The recent revelation by Game of Thrones actress Emilia Clarke, that she suffered two brain aneurysms, reminds us of how challenging and devastating they can be — and how effective our treatments have become. An aneurysm is a balloon-like bulge or weakening of an artery wall. Like a balloon on the side of a garden hose, the bulge becomes thinner and weaker as it grows. It can become so thin that the blood pressure within can cause it to leak or burst open. This can be catastrophic, with about 15% of individuals dying from the hemorrhage before arriving at a hospital and a significant proportion of those remaining at risk of dying within 30 days or surviving with permanent disability.
Typically, individuals harboring a brain aneurysm are entirely unaware of its presence, because aneurysms rarely cause symptoms unless they hemorrhage. When they do rupture, however, they are at very high risk for recurrent hemorrhage, often in just days. Thankfully, natural history information gained over the last 20 years suggests that many unruptured aneurysms remain so and that many individuals with aneurysms die of other causes with their aneurysm, but not because of it. For this reason, clinicians are faced with the unenviable task of determining when and if to treat aneurysms in many cases. Making this critical decision requires a full understanding of this natural history risk and the potential benefits of an ever-growing list of treatment options.
While there are modifiable risks for developing or rupturing an intracranial aneurysm, such as smoking, hypertension, excessive alcohol use, or use of stimulant drugs such as cocaine, there are other risks that cannot be modified. These include female gender, certain genetic disorders of connective tissue (including polycystic kidney disease), and a family history, typically defined as 2 or more first-degree relatives (siblings, parents, children) with an aneurysm. Without a clear definition of the benefit of prophylactic treatment of aneurysms, however, routine screening may not be beneficial. Thus, the management of incidentally found aneurysms depends on factors unique to each patient as well as the treating physician’s familiarity with the treatment options. This requires knowledge of the individual patient’s medical history and life expectancy, a detailed understanding of the anatomy around the aneurysm, and a full familiarity with the tools of the trade. Technological advancements over the last several years have resulted in an explosion of treatment options. While these advances offer terrific opportunity to patients with aneurysms, they require constant learning on the part of the clinician.
Ms. Clarke’s saga of treatment for her two intracranial aneurysms teaches us much about the experience of our patients: the agonizing pain associated with the initial hemorrhage, the fear of disability that follows, the potential failures of treatment even in the best of hands, and the life-saving gift that safe and effective treatments offer. Her story has it all. Those of us intimately involved in the treatment of these frightening lesions are reminded of exactly why we chose this path. And as our field continues to evolve, we strive to produce even more of these success stories. My colleagues and friends in the Endovascular Neurosurgery Research Group (ENRG) and at Mayfield Brain & Spine have dedicated themselves to this effort and will continue to do so. I’m proud of my association with them and value their contributions to our knowledge of the development, natural history, and management of brain aneurysms.
Andrew Ringer, MD, is a neurosurgeon and chairman of Mayfield Brain & Spine. He is editor of Intracranial Aneurysms, published in 2018 by Academic Press, a reference book for neurovascular physicians.
About Intracranial Aneurysms: Intracranial aneurysm result from complex interactions between cerebrovascular anatomy, vascular injury, and adaptive remodeling of the arterial wall and represent a cerebrovascular disorder with the potential for substantial morbidity and mortality. Most intracranial aneurysms occur in the larger arteries near the skull base, in or around the circle of Willis, but variants may appear virtually anywhere in the cerebral vasculature. The aneurysm can leak or rupture, causing life-threatening bleeding, and is the most common cause of spontaneous subarachnoid hemorrhage, the third most common form of stroke. Intracranial aneurysms affect about 1 in 10,000 people per year in the United States (approximately 27,000).
Intracranial Aneurysms will address the natural history, biology, and basic management principles and treatment of aneurysms. The chapters also explore the unique features of each type or location of aneurysm while considering the medical, surgical, and endovascular options. Contributions are by members of the Endovascular Neurosurgery Research Group, a group of recognized expert neurosurgeons who specialize in cerebrovascular and endovascular management of aneurysms.