to experience discernable symptoms, especially if the aneurysm is small, there are symptoms that some individuals may notice, which include:
- Pain in the thigh or groin area, which may be exacerbated by the pressure of sitting
- A noticeable lump that is hot or tender to the touch
- Numbness in the thigh or lower leg
- Easily locating the femoral pulse due to blood pressure, which can be found behind the knee or side of the groin area
- Swelling in the upper or lower leg
Although femoral aneurysms make up a small percentage of aneurysms overall, they have a high rate of rupture in relation to other peripheral aneurysms. If you experience any of the symptoms listed, medical consultation should be sought immediately. Failure to receive prompt evaluation and treatment can lead to aneurysm rupture, thrombosis and embolism.
Aneurysms of the femoral artery are caused by some of the same factors that induce aneurysms in other areas of the body. Amongst the most common are:
- Advanced Age
- Atherosclerosis- hardening of the arteries
- Trauma to the groin or thigh area
- Infection in the leg
- Intravenous drug use
- Congenital disorders
- Vasculitis- an autoimmune induced inflammation of the blood vessel
Diagnosing Femoral Aneurysms
In order to diagnose a femoral aneurysm, your physician will ask you for a list of symptoms, as well as perform a manual examination to try to identify any swelling or masses in the groin and thigh area. Other diagnostic tool may be used including:
- CAT Scan
- Ultrasound imaging
It is interesting to note that only sixty percent of femoral aneurysms manifest as symptoms that cause the patient to seek help. An additional ten percent present with severe symptoms that warrant immediate action. The remaining thirty percent are located by accident when the patient receives an x-ray or ultrasound for an unrelated issue.
Additional Aneurysm Classifications
There are additional ways that the medical community classifies aneurysms. These include the location, cause and size. Additional classifications include:
True vs. False Aneurysms
Aneurysms are also classified by whether they are considered to be true or false aneurysms. This classification is based on the number of layers of the blood vessel that encompass the aneurysm. The blood vessel consists of three layers:
- Endothelium Cells (tunica intimia) – these are smooth, thin cells that are the innermost layer of the blood vessel. Present in the entire circulatory system, endothelium cells ease friction in the flowing blood and allow the blood to pump further with less force from the heart.
- Tunica Media (middle coat) – this layer is made up of stretchy collagen rich fibers and smooth muscular tissue. It also has a sub-layer called the external elastic lamina, which consists of elastic fibers.
- Tunica adventitia (outer layer) – this layer is extremely durable and comprised of collagen, elastic fibers and connective tissue. Because of its makeup, this layer allows for flexibility and expansion of the vessel to handle the varying blood pressure of the body.
If an aneurysm pocket is comprised off all three layers, it is termed a “true aneurysm”. However, there are circumstances where the two innermost layers have been torn or ruptured and all that remains is the tunica adventitia. When this is the case, the classification of a “false aneurysm” or pseudoaneurysm is made.
In false aneurysms, blood leaks out of the tear and pools in the outer layer of the aorta, causing a bulge. If the outermost layer is also torn, the blood may leak into other areas of the brain and cause serious problems over time. It is however, also possible for the leaked blood to clot inside of the aorta, temporarily or permanently plugging the tear.
Shape of the Aneurysm
The shape of an aneurysm can also be used as a classification and to gauge its severity. Based on the shape, an aneurysm is labeled as Dissecting, Fusiform or Saccular. The definitions of these terms are:
As mentioned, blood vessels are made up of three different layers. Dissecting aneurysms are characterized as a tear in the aorta, which occurs in such a way as to cause the three layers to separate from other. When this happens, blood leaks through one or more of the layers, causing a protrusion. Most dissecting aneurysms are “true aneurysms”, meaning they involve all three layers of the aorta.
It is possible for an existing aneurysm to eventually dissect, or for an initial dissection (tear) to expand into an aneurysm (bulge). Although the minority of aneurysms are of the dissecting variety, they can be the most serious, with dissecting aneurysms in the ascending aorta (near the heart) requiring immediate surgery.
Also called Richet’s aneurysm, a fusiform aneurysm usually also presents as a true aneurysm. The elongated bulge extends equally on all sides of the aorta, tapering to a spindle-like point at each end.
Also called an ampullary aneurysm, saccular anuerysms are labeled thus, due to their sac-like appearance. Unlike the fusiform variety, saccular aneurysms present as a bulge on one side of the aorta. Usually a result of internal trauma caused by a motor vehicle accident, or other sudden and high impact occurrence, saccular aneurysms are a result of a tear in the internal layers of the artery, causing blood to pool in the outermost layer.
Cerebral Aneurysm Treatment
Once a positive diagnosis is made, a treatment option will be selected based on the size and location of the aneurysm, as well as whether there is clotting or the risk of embolism. If the risk is not high, occasionally the physician will suggest that the patient make lifestyle changes and forego intervention unless things progress. This may include regulating blood sugar and blood pressure, as well as promoting weight loss. In the event that the state of the aneurysm necessitates clinical intervention, one of the modalities below will be discussed with the patient:
The most common form of surgical treatment is surgical clipping and originated in 1937. In this procedure, a small device made of titanium is used to isolate the aneurysm. Used most commonly in saccular aneurysmsms, the clip functions like a clothes pin. When placed around the neck of the sac-like aneurysm, it effectively cuts off the flow of blood and pressure into the weakened walls of the aneurysm site.
Surgical Clipping for a Cerebral Aneurysm
When applying surgical to a cerebral aneurysm, an operation called a craniotomy is performed. If your aneurysm has already burst, the surgery will be carried out immediately after the aneurysm is located and your blood pressure is lowered to safe levels. If the aneurysm is intact, the surgery will be scheduled in the very near future once a complete set of x rays and blood tests are performed and reviewed. Your doctor will discontinue any NSAID medications a few days before surgery, so as not to interfere with the procedure. You will be instructed not to eat after midnight the day before surgery.
The actual procedure is considered invasive and requires the surgeon to cut into the scull to reach the enlarged blood vessel. After being placed under anesthesia, the patient may be given a medication to relax the brain and relieve pressure or a lumbar drain may be inserted into the back to drain cerebrospinal fluid achieve the same goal. A small portion of the patient’s scalp is also shaven to allow clean access to the scull in preparation for surgery.
The first step in this surgery is to make an incision in the scalp, which is then folded back along with the underlying muscle, exposing the skull. The surgeon will use a special drill and saw to cut a round hole in the scull large enough to reach the aneurysm. The piece of the scull that was cut is removed, exposing the brain.
The next step is extremely delicate. An instrument is used to slightly lift the brain, allowing the doctor to get underneath it to the space between the bottom of the brain and the lower section of the skull. Using an operating microscope and delicate instruments, the surgeon will locate the aneurysm, isolate it from any surrounding arteries and ensure that blood flow is stable. The surgical clip will then be placed on the neck of the aneurysm, effectively cutting the flow of blood from the main artery and eliminating risk of a rupture. Depending on the size and location of the aneurysm, multiple clips may be is used.
After insertion, the clip will be checked thoroughly to ensure that it is in place and has not been attached to any uninvolved arteries. The head of the aneurysm is then punctured. This allows it to drain, as well as ensure that no additional blood is leaking from the main artery.
Once it is confirmed that the aneurysm has been correctly isolated, the brain will be gently released from the retractors, the dura (brain covering) is sown shut, after which titanium plates and screws are used to reconnect the piece of the scull that was removed. The pieces of tissue, muscle and skin are then re-sewn and a special bandage placed over the incision site.
After Surgery (Clipping)
The aftercare protocol differs based on whether you presented with a ruptured or unruptured aneurysm before surgery. The following is the usual procedure for each:
- The patient will be moved to the neurosurgery recovery unit and watched closely to ensure a successful return to consciousness.
- It is quite common to experience headache and nausea after surgery. Appropriate medication will be given upon request.
- Vital signs will be monitored closely stabilization, the patient may be integrated into the general in-patient population
- Most patients are given after surgery instruction and released within a week of surgery.
Patients that received surgery for a ruptured aneurysm are kept in the hospital for a longer period, up to three weeks.
The patient will be monitored closely for any signs of spasms, which cause the artery to constrict and become narrow. This restricts the blood flow to the brain (ischemia) Symptoms include weakness in the legs, confusion and drowsiness. This is possible anywhere from soon after surgery, up until two weeks.
If the patient presents any signs of vasospasm (constricting of the arteries), stroke or infection, brain swelling or seizure, immediate intervention is necessary. Depending on the severity of the symptoms, additional surgery may be required. However, some cases of post surgical vasospasm or stroke will end in death.
Approximately fifty percent of ruptured aneurysms and subarrachnoid hemorrhage cases result in fatality before surgical intervention. Of those that receive treatment, twenty five percent suffer some form of physical or mental restriction.
Endovascular Coiling for Cerebral Aneurysms
Introduce later in 1991, endovascular coiling is a less invasive intervention for cerebral aneurysms. Used primarily in the case of ruptured cerebral aneurysms, coiling is touted as being a safer procedure, with an easier recovery. However, based on the size and location, clipping the aneurysm may provide a better outcome. A skilled neurosurgeon will weigh all of the variables and present the best treatment option for each individual patient based on their unique circumstances. With coiling, the patient may be anesthetized by local anesthetics or receive medication to become unconscious during the procedure.
As mentioned, coiling is less invasive than clipping. In this
procedure, entry is made to the aneurysm through the femoral artery,
which is located in the leg. A catheter is inserted in the femoral
artery and travels through the major arteries until it reaches the brain
and the site of the aneurysm. Once in place, a thin flexible platinum
wire is inserted and run through the catheter by means of a delivery
wire. This process is managed by fluoroscopy imaging, which allows the
surgical team to monitor the progress of the wire through the artery.
Once at the site, the platinum wire is threaded or coiled in such a way as to fill the aneurysm cavity. This seals the area and prohibits blood pressure from causing further damage to the arterial wall and prevents rupture. In the case of a large aneurysm with a wide neck, a stent may be placed over the opening of the aneurysm (between the coils and the inside of the blood vessel). This helps to hold the coils in place.
Comparison to Surgical Clipping
The coiling process is called coil embolization and has been documented as effective in both ruptured and unruptured aneurysms. In the case of ruptured aneurysms, a study performed on over 2,000 patients in the International Subarachnoid Aneurysm Trial (ISAT) showed that the risk of patients suffering from disabilities after one year was reduced by 22.6 percent when endovascular coiling was performed instead of surgical clipping. There has not been a large multi-center study conducted for unruptured aneurysms, however reduced post-procedure symptoms and quicker recovery period have been reported.
After Surgery (Coiling)
If there are no complications, patients are usually released from the hospital within forty eight hours. Full recovery may take anywhere from 1 to 4 weeks. Patients will need to be monitored on a yearly basis to ensure that that the titanium coiling is still in the place.
Another method of repairing an aneurysm is to perform an arterial bypass. This consists of diverting the blood flow from one area of the artery or another, bypassing the aneurysm site and allowing the blood to flow uninterrupted. This is done by harvesting an artery from another part of the body and attaching it to the affected artery, before and after the aneurysm site. A second option is to use an artery from the scalp or neck, detaching one end from its normal position and attaching it to the affected artery, therefore rerouting blood flow.
Arterial bypass surgery is usually not the first choice as there are increased risks, but will be performed if the conditions/symptoms warrant it. A bypass may be more likely to be necessary in a person with an aneurysm in a major artery, such as the middle cerebral artery or interior carotid. These arteries can become affected by fat buildup (atherosclerosis). A bypass may also be performed in the case of a large aneurysm, which is the result of trauma or the side affect of a previous surgery. Genetic and congenital disorders can also be at fault, as well as severely clogged arteries. When considering the proper course of treatment, a cerebral angiogram, PET scan or other ultrasound imagery may be employed.
Performing a Bypass
A cerebral artery bypass is a very complicated procedure and requires immense skill. Because of this, only a relative few neurosurgeons perform this procedure. You will want to receive a referral to a surgeon who has had many successful operations to his credit. The surgical team will include an anesthesiologist who will ensure that the patient is unconscious before the surgery begins and will monitor the vital signs throughout the procedure.
To successfully perform a bypass, a donor artery is needed. This will be used to reroute the blood flow around the aneurysm. The artery may be taken form the leg, arm, scalp or other area. As with the clipping procedure, to perform a cerebral bypass, a portion of the scull will be cut to allow access for the surgical team to the aneurysm. The surgeon first cuts an incision in the scalp and pulls back a portion of the scalp, as well as the muscle tissue to expose the scull. A small hole will be made in the scull to create access to the brain. If necessary, a second incision is made in the neck to provide access to the carotid artery.
Once the brain is exposed, the surgeon will use tiny instruments called micro instruments and an operating microscope to reach the swollen artery. Micro-clips are attached to the artery to prevent blood flow during the operation. The donor artery is attached using micro-suture, which is an extremely fine thread that is barely visible without the aid of the microscope. Also, some doctors choose to use laser technology to connect the donor artery to the recipient artery.
Once the surgery is complete, a safe contrast dye will be injected into the artery to gauge flow. If the blood is flowing unrestricted through the donor artery, the surgery is deemed a success. The portion of the scull that was removed is reattached with titanium screws and the incisions are sutured.
The patient will be monitored closely to ensure that there is no sign of post-operative bleeding, spasms or seizures. Blood thinners will likely be administered to ensure the blow flows unrestricted. The patient will initially be given narcotic level pain medication and may continue with them for up to four weeks post surgery. It is important to watch for signs of addiction and switch to SNAID pain medication once the pain has subsided.
Follow-up will be done within 14 days to check the incision site and remove any sutures, if necessary. An appointment will be made with the neurosurgeon at around three weeks and again in three to six months. At those visits, imaging procedures will be used to verify that there is normalized blood flow throughout the affected artery and the rest of the brain.
Bypass surgery solves the problem of rerouting the blood around the aneurysm. However, if the patient is suffering from genetic or induced weakening of the arteries, another aneurysm in another location cannot be ruled out. For the best chances, patients should avoid smoking and strive to control their blood sugar and blood pressure. Some patients will also need to take anti-seizure medication long term.
Recovering from an Cerebral Aneurysm
After surgery, it is important to carefully follow the discharge instructions. After leaving the hospital, patients should avoid moderate to heavy lifting, housework, exercise, driving and consuming alcohol or cigarettes.
It is common after surgery to feel a high level of fatigue and you should not push yourself. Patients usually focus on rest the first two weeks post surgery and resume minimal activity such as taking short walks within two weeks. Resuming more strenuous activity must be approved by the physician. Any odd symptoms such as fever, signs of infection in the incision and increasing lethargy should be reported to the doctor. Also call the doctor if you experience sharp pains, headache, and vomiting or vision problems. These may be signs of internal bleeding.
For those that suffer a ruptured aneurysm, hemorrhage or stroke and make it through surgery, there is a large chance of physical and cognitive deficiencies. After surgery, recovering from an aneurysm depends on many factors. Amongst them are:
- Whether the aneurysm ruptured before surgery
- The amount of blood that leaks into the brain
- Whether the patient has suffered subarachnoid hemorrhage or stroke
- The experience of the syurgical team and success of the operation
- The age and overall health of the patient
For those who experience side affects after surgery, the flowing is common:
- Anxiety and depression
Unfortunately, in some cases the post-surgery complaints are much worse. If there has been trauma to the brain, there may be damage to portions that control the five major brain functions: movement, language, memory, pain and emotions. While each case is different based on the location and severity of damage, below are possible complications:
- Brain damage
- Memory loss
- Some suffer from hormone imbalances due to damage to the hypothalamus and the pituitary gland
- Partial or full paralysis
- Loss of motor skills
- Cognitive deficit
- Speech problems
- Chronic pain
- Loss of control over bathroom functions
What Therapy Involves
In the cases like these, a recovery team will begin working with the patient soon after surgery. Once the patient is stabilized, they can begin working to recover basic skills that may have been lost, such as speech, holding a cup, walking and dressing themselves. The brain is resilient organ. Although these skills were wiped out when the aneurysm ruptured, the brain is able to relearn them with assistance.
A quarter of people survive a stroke have problems speaking, reading and understanding language. A speech and language therapist will work with the patient to slowly reconnect the dots between thought and verbal communication. Depending on the severity of the damage, a person may have absolutely no verbal skills, akin to a baby. The level of trauma dictates the length of time needed and the likelihood of a full recover of speech and language cognition.
For patients with impaired movement, a physical therapist will work with them to try to regain sensitivity and feeling, increase range of motion and prevent atrophy of the muscles and locking of the limbs. However, some individuals will suffer from permanent paralysis and need assistance for life.
In the case of emotional disorders resulting from stroke or a ruptured aneurysm, the patient will work with a mental health professional to try to resolve them. The most common emotional side affect is a sense of hopelessness and a feeling that one’s life is over. Excessive drowsiness, fatigue, anger and being withdrawn from others are common emotional responses. Patients with extreme cases may also be suicidal. Working with a psychotherapist to receive counseling and appropriate medication can help to improve or alleviate these symptoms.
Stroke sufferers will work with an entire rehabilitation team to work towards the best outcome. Some of the professionals may include Physical Therapists, Rehabilitation Nurses, Speech and Language Pathologists, Recreational Therapists and Vocational Therapists.
Aortic Aneurysm Treatment
Treatment for an aortic aneurysm will vary based on the location and size of the aneurysm, as well as the patient’s medical history. Below are the common treatments for both theoracic aortic aneurysms and abdominal aortic aneurysms.
The Wait and See Approach
If an aneurysm is discovered and is relatively small in size, not causing discomfort or threatening to rupture, the physician will often recommend forgoing medication at this point. The patient will be monitored every three to six months to assess the aneurysm for any growth. Based on the results, the doctor will either continue the present course, or prescribe medication or other interventions.
While not being actively treated, the doctor will want to control any contributing factors, such as high blood pressure, diabetes, high cholesterol and smoking. Medication may be prescribed to help control these risk factors.
There are two main surgical options for repairing an aneurysm of the aorta. They are “open repair surgery” of the chest or abdomen, or “endovascular aneurysm repair”. The means of treatment are very dissimilar, with a big difference in recovery time and discomfort.
Open Chest/Open Abdominal Surgery
When using open surgery to repair the aneurysm, an incision is made in the patient to expose the aorta (main artery) after the patient has become unconscious. This allows a clear view of the aneurysm and makes removing it relatively easy. Once the aneurysm is removed, an artificial graft is used to reconnect the two sections of artery. This graft is usually constructed from Teflon or Dacon. If the aneurysm is in the aortic arch, additional repair may be needed to repair damaged heart valves. This can be done at the same time that the aneurysm is removed.
When prepping for open chest surgery, the physician will determine whether an incision should be made under the breastbone or in the back, depending on the location of the aneurysm on the aorta. If the aneurysm involves the ascending or aortic arch, a six to eight inch incision will be made under the breast area. If the aneurysm is on the descending aorta, an incision may be made in the back under the shoulder blade and curve under the arm towards the chest.
After the surgery is complete, the surgeon will repair the incision. If the cut was made in the chest, the surgeon will close the breastbone, wire it together and then suture the overlying muscle and skin. If the incision was made in the back, that area is secured and sutured as well.
Recovering From Open Surgery
Open surgery is considered major surgery and may take a month to six weeks to recover from. Initially, the patient will spend 1-2 days in the Intensive Care Unit right after surgery. The aorta will be monitored via imaging technology to ensure proper blood flow. The patient will also receive medication to stave off infection.
The total hospital stay is seven to ten days. When the patient is released, they will experience limited mobility as the surgical site heals. The patient should be alert for signs of complications, such as infections, blood clots or fluid leakage.
Endovascular Aortic Repair
Much less invasive, endovascular repair is a newer form of aneurysm repair, but has been lauded for the comparatively easier recovery. It has been noted that patients who receive endovascular repair have a shorter hospital stay, less blood loss and less damage to the aortic artery.
Endovascular repair consist of running a catheter through the femoral artery in the groin, up to the aorta in the abdomen or chest. There is a stent graft (thin tube) attached to the catheter, which is threaded into the walls of the swollen artery. Once securely in place, the tube is expanded until it fills the artery and creates a tunnel for the blood to pass through. The stent graft fortifies the artery walls that were weakened by the aneurysm and prevents future rupture. Because it is not being supplied with blood, the aneurysm usually shrinks.
Recovery from Endovascular Repair
Because of the less invasive nature of this procedure, the patient is usually able to recover within two weeks. After that time, the patient should enjoy full mobility. Follow-up examinations are required every six months to ensure no complications.
The most common complication that the doctor will screen for is Endoleak. This is classified as blood escaping the artery and flowing into the body, despite the presence of the graft. This happens when the stent has not totally integrated into the vessel tissue in a way that forms a complete seal. The aneurysm continues to be supplied with blood and eventually dissects or ruptures. This presents all of the risks originally associated with the aneurysm and must be treated as an emergency. Patients should also be alert for any respiratory discomfort or chest pains.
Peripheral Aneurysm Treatments
Peripheral aneurysms are ones that are located in areas other than the brain, chest and abdomen. These most frequently occur behind the knee, in the groin area, in the arm and in the neck. Femoral and Popliteal aneurysms, which were discussed above are classified as peripheral and present in the groin and knee, respectively.
The main concern in a peripheral aneurysm is not rupture, but thrombosis (clotting). Blood clots form in the aneurysm sack and then escape. The clots can travel the length of the arm or leg and become stuck in an artery or vein, inhibiting blood flow. Over time, this can cause painful swelling, sores on the toes and fingers and gangrene, which would necessitate amputating the limb.
To avoid the risks and results of thrombosis, patients may be given anti-coagulation medication in an effort to thin the blood and break up the clots. If this is unsuccessful, then surgery is necessary to prevent the clots from causing blood loss to the extremities or even stroke.
The standard surgical treatment for peripheral aneurysms is open surgery to perform a bypass or a full replacement of the artery. As mentioned above, a bypass uses either a donor artery from elsewhere in the patient’s body or an artificial graft. In the case of a bypass, the new artery is attached to the one that is affected, rerouting the flow of blood. In a replacement, the aneurysm is removed and a graft attached to each end of the affected artery, connecting them.
In the case that a patient did not receive a diagnosis and treatment early enough, there may already bee too much damage to the associated limbs. If gangrene has already set in, or there is major arterial or tissue damage, an amputation is a likely last resort.
Recovering from a peripheral aneurysm will vary based on the location and severity of the aneurysm. For non-severe cases, the patient may stay in the hospital for as little as two days, while more severe cases may require a week or two. During this time, the patient will be monitored for any complications and will be given blood thinners and pain medication as needed. For patients that require an amputation, post-operative therapy will be required to teach them how to operate without the missing limb or digits.
While there are some congenital and genetic factors to developing an aneurysm, there are things that can be done to reduce risk. They include:
- Not smoking
- Eliminating use of narcotics, especially cocaine
- Controlling blood pressure
- Maintaining a healthy weight
- Maintain good cholesterol levels
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