Cerebral aneurysm is also known as cerebral, intracranial or intracranial. It is a bulge on the vessel.

Sometimes it ruptures, which causes blood to splash into the space around the brain. These areas are called subarachnoid and hence this type of cerebral hemorrhage is called.

It is one of the causes that can lead to serious brain damage and death.

Statistical indicators

In approximately 0.2-3.0% of cases, a cerebral aneurysm ruptures and bleeds. For example, in the United States there are 30,000 such patients annually, of whom 10-15% die before reaching the hospital, and more than 50% die despite appropriate treatment within the first 30 days.

Even of those who survive, more than half suffer permanent neurological disability. You can get a cerebral aneurysm at any age, but most often at the age of 35-60 years (more often in women).

Causes

First of all, it is necessary to mention genetic predisposition, as a result of which various defects occur on the vascular wall - thinning or lack of elasticity.

Therefore, it is good to know in advance whether anyone in the family has suffered from vascular diseases, which may have a genetic origin.
Often an aneurysm affects people who have certain genetic disorders and circulatory disorders.

Other causes include atherosclerosis, various.

Risk factors include smoking, high blood lipids (hyperlipidemia), high blood pressure and drug use.

Clinical picture

Minor blood leaks or sudden expansion of the walls of the aneurysm can manifest themselves as so-called warning headaches, which, however, are difficult to distinguish from “normal” ones that arise for other reasons.

With major bleeding, a very severe headache is typical. It often appears after some stress.

Pain should always be a signal for proper examination. It can be accompanied by a disorder of consciousness, movement, and in the worst case, the patient dies.

An unruptured cerebral aneurysm may not manifest itself at all, but in about 40% of patients, any of the following is sometimes present. the following symptoms or their complex:

• violation peripheral vision(to the sides, top and bottom);
• difficulty thinking or performing certain activities;
• speech problems;
• problems related to perception (touch, heat, cold, pain);
• sudden changes in behavior;
• impaired balance and coordination of movements;
• significant decrease in the ability to concentrate;
• impairment of short-term memory;
• fatigue.

A ruptured brain aneurysm is accompanied by distinct symptoms

• headache (patients sometimes describe it as “the worst headache they have ever experienced”);
• vomiting or at least the urge to vomit;
• stiff neck or neck pain;
• broken or ;
• weakening or numbness in the limbs (sometimes one half of the body);
• pain above and behind the eyes;
• dilated pupils;
• sensitivity to light;
• Impaired skin sensitivity (to touch).

However, because the symptoms of an aneurysm (especially an unruptured one) are similar to those of many other diseases, detailed neurological and neuroradiological examinations are necessary for diagnosis.

Diagnostic criteria and methods

For diagnostic purposes, the following methods are used:

Goals and methods of therapy

The goal of treatment for cerebral aneurysm is to prevent recurrent bleeding, which determines a high percentage of the patient’s threat of death or other severe consequences in case of rupture.

At any stage, treatment is carried out in two ways:

1. Microsurgical method – clipping cerebral aneurysms (from the English Clip - clamp). It involves clamping the blood vessels while maintaining their patency. Clipping is performed by microsurgical operation with opening of the cranial cavity (craniotomy)
2. Endovascular method carried out under x-rays using a catheter. During this therapy, special metal coils are inserted into the bulge, on which a blood clot forms, causing the bulge to close. IN last years The introduction of reinforcing stents in this way is increasingly being used to further expand the possibilities of this treatment method. Therapy is carried out by inserting a catheter through the groin into the femoral artery, and then through the vascular system to the corresponding vessels of the brain.

Ideally, a solution is needed within 3 days of the onset of bleeding due to high risk recurrent bleeding from an already ruptured aneurysm; after 72 hours, due to the breakdown of hemoglobin and the release of toxic substances, cerebral vascular spasms occur, so the indication for surgery at this time is set on a strictly individual basis.

Deferred decision is performed quite rarely - with late diagnosis or in cases where the patient’s condition is so severe that there is a risk serious complications with immediate therapeutic intervention. The procedures in this case are the same as in the acute phase, but are used after the spasms of cerebral vessels have been eliminated.

The course of each therapy method is determined by the specific location and shape of the bulge, the patient’s condition, his age and other factors. Each of them has its own advantages and disadvantages.

The endovascular method is more convenient from the point of view that the patient does not open the cranial cavity surgically. But, along with this, some complications are possible during the operation, for example, rupture of the aneurysm during the intervention.

The disadvantage also lies in the absence of a 100 percent guarantee that the coils inserted by the catheter will not move and the aneurysm will not begin to fill again.

In contrast, clipping with opening of the skull is considered an operation in which the patient is cured completely, however, open brain surgery is more difficult for the patient. A team of specialists, consisting of neurosurgeons and radiologists, decides which treatment method to use.

What is the danger?

Danger with this disease can await the patient from any side.

Consequences of an aneurysm as such

There are often serious consequences associated with natural course diseases. occurs as a result of the accumulation of cerebrospinal fluid, and an increase in the volume of bleeding from the aneurysm.

Impairment of consciousness develops up to its loss. Spasms (narrowing) of the arteries of the brain caused by the reaction vascular wall on bleeding, can lead to, and most often occur within 4-15 days after hemorrhage; repeated bleeding of the aneurysm worsens the condition.

Complications and consequences associated with diagnosis

In this case, there may be allergic reactions after administration of contrast agents during CT or angiography, which manifest as rash, drop in blood pressure, breathing problems, hemorrhage and swelling at the site of insertion of the catheter in the groin during angiography.

Difficulties associated with treatment

May be observed:

• in the area of ​​the treated or nearby vessel;
• bleeding of the aneurysm during insertion of the coil;
• formation of a false aneurysm at the injection site in the groin;
• allergies when a contrast agent is administered;
• complications after anesthesia ( heart attack or stroke).

The prognosis after surgery is uncertain. Late complications may occur, such as re-bulging of blood vessels in their weakened walls. Any of these complications may require further surgery. The 5-year survival rate of patients who survive an aneurysm is 60% of cases.

How to prevent the development of the disease?

From a genetic perspective, there is little that can be done to prevent an aneurysm. It is necessary to warn the doctor about the presence of the disease in the family, in order to carry out timely treatment and preventive measures aimed at maximum protection vascular walls from adverse effects.

It is mandatory to prevent atherosclerotic changes in the vascular walls. This fact is significantly influenced by smoking, so it should definitely be avoided.

In addition, high blood pressure should be mentioned, which can be associated in particular with a poor lifestyle and a lot of stress or insufficient exercise.

Obesity and high levels of lipids (fats) in the blood plasma are another potential “creator” of atherosclerosis. As a rule, preventing the deposition of fat in blood vessels requires a general change in lifestyle, including diet and inclusion in daily life enough movements.

Maintaining all body systems good condition- not an easy job, and it’s simply unrealistic to monitor this constantly. If any of the organs is damaged, the body lets us know about it through pain. But what if it is not the organ that is damaged, but the blood vessels of the brain? But an aneurysm may not manifest itself. To protect yourself from the consequences, you need to know everything about it.

Intracranial aneurysm is a pathology in the form of a formation on the wall of a brain vessel that gradually fills with blood and increases in volume.

As it grows, it begins to put pressure on adjacent nerves, blood vessels and brain tissue, which causes subsequent symptoms. But the worst thing is a rupture of an aneurysm, when there is a huge probability fatal outcome.

Classification of intracranial aneurysms

Pathology can be classified according to several criteria, for example:

• form;
• size;
• location;
• nature of occurrence;
• number of cameras.

Forms

The following types of aneurysms are distinguished:

• Saccular or “berry”. The most common form (appears in more than 90% of cases). It is named so because it looks like a bag or a large berry.
• Fusiform or fusiform. Cause of occurrence: expansion of the walls of the vessel in any area. Unlike the berry artery, the artery expands on both sides.
• Lateral. It looks like a tumor. It is located on the side, on the wall of the artery.

Magnitude

The size of the formation is determined by the diameter:

• milliary (up to 3 mm);
• small (3-10 mm);
• normal or medium (11-15 mm);
• large (16-25 mm);
• gigantic (more than 25 mm).

Location

Most often, in 47% of cases, pathology occurs in the anterior cerebral and communicating arteries.

The rest are localized on arteries such as:

• middle cerebral (23%);
• internal carotid (22%);
• vertebrobasilar system (6%);
• on more than one (15%).

Number of cameras

Aneurysms are divided into:

• single-chamber;
• multi-chamber.

Nature of occurrence

According to the nature of its occurrence, the pathology is divided into:

• congenital;
• acquired.

It is important to know that severe symptoms can last up to 24 hours. Further progress in the clinical picture of the attack is usually attributed to a stroke. You will read about this in the article.

It is very important to distinguish and correctly develop imitative and global synkinesis. How this happens, you will find

Symptoms and signs of intracranial aneurysm

An aneurysm is most often asymptomatic, until it reaches a large size or ruptures.

Occasionally, pain may appear in the frontal part of the head.

Symptoms of a growing mass do not appear immediately, and sometimes may subside.

Expressed in:

• pain in the forehead and eyes;
• numbness, a feeling of stiffness or partial paralysis of one side of the face;
• weakness of the facial muscles;
• blurred vision;
• pupil dilation.

Rupture of a cerebral aneurysm

Before the pathology ruptures, short-term pain may appear in different parts of the head.

Signal pain can last up to several weeks before the formation ruptures, and will make itself felt with the following symptoms:

• Sudden and sharp. At first it is local in nature, then spreads to the entire head.
• A sharp deterioration in vision, double vision.
• Nausea and repeated vomiting.
• Repeated attacks of loss of consciousness of varying duration.
• Increased muscle tone in the back of the head (rigidity).
• Seizures and mental disorders of varying severity may occur (from disorientation to acute psychosis).

Signs of a ruptured aneurysm

Hemorrhage of the subarachnoid type leads to vasospasm. In more than 60%, it leads to various types of brain damage, for example, and.

In 20-24% of cases, intracerebral hematoma is observed, occurring due to hemorrhage into the structures of the brain.

In 10-15% of cases, hemorrhage occurs in the ventricles of the brain. This is the worst option for the development of an aneurysm, because it most often leads to death.

The remaining signs can be distributed according to the location of the lesion:

• Anterior cerebral artery - psychosis, personality disorders, paresis of the lower extremities.
• Middle cerebral artery - disorders speech apparatus and hemiparesis.
• The area of ​​the bifurcation of the carotid artery - visual impairment.
• Area in the vertebrobasilar system - paralysis and paresis of the facial nerves, nystagmus, dysphagia, ataxia, damage to the ternary nerve.

Aneurysm in children

Pediatric pathology most often occurs in:

• children over 2 years old;
• boys;
• in the postcranial fossa;
• in large and gigantic sizes.

Symptoms are the same as in adults, perhaps also:

• increased ICP;
• the appearance of heart failure;
• intracranial hemorrhage.

Intracranial aneurysm is rare in children (occurs in approximately 5% of cases).

However, in medicine there are known cases of congenital cerebral aneurysms. Most often they were the consequences of intrauterine infections and fetal diseases.

Causes of cerebral aneurysm

Doctors have different theories regarding the causes of aneurysms. The majority supports the method of dividing them into predisposing and producing factors.
Predisposing factors

Predisposition factors are divided according to the nature of the formation:

• Congenital can be called an anomaly of vascular development in the fetus. Due to failures, mutations and the influence of certain factors, the structure of the vessel wall is disrupted, and therefore an aneurysm is formed.

  In this case, not one pathology is observed, but several (in more than 70%), for example, polycystic disease, AVM or dysplasia connective tissue.

• The acquired may occur:

  — As a consequence of non-inflammatory diseases, for example, atherosclerosis and hyalinosis.

  - Due to radiation exposure.

  — Due to embolisms of various kinds. Doctors call such an aneurysm mycotic.

Producing factors

Generating factors are those that cause the occurrence of pathology.
The main such factor is hemodynamic, when it is noted sharp increase Blood pressure and laminar blood flow are replaced by turbulent ones.

Fast pace of life, prolonged exposure to stress, constant anxiety for loved ones can lead to the development of a disease such as cardioneurosis. are quite unpleasant, difficult to tolerate and make a person suspect that he has a severe heart pathology.

You can read the article about the dangers of cerebral edema in newborns and why it develops.

All about treatment vascular dementia you will find it at the link.

Diagnosis of aneurysms

Differential diagnostic procedures are carried out based on the patient's symptoms and signs. After questioning and making a topical diagnosis (determining the location possible education) the neurologist, together with the patient, decides on further hardware examination.

Tests are sometimes used to assess the condition of patients, for example:

Hardware examination

Hardware examination includes many measures, but it is advisable to use only some of them:

• X-ray and tomography. The very first thing the neurologist prescribes. However, these options are not always reliable and applicable.
• X-ray of the skull. Allows identification of petrified aneurysm.
• CT and . They make it possible to recognize pathology with a high probability, as well as assess the state of blood flow.
• Electroencephalography. Allows you to determine the duration of the operation:

  — EEG types 1 and 2 allow surgical intervention;

  - with type 4 EEG, surgery can only be performed if there is a direct threat to life.

• TDKG. They are carried out very rarely, mainly to determine the speed of blood flow and the degree of vessel spasm.
• Angiographic examination. Gives the most reliable result, allows you to create a 2D and 3D image showing the location, type and size of the aneurysm. It can be carried out even in acute rupture conditions.

Other examination methods

These methods are used occasionally:

• Lumbar puncture. It is carried out if it is impossible to conduct a more accurate hardware examination of the ruptured formation. If even a little blood is present in the analysis, then a cerebral hemorrhage has already occurred.
• Apoplectic aneurysm is determined from an attack of epilepsy or ischemia, stroke or
  .

Treatment of aneurysm

Unruptured pathology of small size must be constantly monitored by a doctor.

Since it is not a reason for surgical intervention, the doctor may approve other treatment methods, for example:

• Compliance with preventive measures.
• Acupuncture and reflexology.
• Folk methods.

Embolization of aneurysms

The essence of the method is that emboli block the blood supply to one or another structure of the body, thereby blocking the pathology and reducing its size.

Embolization is a relatively new method that can replace surgical measures.

The procedure is performed under general anesthesia. The following are used as emboli:

• spirals;
• cylinders;
• particles;
• gelatin sponge;
• cylinders.

The procedure takes place in two stages:

• A catheter is used to access the vessel.
• An embolus is injected and its effect is monitored using angiography.

The spiral installation process is schematically discussed below:

Surgical treatment of aneurysm

Operations are performed on unruptured pathology:

• clipping of the aneurysm neck;
• radiosurgical and transcranial removal.

The following surgical interventions are performed on a ruptured aneurysm:

• removal of hematoma;
• endoscopic evacuation of hematoma;
• stereotactic aspiration of hematoma.

If hemorrhage occurs in the ventricles, ventricular drainage is performed.

The photo shows the result of surgery for a cerebral aneurysm:

Traditional methods

Herbal treatment focuses on taking infusions, for example:

• dill;
• hawthorn;
• jaundice;
• elderberries.

Prevention of aneurysms

Preventive measures include:

• A diet with minimal fat, carbohydrates and salt.
• Moderate physical activity.
• Quitting smoking and alcohol.
• Control of blood pressure and heart rate.

is a disease of the nervous system that affects motor (motor) neurons. How dangerous it is and how to prevent it.

Everything about the symptoms and manifestations of acoustic neuroma is described in detail in

Consequences and forecasts

The prognosis depends on many factors:

• localization;
• sizes;
• from the presence of concomitant pathologies.

If the formation is small and does not increase, then you can live with it for a long time without feeling any consequences.

Educational disruption leads to:

• disability in 25-37%;
• deaths in 35-52%.

The risks of recurrent hemorrhages are shown in the table:

You can avoid becoming disabled and avoid death due to a ruptured aneurysm by carrying out preventive measures in advance (and this includes collecting information, including watching educational programs) and consulting a doctor.

On the video - the TV show “Live Healthy!”, topic “Cerebral Aneurysm”:

Modern treatment methods make it possible to remove the formation without surgery. You should not wait for breakthrough symptoms, acute headaches are the weakest of which, it is better to make sure that there is no problem at an appointment with a neurologist.

Brain diseases are the third most common. If timely diagnosis and treatment are not provided, these pathologies can lead to irreversible consequences.

It is recommended to undergo examinations every six months to a year to monitor the condition, especially for patients who are at risk. Not worth it study self-treatment, as this can only make the situation worse.

Brain aneurysm

is a specific bulging of the wall of an artery or heart that occurs due to thinning or stretching. As a result, the patient experiences the appearance of an aneurysmal sac, which can exert negative pressure on nearby tissues and organs.

This pathology can be congenital or acquired. Congenital aneurysm is not always diagnosed at birth, but it does not have a negative impact on the development of the baby.

Aneurysm rupture

The risk of developing the disease increases with t injury and injury to blood vessels. Not always this pathology can be diagnosed on early stage and provide timely treatment, since she does not show any characteristic symptoms.

Aneurysm rupture has consequences that are negative for the patient’s health:

• Hemorrhage.
• Fatal outcome.

It is also worth saying that this pathology is still not given attention in many countries and not many people die from it. less people than from any sexually transmitted diseases. Acquired aneurysm in most cases develops in aged patients from 49 years old. It happens that it is also observed in young people, but as a consequence after injuries.

Ask your doctor about your situation

Cerebral aneurysm

Cerebral aneurysm– an increase in the size of the arteries of this organ. Thinning of the vessel walls and the formation of an aneurysmal sac are noted. This pathology is practically asymptomatic in the first stages.

Causes of the disease:

1. Injury walls of blood vessels, arteries, which was received as a result of surgery or a gunshot wound.
2. Defeat vessels of this organ of an infectious nature.

Factors that may contribute to the formation of vascular aneurysm:

• High blood pressure.
• Tobacco smoking.
• Blood cholesterol levels are higher than normal.

As for treatment, to get rid of brain pathology you need to perform surgery:

1. Clipping of protruding vessel walls.
2. Intravascular intervention.

Aortic aneurysm

Aortic aneurysm– an expansion that promotes the formation of a sac in a blood vessel. This type The pathology does not have strong pronounced symptoms, and in most cases there are no symptoms at all. It occurs due to thinning and overstretching of the vascular walls.

Certain factors can also influence the formation of an aortic aneurysm:

1. Atherosclerosis.
2. Late stage of syphilis.
3. Injury infectious vessels.
4. Congenital vascular wall defects.

We also note the following reasons that provoke aortic aneurysm:

• Genetic factors.
• Infection.
• Age category over 49 years old.
• Injuries.
• Inflammatory process in the aorta.

Treatment depends on its size and speed of development. If the pathology is large and intensively developing, then surgical intervention is performed. Ignoring this fact can lead to aneurysm rupture.

The disease, which is small in size, bursts into in rare cases, and treatment involves taking medicines, which reduce the load on the aortic wall and lower cholesterol levels in the blood, exercise, and diet. You definitely need to give up bad habits.

If the patient has previously had surgery to correct this pathological condition, then it is recommended take place regularly examination and ultrasound, which helps to monitor the parameters of the aneurysm.

Types of Aneurysm

Heart aneurysm

IN modern medicine There are several types of aneurysm:

1. Aneurysm of the cerebral arteries. It is considered the most common pathology. Characterized by abundant dilation of the arteries. If the patient has a rupture, then symptoms such as a sharp headache and loss of consciousness occur. Leads to death, but if the patient survives, he remains disabled. In most cases, an aneurysm is confused with a brain tumor.
2. Aortic aneurysm. It is not considered so dangerous pathology. Develops in various areas of blood vessels. At a late stage of the disease, the patient experiences symptoms such as pressing pain in one or another part of the body. Aortic aneurysm comes in several types and can develop over a long period of time.
3. Aneurysm of peripheral vessels. A rare disease that can cause symptoms such as severe painful sensations in the limbs.
4. Cardiac aneurysm. Acquired aneurysm occurs due to myocardial infarction. It can develop both immediately after a heart attack and for a long period after it.

Symptoms of an aneurysm

As for the symptoms of this pathology, an aneurysm can develop over the course of long period without showing any negative signs. If there is a sharp increase in pathology, then in rare cases the patient complains of a sharp headache in the fronto-orbital region.

If a cerebral aneurysm ruptures due to provoking factors, blood enters the cavity of the cranium. In this situation, the symptoms will depend on where the blood ends up:

1. If blood enters the subarachnoid space:

• Sudden and sharp headache that develops into a migraine.
• Violation of light perception.
• Nausea and vomiting that do not help relieve the condition.
• Loss of consciousness.

1. If blood enters the brain matter:

• Violation visual function and eye movements.
• Paralysis of arms and legs.
• Speech dysfunction.
• Cramps in the limbs and throughout the body.
• Loss of consciousness.

Causes and signs of aneurysm

Brain aneurysm

In modern medicine, they have not yet established exactly how the development of this brain pathology occurs, but they have studied the provoking factors quite carefully:

1. Birth defects. They are considered the most dangerous cause. Aneurysm occurs in most cases at strong bends of arteries and their connections. The disease can also be caused by collagen deficiency, which is a hereditary factor.
2. Hemodynamic disorders. They occur in areas where arteries branch. As a result, blood flow is disrupted and pressure is exerted on the deformed vascular walls.
3. Genetic disorders which cause vascular damage. They are considered pathological phenomena, as a result of which the veins and arteries of the brain become intertwined, and blood flow is disrupted.

Very often, aneurysms develop in parallel with malignant neoplasms.

It is also worth noting the following causes of aneurysm:

• Tobacco smoking.
• Drug addict.
• Diseases vascular system.
• Atherosclerosis.
• Oncology.
• Infectious diseases.
• Hypertension.
• Trauma and head injury.

All of the above reasons have Negative influence on the circulatory system and blood vessels.

Diagnosis of aneurysm

Diagnosis of aneurysms is carried out after the patient contacts a specialist with severe symptoms. It is based on clinical data and instrumental examination data.

Includes:

1. Neurological examination. If the aneurysm has not ruptured, the patient may complain of an intense headache. During the examination, no neurological pathologies or disorders are detected. The patient may also experience paralysis of the limbs, impaired visual and speech function. If a rupture occurs, then clear neurological pathologies and disorders are noted.
2. Computed tomography and magnetic resonance imaging brain with a vascular program.
3. Cerebral angiography and magnetic resonance angiography.
4. If necessary, assigned consultation with a therapist.

Treatment

To cure cerebral aneurysms, surgery is necessary. If the pathology is small and does not develop, then the patient is prescribed drug therapy.

There are two types of surgical intervention:

1. Clipping sections, which have stretched. This stops blood from entering the aneurysm.
2. Intravascular intervention. If the patient is prescribed this method, then a catheter is passed through the arteries to the vessels of the brain.

Operation and its cost

Surgery for an aneurysm is considered the best option. This is explained by the fact that this pathology is detected at a late stage, when non-surgical treatment is no longer so effective.

The patient may be prescribed such operations as:

1. Clipping.
2. Strengthening vascular walls.
3. Endovascular surgery.

The choice of surgical intervention depends on the patient’s condition and the general condition of the blood vessels. The minimum cost of surgery is from 35 thousand rubles. The cost will depend on the type of operation and the area where it will be performed.

Sometimes there are cases when after surgery the patient experiences complications that are associated with brain hypoxia and vascular spasms. The patient may also experience oxygen starvation. Death probable with a significant size of the pathology and at the last stage of development.

Non-surgical treatment methods

In rare cases, if the aneurysm was discovered by chance, a conservative treatment. It is recommended that the patient be under constant supervision of specialists. In such a situation, an individual approach is required, taking into account the general condition and characteristics of the body. Also, this method of therapy is not the last place in surgical intervention.

The patient is prescribed medications to prevent rupture pathological formation and improve general condition:

1. Painkillers and antiemetics. Help relieve the condition.
2. Drugs that stabilize blood pressure. If the pressure constantly increases, this can provoke rupture of the aneurysm and, as a result, hemorrhage.
3. Drugs that eliminate seizures.
4. Calcium channel blockers.

In order to achieve positive result, it is necessary to combine operative and non-operative surgical treatment.

Consequences

If the aneurysm does not rupture, it goes unnoticed and may not cause harm to the body throughout life. If it began to grow rapidly and a rupture occurred, the patient was not provided with timely treatment and assistance, then this can lead to lethal outcome.

A gap can also provoke:

• hemorrhagic stroke;
• vasospasm. Read about it here.
• hydrocephalus;
• to whom.

The prognosis after a rupture will depend on age group patient and general well-being, as well as from neurological disorders. Concerning rehabilitation therapy, then less of it will be required if the treatment was carried out specifically for an unruptured aneurysm. Recovery after treatment and rupture can be carried out within several weeks or months.

Cerebral aneurysm: causes, signs, consequences, surgery

Among cerebrovascular diseases, aneurysm can be considered the most dangerous. Due to changes in the structure of the vessel, it loses its elasticity, which can result in a rupture with hemorrhage in the subarachnoid region or the substance of the brain. Aneurysm of cerebral vessels leads to serious circulatory disorders and death. The neoplasm in the vessel gradually fills with blood and increases in size. In addition to the rupture of an aneurysm, the very fact of deformation of the vessel also poses a danger. The convex area can put pressure on brain tissue and nerves.

An aneurysm has a peculiar structure, which determines the high risk of its rupture. The natural three-layer structure of the artery is preserved only in the neck of the formation; this section is the strongest. In the walls of the body of the formation, the elastic membrane is already broken, and there is a lack of a muscle layer. The thinnest part of the aneurysm is the dome formed by the intima of the vessel. Here it ruptures, causing hemorrhage.

Brain aneurysm: types

Cerebral aneurysms differ in shape, size, and type. The formations can be fusiform, saccular, lateral, or consist of several chambers and one. A spindle-shaped aneurysm forms after the expansion of a certain section of the vessel wall. A lateral aneurysm is characterized by its formation on the wall of a vessel.

Giant formations are usually located in the bifurcation region, passing through cavernous sinus carotid artery, reach 25 mm. The small formation measures up to 3 mm. The risk of hemorrhage increases sharply as the size of the aneurysm increases.

It is customary to distinguish two main types of formations in the vessels of the brain: arterial and arteriovenous.

Arterial aneurysm

When the walls of arterial vessels bulge like a sphere or sac, this is an arterial aneurysm. Most often, the location of these formations is at the base of the skull. This is where the arteries branch as much as possible. There are multiple, single, giant, and small formations.

Arteriovenous aneurysm

When venous vessels brain are expanded and form a tangle; the formation is an arteriovenous aneurysm. When venous and arterial vessels communicate, this type of aneurysm can develop. In the veins less pressure blood compared to this indicator in the arteries. Arterial blood is released under high pressure into the veins, causing the walls to expand, become deformed, and aneurysms occur. Nerve tissue is subjected to compression, and there is a disruption in the blood supply to the brain.

Aneurysm of the vein of Galen

Aneurysm of the vein of Galen is rare. However, a third of young children and newborns are affected by this anomaly. This formation is twice as common in boys. The prognosis for this disease is unfavorable - death occurs in 90% of cases in infancy and the neonatal period. Embolization maintains a high mortality rate of up to 78%. There are no symptoms in half of the sick children. Signs may appear and hydrocephalus develops.

Saccular aneurysm

A round sac of blood visually resembles a saccular aneurysm. It is attached to the branch site of the blood vessels, the main artery, by its neck. This type aneurysms are the most common. It most often develops at the base of the brain. It usually occurs in adults. A typical formation is small in size, less than 1 cm. Structurally, it consists of a bottom, body and neck.

Symptoms of the disease

The symptoms of an aneurysm depend largely on the area of ​​the vessel where it is located. Symptoms of an aneurysm:

• Weakness;
• Nausea;
• Deterioration of vision;
• Photophobia;
• Dizziness;
• Speech impairment;
• Hearing problems;
• Numbness on one side of the body, face;
• Headache;
• Double vision.

It is easier to identify a formation at the stage of its rupture, when the signs are more obvious.

Paroxysmal headache

Local pain in the head of varying intensity, which is repeated in one area, is characteristic of a cerebral aneurysm. When the basilar artery is damaged, pain occurs in one half of the head; when the formation is located in the posterior cerebral artery, pain appears in the temple, occipital region. For aneurysms of the anterior communicating and anterior cerebral arteries, severe pain in the fronto-orbital area is common.

Other signs of an aneurysm

There are other signs of a brain aneurysm. The following symptoms are possible:

1. Sharp whistling noise in the ear;
2. There is strabismus;
3. Hearing loss is unilateral;
4. The upper eyelid droops (ptosis);
5. The pupil dilates;
6. Double vision appears;
7. Sudden weakness in the legs;
8. Vision is impaired: everything becomes cloudy, objects are distorted;
9. Paresis of the facial nerve of a peripheral type;
10. Fields of vision are distorted or disappear.

In general, the symptoms of an aneurysm may resemble those of a stroke or circulatory disorder.

Attention! Even if they are observed individual symptoms aneurysm, you should immediately consult a doctor. When the condition is serious, it is important to immediately call an ambulance. Timely treatment, surgery able to cope with the disease.

Causes of cerebral aneurysms

At the moment, a complete theory of the occurrence of aneurysms is under development. However, the factors that contribute to the development of formations have been studied in sufficient detail.

Most serious reason aneurysm development - congenital defects present in the muscular layer of the cerebral arteries. They often appear in areas of strong bends of arteries and their connections. There is a deficiency of collagen, causing abnormal formations. This factor is hereditary.

They also cause the development of aneurysms and hemodynamic disturbances: uneven blood flow, high blood pressure. This is most pronounced in areas where the arteries branch. The blood flow is disrupted and puts pressure on the already deformed vessel wall, which leads to its thinning and rupture.

A genetic disorder that causes vascular damage is a pathological phenomenon when the veins and arteries of the brain intertwine, impairing blood circulation. Aneurysms are also accompanied by malignant neoplasms when tumors of the neck and head metastasize. Some other causes of aneurysms should be noted:

• Smoking;
• Drug use, in particular cocaine;
• Various diseases of the vascular system as a whole;
• Infections;
• Wound, head injury.

All these factors put the circulatory system and blood vessels at risk and contribute to the development of aneurysms.

Aneurysm rupture and its consequences

Rupture of an aneurysm in the thinnest place leads to either an intracerebral hematoma. Blood can enter the ventricles of the brain and brain tissue. In 100% of cases it develops. Possible acute occlusion when the cerebrospinal fluid passages are closed by blood accumulated in the ventricles, cerebral edema. Brain tissue reacts to blood breakdown products, characterized by necrosis and cessation of the work of individual brain areas.

When an aneurysm ruptures, partial paralysis, severe nausea, headache, and vomiting occur. Consciousness becomes confused, the patient may fall into a coma. Convulsions appear, ptosis and various visual impairments are characteristic.

Complications after aneurysm rupture

Due to hemorrhage caused by aneurysm rupture, a number of complications are observed. Cerebral vasospasm occurs, and re-rupture of the aneurysm is likely. Development is possible, which leads to death in 17% of cases. Complications are similar to those of ischemic, hemorrhagic stroke. IN in some cases after rupture of the formation, a convulsive syndrome develops. The following complications are possible.

1. Pain syndrome. After a stroke, painful attacks of varying intensity and duration may develop. Throbbing and shooting pain, a feeling of heat, is difficult to relieve with painkillers.
2. Cognitive impairment. Patients lose the ability to process external information and perceive it. Logic and clarity of thinking, memory are impaired, the ability to plan, learn, and make decisions is lost.
3. Psychological disorders. Characteristic depressive states, sudden mood swings, increased irritability, insomnia, anxiety.
4. Difficulty defecating and urinating. Patients have difficulty with bladder, intestines, their emptying.
5. Visual impairment. characterized by decreased visual acuity, loss of areas of the visual field, double vision.
6. Difficulty or impaired swallowing.This complication may cause food to enter the trachea and bronchi rather than the esophagus. Dehydration and constipation are likely.
7. Behavioral disorders. Characterized by emotional lability, slow reactions, aggression or fearfulness.
8. Perception disorders. The patient is unable to pick up an object and does not understand what he sees in front of him.
9. Speech problems. Difficulty understanding and reproducing speech. Patients experience difficulties in counting, writing, and reading. This complication is typical when the left hemisphere of the brain is damaged (in right-handed people).
10. Motor disorders. Paralysis and weakness occur, patients move and walk with difficulty, and coordination is impaired. Sometimes hemiplegia is observed - disturbances in the movement of one side of the body.

After a rupture of an aneurysm, it is important to begin treatment in a timely manner and properly organize the subsequent rehabilitation of the patient.

Surgery

In most cases the most effective means for the treatment of aneurysm is considered. They perform clipping, strengthen the walls of blood vessels, and disrupt the patency of blood vessels in the affected area using special microscopic spirals.

Clipping

Aneurysm clipping

It is carried out with direct surgical intervention. The operation is open, intracranial. The aneurysm is excluded from the general blood flow, while the patency of the carrier and surrounding vessels is maintained. It is necessary to remove blood from the entire subarachnoid space or drain it intracerebral hematoma.

This operation is recognized as one of the most difficult in neurosurgery. The neck of the aneurysm must be blocked immediately. The optimal surgical approach is selected, modern microsurgical equipment and an operating microscope are used.

Strengthening the walls of the vessel

Sometimes they resort to the method of strengthening the walls of the aneurysm. The affected area is wrapped in surgical gauze, which provokes the formation of a special capsule from the connective tissue. The disadvantage of the method is high probability bleeding in the postoperative period.

Endovascular surgeries

Nowadays, the method of targeted disruption of the patency of the aneurysm is popular. The desired area of ​​the vessel is artificially blocked using special microspirals. The patency of adjacent vessels is carefully examined, and the operation is controlled thanks to. This method minimally invasive, widely used in Germany. The operation does not require opening the skull and is less traumatic.

Aneurysm BEFORE and AFTER endovasal surgery

Postoperative complications

Often arise postoperative complications. They are usually associated with the development of brain hypoxia, vasospasm, especially when the intervention was carried out in acute period cerebral hemorrhages. Complications are also observed when the walls of aneurysms are damaged. In some cases, the microspiral pierces the wall.

Oxygen starvation is characteristic of complete or partial obstruction of the vessel that carries the aneurysm. Now, thanks to modern techniques, the space of the vessel can be expanded and strengthened artificially in order to ensure the necessary blood flow in strictly defined areas.

A fatal outcome is likely if the aneurysm is giant and is at a severe stage of development. It is important to start treatment on time and perform surgery without triggering the disease. Mortality is minimal, if the disease has not yet reached the acute stage, the operation is direct. Some deaths are likely due to individual characteristics of the body that are not directly related to the disease or surgery.

Non-surgical treatment methods

Despite the fact that the main and radical method To combat the disease, surgical intervention is carried out, and conservative treatment is also carried out. First of all, you must constantly be under the supervision of a doctor. Every patient needs individual approach, you need to take into account its condition as a whole, all the characteristics of the body. This approach is also important when choosing surgical treatment. Are used various drugs to prevent aneurysm rupture and improve general condition.

• Antiemetic and painkillers. They are necessary to alleviate the patient's condition.
• Medicines to stabilize blood pressure. The most important thing is to provide a certain fixed threshold above which the pressure will not rise. An increase in blood pressure can lead to aneurysm rupture and hemorrhage.
• Anticonvulsant medications. These drugs are also usually prescribed because seizures are likely to occur.
• . The drugs prevent cerebral spasm and stabilize blood vessels. It is necessary to use medications so that blood access to those parts of the brain that are damaged due to the development of an aneurysm is not interrupted.

It is optimal to combine conservative and surgical treatment, since a cerebral aneurysm requires surgical intervention to reduce the risk of its rupture and prevent death.

Prevention of cerebral aneurysm

First of all, it is necessary to pay attention to the factor of hereditary transmission of the disease and predisposition to it. Prevention of cerebral aneurysm is based on timely diagnosis of the disease, identification of symptoms, examination, after which appropriate treatment is immediately prescribed. Magnetic resonance imaging provides fairly reliable results. Angiography is also performed.

A person who already suspects the presence of this disease should maintain himself in a special state not only physically, but also emotionally. It is important not to overexert yourself and avoid overwork. Efforts must be made to constantly stabilize the emotional background and not become overexcited. We must forget about stress, worries, unnecessary grievances and doubts, we must live in the present and enjoy every day.

It is important to reduce the risk of vascular damage and head injuries to a minimum. Blood pressure must be constantly monitored. Timely detection of primary warning bleeding plays an important role. You cannot ignore the symptoms of a cerebral aneurysm; you must immediately contact a specialist.

Video: cerebral aneurysm in the program “Live Healthy!”

A brain aneurysm (cerebral aneurysm, intracranial aneurysm) is vascular disease and is a protrusion of the artery wall. Rupture of a cerebral aneurysm is the most common cause the occurrence of non-traumatic subarachnoid hemorrhage (more than 50%), in which blood penetrates into the subarachnoid space of the brain. Non-traumatic subarachnoid hemorrhage (SAH) is one of the most severe and common forms acute disorder cerebral circulation. IN Russian Federation The incidence of SAH is approximately 13:100,000 population per year. More often, cerebral aneurysms are observed in women. Thus, per 100,000 population, 12.2 are detected in women, and 7.6 in men. Thus, the ratio of women to men is 1.6:1 - 1.7:1. SAH due to ruptured aneurysms occurs in individuals aged 40 to 70 years ( average age 58 years old). Proven risk factors for aneurysm rupture are arterial hypertension, smoking and age.

Approximately 10 - 15% of patients die from hemorrhage after aneurysm rupture before treatment medical care. Mortality during the first 2 - 3 weeks after aneurysm rupture is 20 - 30%, within 1 month it reaches 46%, about 20-30% of patients become disabled. Recurrent rupture is the main cause of high mortality and disability. The risk of re-rupture of an aneurysm within the first 2 weeks reaches 20%, within 1 month - 33%, and within the first 6 months - 50%. The mortality rate from recurrent rupture of cerebral aneurysms is up to 70%.

For the first time, a cerebral aneurysm was described on section by the Italian J.B. Morgagni in 1725. The first cerebral angiography for non-traumatic SAH was performed in 1927 by the Portuguese E. Moniz, and in 1937 by the American W.E. Dandy performed the first microsurgical intervention for a ruptured cerebral aneurysm, disconnecting it from the bloodstream using a silver clip.

1. Structure of the aneurysm

Aneurysms are characterized by the absence of a normal, three-layer structure of the vascular wall. The wall of the aneurysm is represented only by connective tissue; the muscle layer and elastic membrane are absent. The muscle layer is present only in the area of ​​the aneurysm neck. An aneurysm is divided into a neck, body and dome. The neck of the aneurysm retains the three-layer structure of the vascular wall, therefore it is the most durable part of the aneurysm, while the dome is represented by only one layer of connective tissue, therefore the aneurysm wall in this part is the thinnest and most often susceptible to rupture (Fig. 1).

2. Classification of aneurysms

By form:

· baggy

spindle-shaped

fusiform.

By size:

milliary (diameter up to 3 mm)

regular size (4-15 mm)

· large (16-25mm)

· gigantic (more than 25 mm).

By the number of chambers in the aneurysm:

single-chamber

· multi-chamber.

By localization:

· on the anterior cerebral - anterior communicating arteries (45%)

on the internal carotid artery (26%)

on the middle cerebral artery (25%)

· on the arteries of the vertebrobasilar system (4%)

· multiple aneurysms - on two or more arteries (15%).

Causes of cerebral aneurysms

Currently, there is no single theory of the origin of aneurysms. Most authors agree that the origin of aneurysms is multifactorial. There are so-called predisposing and producing factors.

To predisposing These are the factors that result in changes in the normal vascular wall:

1. hereditary factor - congenital defects in the muscular layer of the cerebral arteries (type III collagen deficiency), most often observed in places where the arteries bend, their bifurcation, or where large branches depart from the artery (Fig. 2). As a result, cerebral aneurysms are often combined with another developmental pathology: polycystic kidney disease, hypoplasia renal arteries, coarctation of the aorta, etc.
2. arterial injury
3. bacterial, mycotic, tumor embolism
4. exposure to radiation
5. atherosclerosis, hyalinosis of the vascular wall.

Producing These are the factors that directly result in the formation and rupture of an aneurysm. The main producing factor is hemodynamic - an increase in blood pressure, a change from laminar blood flow to turbulent one. Its effect is most pronounced in places of arterial bifurcation, when an already altered vascular wall is subject to constant or periodic exposure to impaired blood flow. This leads to thinning of the vascular wall, the formation of an aneurysm and its rupture.

Clinical picture of aneurysm rupture

The symptoms of aneurysm rupture depend on the anatomical form of hemorrhage, the location of the aneurysm, and the presence of complications of intracranial hemorrhage. The typical clinical picture of aneurysm rupture develops in 75% of patients and has both general signs non-traumatic subarachnoid hemorrhage, as well as a number of features. The disease most often begins suddenly with a severe headache of the “blow” type, which can be accompanied by nausea and vomiting, often against the background of physical exertion, psycho-emotional stress, and a rise in blood pressure. The resulting headache is of a “burning”, “bursting” nature, as if “boiling water was spilled in the head.” Short-term and sometimes long-term disturbances of consciousness of varying severity from moderate stupor to atonic coma may occur. In the acute period, hemorrhage often occurs psychomotor agitation, hyperthermia, tachycardia, increased blood pressure.

However, almost every third patient with SAH has a different clinical picture. The following atypical variants of SAH are distinguished, which are characterized by one of the leading syndromes: migraine-like, false-inflammatory, false-hypertensive, false-radicular, false-psychotic , false toxic. At the same time, what they have in common is that the manifestations of a sudden brain catastrophe are obscured, the absence of clear indications of a combination of loss of consciousness and acute cephalgia, meningeal symptoms that are not expressed in the first days of the disease, and the symptoms of other diseases, including chronic ones, come to the fore.

Meningeal symptoms are observed in almost all cases of SAH: the patient has a stiff neck, photophobia, increased sensitivity to noise, Kernig's, Brudzinsky's symptoms, etc.

With SAH, blood enters under the arachnoid membrane and spreads through the basal cisterns of the cerebrum (chiasma, carotid arteries, lamina terminalis, interpeduncular, encircling, quadrigeminal), penetrates the grooves of the convexital surface of the brain, interhemispheric and Sylvian fissures. Blood also enters the cisterns of the posterior cranial fossa (prepontine, greater occipital cistern, cerebellopontine angle) and then enters the spinal canal. The source and intensity of hemorrhage determine the nature of the spread of blood through the subarachnoid spaces - it can be local, or it can fill all subarachnoid spaces of the brain with the formation of blood clots in the cisterns. When brain tissue is destroyed in the area of ​​hemorrhage, areas of parenchymal hemorrhage appear in the form of soaking of the brain matter with blood or the formation of a hematoma in the brain matter (subarachnoid-parenchymal hemorrhage). With a significant flow of blood into the subarachnoid space, reflux of blood into the ventricular system may occur through the inversions of the IV ventricle (foramina of Magendie and Luschka) and further through the cerebral aqueduct in the III and III. lateral ventricles. Direct penetration of blood into the ventricles of the brain through a damaged terminal plastic is also possible, which more often occurs with rupture of an aneurysm of the anterior communicating artery (subarachnoid-ventricular hemorrhage). With significant parenchymal hemorrhage against the background of SAH, the hematoma may break through into the ventricles of the brain (subarachnoid-parenchymal-ventricular hemorrhage).

Each of the anatomical forms of hemorrhage can be accompanied by occlusion of the cerebrospinal fluid pathways and brain dislocation and, as a consequence, the development of hypertensive-dislocation syndrome.

In addition to the described variants of the course of the disease, the clinical picture of SAH can also be determined by the location of the aneurysms.

Aneurysm of the internal carotid artery. If the aneurysm is located in the area of ​​the mouth of the ophthalmic artery, the headache may be localized in the paraorbital region on the ipsilateral side and be accompanied by visual disturbances in the form of decreased visual acuity and/or loss of visual fields. When the aneurysm is localized at the mouth of the posterior communicating artery, paresis usually develops oculomotor nerve, focal hemispheric symptoms in the form of contralateral hemiparesis are possible. When the aneurysm is located at the mouth of the anterior choroidal artery, paresis of the oculomotor nerve is also often observed, and when an intracerebral hematoma is formed, hemiparesis or hemiplegia can develop. When aneurysms of the bifurcation of the internal carotid artery rupture, the headache is also more often localized in the ipsilateral frontal region, and contralateral hemiparesis or hemiplegia may develop.

Aneurysm of the anterior communicating artery. The clinical picture of rupture of aneurysms of this localization is determined by damage to nearby anatomical structures, including the hypothalamus. Characteristic are mental changes, which include emotional lability, personality changes, psychomotor and intellectual decline, memory impairment, attention disorders, akinetic mutism. Korsakoff's confabulatory-amnestic syndrome is often observed. When aneurysms of this localization rupture, electrolyte disturbances and diabetes.

Aneurysm of the middle cerebral artery. When an aneurysm of the middle cerebral artery ruptures, hemiparesis (more pronounced in the arm) or hemiplegia, hemihypesthesia, motor, sensory or total aphasia with damage to the dominant hemisphere, homonymous hemianopsia most often develop.

Aneurysms of the basilar artery. There are upper and lower symptoms of basilar artery aneurysms. Symptoms of aneurysms upper segment main artery are unilateral or bilateral paresis of the oculomotor nerve, Parinaud's symptom, vertical or rotatory nystagmus, ophthalmoplegia. When a basilar artery aneurysm ruptures, ischemic disorders in the posterior cerebral artery basin are possible in the form of homonymous hemianopsia or cortical blindness. Ischemia of individual structures of the brain stem is manifested by corresponding alternating syndromes. The classic but rare clinical picture of a ruptured basilar artery aneurysm is the development of coma, respiratory failure, lack of response to irritation, and wide pupils without a photoreaction.

Aneurysm of the vertebral artery. The main signs of rupture of aneurysms of this localization are dysphagia, dysarthria, hemiatrophy of the tongue, impairment or loss of vibration sensitivity, decreased pain and temperature sensitivity, and dysesthesia in the legs. With massive hemorrhage, coma develops with breathing problems.

Instrumental diagnostics

To identify non-traumatic subarachnoid hemorrhage due to rupture of aneurysms, determine the prognosis of the disease, the likelihood of complications, and develop treatment tactics, a number of instrumental diagnostic methods are used.

Lumbar puncture - in the first hours and days, the cerebrospinal fluid (CSF) is intensely and evenly stained with blood, usually flows out under increased pressure. However, lumbar puncture is contraindicated in the clinical picture of an intracranial space-occupying process (hematoma, ischemic focus with an area of ​​perifocal edema and mass effect phenomena) and signs of dislocation syndrome (at the level of the greater falciform process, tentorium and foramen magnum). In such cases, during lumbar puncture, the removal of even a small amount of CSF can lead to a change in the intracranial pressure gradient and the development of acute brain dislocation. In order to avoid this, patients with clinical manifestations of an intracranial space-occupying process should undergo echoencephaloscopy or computed tomography brain.

Computed tomography (CT) of the brain is currently the leading method in the diagnosis of SAH, especially in the first hours and days of hemorrhage. Using CT, we determine not only the intensity of basal hemorrhage and its distribution in the cisterns, but also the presence and volume of parenchymal and ventricular hemorrhage, the severity of hydrocephalus, the presence and prevalence of foci of cerebral ischemia, the severity and nature of dislocation syndrome. The detection rate of SAH in the first 12 hours after hemorrhage reaches 95.2%, within 48 hours - 80-87%, on days 3 - 5 - 75% and on days 6-21 - only 29%. The degree of detection of blood clots in SAH depends not only on the intensity of the hemorrhage itself, but also on the ratio of blood clots and the plane of sections on CT (Fig. 3).

In addition, with the help of CT scan of the brain (CT angiography), it is often possible to establish the real reason hemorrhages, topographic-anatomical relationships, especially if the study is supplemented with contrast enhancement and 3D reconstruction.

The most common CT classification of hemorrhage is the classification proposed by C.M. Fisher et al. in 1980:

1) CT scan shows no signs of hemorrhage - type 1 changes;

2) diffuse basal hemorrhage is detected with the thickness of blood clots less than 1 mm - type 2 changes;

3) blood clots more than 1 mm thick are detected - type 3 hemorrhage;

4) CT scan reveals intracerebral hematoma or hemorrhage into the ventricles without or in combination with diffuse SAH - type 4 hemorrhage.

CT data (the amount and extent of bleeding) correlate well with the severity of the condition and the prognosis of the disease - pronounced basal SAH is prognostically unfavorable, since in almost all patients it is accompanied by the development of pronounced and widespread arterial spasm.

Digital subtraction cerebral angiography is the “gold standard” for the most accurate identification of the cause of hemorrhage. It is mandatory to study two carotid and two vertebral basins in direct, lateral and oblique projections. With cerebral angiography, it is possible not only to detect an aneurysm (Fig. 4A, 4B), but also vascular spasm.

Magnetic resonance imaging (MRI) - this diagnostic method has high sensitivity and specificity. If CT of the brain has excellent detection of SAH and aneurysms in the acute period of hemorrhage, then MRI is indispensable in detecting hemorrhages in the subacute and chronic periods. Verification of aneurysms with magnetic resonance angiography (MR-AG) reaches 80-100%, which allows in some cases to abandon traditional invasive cerebral angiography (CAG) when for some reason it is contraindicated (for example, with individual intolerance to iodine preparations) (Fig. . 5). In addition, when compared with traditional angiography, CT-AG is superior to it in diagnosing small aneurysms (less than 3 mm), which indicates the significant resolution of the method.

Complications of non-traumatic subarachnoid hemorrhage

The most common complications of subarachnoid hemorrhage due to aneurysm rupture include the following: cerebral vasospasm, cerebral ischemia due to vasospasm, re-bleeding from the aneurysm and the development of hydrocephalus.

One of the most severe and frequent complications of SAH is vascular spasm and cerebral ischemia. By “vascular spasm” one should understand complex and consistent changes in all layers of the arterial wall, leading to a narrowing of the lumen. These changes occur in response to hemorrhage that occurs in the cisterns of the base of the brain. The direct cause of narrowing of the arteries is blood and its breakdown products. Angiospasm develops in 23-96% of patients with massive basal SAH (Fisher type III) and can lead to severe ischemic brain damage (Fig. 5).

Angiospasm can be diagnosed during cerebral angiography (Fig. 6) or with transcranial Dopplerography (TCDG) of cerebral vessels (Fig. 7), and the dynamics of its development are monitored using TCD, which can be performed as often as desired. Linear blood flow velocity (LBV) is determined in all large arteries of the brain (anterior, middle, posterior cerebral, internal carotid and basilar arteries). Angiospasm does not develop immediately after hemorrhage, but on days 3-7, when blood breakdown products accumulate in the cerebrospinal fluid, and can last up to 2-3 weeks.

Rebleeding from an aneurysm is the second most common complication observed after aneurysm rupture. Repeated bleeding develops in 17 - 26% of patients. Recurrent bleeding is usually caused by lysis of a blood clot covering the site of the aneurysm rupture. Recurrent bleeding occurs more often during the first day (4%), and over the next 4 weeks their frequency remains stable, amounting to 1-2% per day. Repeated bleeding is very severe and causes up to 80% of deaths due to massive intraventricular or parenchymal hemorrhage.

There are no effective methods for preventing recurrent bleeding. Neither bed rest, nor antihypertensive therapy do not reduce the incidence of rebleeding. The only method of preventing rebleeding is to remove the aneurysm from the bloodstream earlier.

Enough a common complication NAC is hydrocephalus , observed in 25-27% of patients. IN early period disease, the development of hydrocephalus in SAH is caused by blockade by blood clots of the basal cisterns, aqueduct of Sylvius, inversions of the fourth ventricle and occlusion of the cerebrospinal fluid pathways. long term the development of hydrocephalus is caused by impaired resorption of cerebrospinal fluid. With the development of dysresorptive normotensive hydrocephalus in the long-term period of SAH, the leading one is Hakim-Adams syndrome (apatico-abulic syndrome, gait apraxia and dysfunction of the pelvic organs).

Assessment of the severity of the patient's condition

With all the diversity clinical picture The course and complications of subarachnoid hemorrhage in practice use only a few classifications of the severity of the patient’s condition (Tables 1 and 2).

Assessment of level of consciousness using the Glasgow Coma Scale (recommended for ages 4 years and older).

* when checking eye opening for pain, peripheral stimulation should be used (a painful grimace with central pain stimulation leads to squinting of the eyes)
# in the absence of a motor response, it is necessary to exclude damage to the spinal cord.

Assessment of the severity of patients' condition using the W. Hunt scale - R. Hess, 1968.

• in the presence of serious general disease (hypertonic disease, diabetes mellitus, severe atherosclerosis, chronic obstructive pulmonary disease) or severe vasospasm, the assessment of the severity of the patient’s condition is increased by one degree
• the original work did not take into account the age of the patients, the location of the aneurysms, or the time since the hemorrhage; The severity of the patients was assessed upon admission and before surgery.

The creation of such scales for assessing the severity of the condition is due to the need to standardize data on the study of examination results, conservative and surgical treatment of patients with non-traumatic SAH, and prognosis of the outcome of the disease.

Treatment of cerebral aneurysms

If an aneurysm is detected, the patient is advised surgery. The main goal of open surgery is to exclude the aneurysm from the bloodstream to prevent re-bleeding and to remove blood clots from the basal cisterns to prevent vascular spasm and cerebral ischemia. And also, the goal early operations is the prevention of re-rupture of an aneurysm, since the risk of re-hemorrhage in the first two weeks from a rupture of an aneurysm is up to 25%. If the patient is in a serious condition, with a decrease in wakefulness to the point of coma, the operation is also inappropriate, since postoperative mortality in patients in extremely serious condition exceeds 80 %.

The choice of treatment tactics is determined by the location of the aneurysm, the presence or absence of its rupture, the time period from the moment of hemorrhage, the clinical condition of the patient, and the presence of complications.

For patients with unruptured aneurysms The timing of the operation, as a rule, does not have of great importance, since the probability of aneurysm rupture is 1-2% per year. Thanks to the modern availability of methods for studying the brain and its vessels, aneurysms are increasingly being found by chance when conducting a brain examination for other diseases. Knowing the danger of potential aneurysm rupture and the difficulty of treating patients after the development of hemorrhage, neurosurgeons increasingly began to operate on patients with accidentally detected aneurysms.

In the most acute(up to 3 days) and the acute period of non-traumatic SAH (up to 14 days), due to rupture of an aneurysm, surgical treatment is carried out for patients with an uncomplicated course of the disease (I-II, III degree severity according to Hunt-Hess), the patient’s compensated condition, as well as in patients at risk of re-bleeding from an aneurysm or the development of clinically significant vasospasm.

Also, according to vital indications, patients with IV-V severity according to the Hunt-Hess classification are operated on, who have acute compression of the brain by a hematoma, severe occlusive hydrocephalus with dislocation of the brain stem, and extensive foci of ischemia. In such patients, surgery is considered as a stage of resuscitation.

In the delayed period of SAH (after 14 days), surgical treatment of patients is performed when the course of the disease is complicated due to vasospasm with serious condition(Hunt-HessIV, grade V according to Hunt-Hess) after improvement of the patient’s condition, as well as in the presence of an aneurysm of a hard-to-reach localization.

Aneurysms are isolated from the bloodstream using an open or endovascular method. Open operations for ruptured aneurysms, it is performed under general anesthesia, always using an operating microscope and microsurgical equipment. The operation consists of several stages: craniotomy, opening of the hard meninges, dissection of the arachnoid membrane at the base of the brain and aspiration of CSF, isolation great vessels brain, isolating the artery carrying the aneurysm, the aneurysm and turning it off from the bloodstream by clipping (Fig. 8).

If the rupture of an aneurysm is accompanied by the formation of an intracerebral hematoma with the development of brain compression, then the operation is performed as an emergency, and in addition to clipping the aneurysm, the intracerebral hematoma is removed. And if an aneurysm ruptures with the formation of ventricular hemorrhage, leading to occlusion of the cerebrospinal fluid circulation pathways (acute occlusive hydrocephalus), in addition to clipping the aneurysm, external drainage of the lateral ventricles of the brain is required in order to evacuate blood from them and relieve cerebral hydrops. After restoration of cerebrospinal fluid patency natural ways, as a rule, after 7-10 days, the drains are removed. For patients with chronic dysresorptive hydrocephalus that develops several weeks or months after SAH, ventriculoperitoneal or ventriculoatrial shunts are installed, but only after the aneurysm is removed from the bloodstream.

Endovasal intervention carried out when it is impossible to clip the aneurysm during open surgery, with aneurysms of difficult to reach localization (aneurysms of the vessels of the vertebrobasilar region, aneurysms of the internal carotid artery proximal to the ophthalmic segment), in patients old age(over 75 years old). During endovascular surgery, the aneurysm is closed with electrically separated platinum microcoils, or isolated from the parent artery using a stent (Fig. 19-20). Thanks to microspirals and stents, thrombus formation develops in the aneurysm cavity, which prevents repeated hemorrhages. Complete occlusion can be achieved in 81% of patients.

Postoperative management

From the operating room, regardless of the severity of the condition, the patient is transferred to the neurointensive care unit. This department monitors the patient’s condition and prevents complications. If within 24 hours the patient’s condition is assessed as satisfactory or medium degree severity, he is transferred to the neurosurgical department. If there is a deterioration in the condition, then an emergency CT scan of the brain, TDCG, is performed. Based on the results of these examinations, further tactics for patient management are determined.

Outcomes

Surgical activity for ruptured aneurysms in our clinic is 82 - 90%. For most patients, exclusion of aneurysms from the bloodstream is performed openly (92%), endovascularly - 8%. The overall postoperative mortality rate is 10-12%.