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Cerebral aneurysm
A cerebral or brain aneurysm is a cerebrovascular disorder in which weakness in the wall of a cerebral artery or vein causes a localized dilation or ballooning of the blood vessel. Signs and symptoms A small, unchanging aneurysm will produce little, if any, symptoms. Before a larger aneurysm ruptures, the individual may experience such symptoms as a sudden and unusually severe headache, nausea, vision impairment, vomiting, and loss of consciousness, or the individual may be asymptomatic, experiencing no symptoms at all. Symptoms depend on the location of the aneurysm, whether it breaks open, and what part of the brain it is pushing on, but they may include:

Double vision Loss of vision Headaches Eye pain Neck pain Stiff neck

A sudden, severe headache is one symptom of an aneurysm that has ruptured. Other symptoms of an aneurysm rupture may include:

Confusion, lethargy, sleepiness, or stupor Eyelid drooping Headaches with nausea or vomiting Muscle weakness or difficulty moving any part of the body Numbness or decreased sensation in any part of the body Seizures Speech impairment Stiff neck (occasionally) Vision changes (double vision, loss of vision)

If an aneurysm ruptures, it leaks blood into the space around the brain. This is called a subarachnoid hemorrhage. Depending on the amount of blood, it can produce:[3] a sudden severe headache that can last from several hours to days nausea and vomiting

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drowsiness and/or coma

The ruptured aneurism (hemorrhage) may also damage the brain directly, usually from bleeding into the brain itself. This is called a hemorrhagic stroke. This can lead to:[3]

weakness or paralysis of an arm or leg trouble speaking or understanding language vision problems seizures

Causes Aneurysms may result from congenital defects Preexisting conditions such as high blood pressure and atherosclerosis (the buildup of fatty deposits in the arteries) Head trauma. Cerebral aneurysms occur more commonly in adults than in children but they may occur at any age. They are more common in women than in men, by a ratio of 3 to 2. Types: There are many different types of aneurysms. The most common type is called a berry aneurysm. This type can vary in size from a few millimeters to over a centimeter. Giant berry aneurysms can be bigger than 2 centimeters. These are more common in adults. Multiple berry aneurysms are passed down through families more often than other types of aneurysms. Other types of cerebral aneurysm involve widening of an entire blood vessel, or they may appear as a "ballooning out" of part of a blood vessel. Such aneurysms can occur in any blood vessel that supplies the brain. Atherosclerosis, trauma, and infection, which can injure the blood vessel wall, can cause cerebral aneurysms. Locations: A common location of cerebral aneurysms is on the arteries at the base of the brain, known as the Circle of Willis. Approximately 85% of cerebral aneurysms develop in the anterior part of the Circle of Willis, and involve the internal carotid arteries and their major branches that supply the anterior and middle sections of the brain. The most common sites include the anterior cerebral artery and anterior communicating artery (3035%), the bifurcation, division of two branches, of the internal carotid and posterior communicating artery (3035%), the bifurcation of the middle cerebral artery(20%), the bifurcation of the basilar artery, and the remaining posterior circulation arteries (5%). Onset and risks Onset is usually sudden and without warning. Rupture of a cerebral aneurysm is dangerous and usually results in bleeding into the meninges or thebrain itself, leading to a subarachnoid hemorrhage (SAH) or intracranial hematoma (ICH), either of which constitutes a stroke.

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Rebleeding,hydrocephalus (the excessive accumulation of cerebrospinal fluid), vasospasm (spasm, or narrowing, of the blood vessels), or multiple aneurysms may also occur. The risk of rupture from an unruptured cerebral aneurysm varies according to the size of an aneurysm, with the risk rising as the aneurysm size increases Classification Cerebral aneurysms are classified both by size and shape. Small aneurysms have a diameter of less than 15 mm. Larger aneurysms include those classified as large (15 to 25 mm), giant (25 to 50 mm), and super giant (over 50 mm). Saccular aneurysms are those with a saccular outpouching and are the least common form of cerebral aneurysm. Berry aneurysms are saccular aneurysms with necks or stems resembling a berry. Fusiform aneurysms are aneurysms without stems. In outlining symptoms of ruptured cerebral aneurysm, clinicians make use of the Hunt and Hess scale[5] of subarachnoid hemorrhage severity:

Grade 0: Incidentally discovered, un-ruptured, asymptomatic aneurysm. Grade 1: Asymptomatic; or minimal headache and slight nuchal rigidity. Grade 2: Moderate to severe headache; nuchal rigidity; no neurologic deficit except sixth nerve palsy. Grade 3: Drowsy; minimal neurologic deficit. Grade 4: Stuporous; moderate to severe hemiparesis; possibly early decerebrate rigidity and vegetative disturbances. Grade 5: Deep coma; decerebrate rigidity; moribund.

The Fisher Grade[6] classifies the appearance of subarachnoid hemorrhage on CT scan: Grade 1: No hemorrhage evident. Grade 2: Subarachnoid hemorrhage less than 1 mm thick. Grade 3: Subarachnoid hemorrhage more than 1 mm thick. (Highest risk of vasospasm.) Grade 4: Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension.

The Fisher Grade is most useful in communicating the description of SAH and stratifies patients' risk for vasospasm. It is not intended to be used as a prognostic scale, unlike the Hunt-Hess scale. An eye exam may show signs of increased pressure in the brain, including swelling of the optic nerve or bleeding into the retina of the eye. A brain and nervous system exam may show abnormal eye movement, speech, strength, or sensation. Tests The following tests may be used to diagnose cerebral aneurysm and determine the cause of bleeding in the brain:

Cerebral angiography or spiral CT scan angiography of the head to reveal the location and size of the aneurysm Cerebrospinal fluid exam (spinal tap)

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CT scan of the head Electroencephalogram (EEG) MRI of the head, or MRI angiogram Spinal tap

Treatment Two common methods are used to repair an aneurysm: Clipping is done during open brain surgery (craniotomy).

Endovascular repair is most often done. It usually involves a "coil" or coiling. This is a less invasive way to treat some aneurysms.

If an aneurysm in the brain ruptures, it is an emergency that needs medical treatment and often requires surgery. Endovascular repair is more often used when this happens. Even if there are no symptoms, your doctor may order treatment to prevent a future, possibly fatal, rupture. Not all aneurysms need to be treated right away. Those that are very small (less than 3 mm) are less likely to break open. Your doctor will help you decide whether it is safer to have surgery to block off the aneurysm before it can break open (rupture). Someone may be too ill to have surgery, or it may be too dangerous to treat the aneurysm because of its location. Treatment of a ruptured aneurysm may involve:

Being admitted to the hospital's intensive care unit (ICU) Complete bedrest and activity restrictions Drainage of blood from the brain area (cerebral ventricular drainage) Drugs to prevent seizures Medicines to control headaches and blood pressure Medicines through a vein (IV) to prevent infection

Once the aneurysm is repaired, prevention of stroke from a blood vessel spasm may be needed. You may receive medicines through an IV and treatments to prevent high blood pressure. Emergency treatment for individuals with a ruptured cerebral aneurysm generally includes restoring deteriorating respiration and reducing intracranial pressure. Currently there are two treatment options for securing intracranial aneurysms: Surgical clipping or endovascular coiling . If possible, either surgical clipping or endovascular coiling is usually performed within the first 24 hours after bleeding to occlude the ruptured aneurysm and reduce the risk of rebleeding.

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Surgical clipping Surgical clipping was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. It consists of performing a craniotomy, exposing the aneurysm, and closing the base of the aneurysm with a clip chosen specifically for the site. The surgical technique has been modified and improved over the years. Surgical clipping has a lower rate of aneurysm recurrence after treatment. Endovascular coiling Endovascular coiling was introduced by Guido Guglielmi at UCLA in 1991. It consists of passing a catheter into the femoral artery in the groin, through the aorta, into the brain arteries, and finally into the aneurysm itself. Once the catheter is in the aneurysm, platinum coils are pushed into the aneurysm and released. These coils initiate a clotting or thrombotic reaction within the aneurysm that, if successful, will prevent further bleeding from the aneurysm. These procedures require a small incision, through which a catheter is inserted. In the case of broad-based aneurysms, a stent may be passed first into the parent artery to serve as a scaffold for the coils ("stent-assisted coiling"), although the long-term studies of patients with intracranial stents have not yet been done.

Aneurysm in the brain Aneurysm - cerebral; Cerebral aneurysm Last reviewed: September 14, 2012. An aneurysm is a weak area in the wall of a blood vessel that causes the blood vessel to bulge or balloon out. When an aneurysm occurs in a blood vessel of the brain, it is called a cerebral aneurysm. Causes, incidence, and risk factors Aneurysms in the brain occur when there is a weakened area in the wall of a blood vessel. An aneurysm may be present from birth (congenital) or it may develop later in life, such as after a blood vessel is injured. About 5% of the population has some type of aneurysm in the brain, but only a small number of these aneurysms cause symptoms or rupture. Risk factors include a family history of cerebral aneurysms, and certain medical problems such as polycystic kidney disease, coarctation of the aorta, and endocarditis. Complications

Increased pressure inside the skull Loss of movement in one or more parts of the body Loss of sensation of any part of the face or body Seizures Stroke

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Subarachnoid hemorrhage

Vasospasm One complication of aneurysmal subarachnoid hemorrhage is the development of vasospasm, a condition in which a blood vessel spasm leads to vasoconstriction. Peak risk of vasospasm is in days 0-21 following the initial hemorrhage, patients may experience 'spasm' of the cerebral arteries, which can result in stroke. Up to 60% of patients with aneurysmal subarachnoid hemorrhage will experience radiographic vasospasm. The etiology of vasospasm is thought to be secondary to an inflammatory process that occurs as the blood in the subarachnoid space is resorbed. It appears that macrophages and neutrophils that enter the subarachnoid space to phagocytose erythrocytes and clear extracorpuscular hemoglobin, remain trapped in the subarachnoid space, die and degranulate 34 days after their arrival, and release massive quantities of endothelins and free radicals that in turn induce vasospasm. [7] Vascular narrowing, however, is only one component of the transient inflammatory injury, which is extensive. Vasospasm is monitored in a variety of ways. The most important method of monitoring is frequent neurological check and ICU monitoring. Non-invasive methods include transcranial Doppler, which is a method of measuring the velocity of blood in the cerebral arteries using ultrasound. As the vessels narrow due to vasospasm, the velocity of blood increases. The amount of blood reaching the brain can also be measured by CT or MRI or nuclear perfusion scanning. The most common method of preventing or decreasing the severity of SAH-induced vasospasm is nimodipine, along with adequate volume resuscitation. The definitive, but invasive method of detecting vasospasm is cerebral angiography. It is generally agreed that in order to prevent or reduce the risk of permanent neurological deficits, or even death, vasospasm should be treated aggressively. This is usually performed by early delivery of drug and fluid therapy, or 'Triple H' (hypertensive-hypervolemic-hemodilution therapy) (which elevates blood pressure, increases blood volume, and thins the blood) to drive blood flow through and around blocked arteries. For patients who are refractive (resistant) to Triple H therapy, narrowed arteries in the brain can be treated with medication delivered into the arteries that are in spasm and with balloon angioplasty to widen the arteries and increase blood flow to the brain. Although the effectiveness of these treatments is well established, angioplasty and other treatments delivered by interventional radiologists have been in evolution over the past several years. It is generally recommended that aneurysms be evaluated at specialty centers which provide both neurosurgical and interventional radiology treatment and which also permit angioplasty, if needed, without transfer.

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