Elle Hughes had just been given an overseas job and was celebrating with friends at the home she shares with her nine-year-old son, Amani.
The 48-year-old teacher was fit and healthy, ate an organic diet, was a non-smoker, drank little alcohol, practised yoga daily and led a low-stress lifestyle. But she had a ticking time bomb in her brain and there was no warning it was about to explode.
She took her first sip of wine for the night, then grasped her head in pain and collapsed, her body racked with convulsions. She was rushed by ambulance to a local hospital, where a CT scan revealed a subarachnoid haemorrhage – the life-threatening result of a ruptured brain aneurysm.
Hughes was airlifted to Royal Brisbane and Women’s Hospital, where she underwent a five-hour procedure to stop the bleeding and prevent further bleeds. Due to her early diagnosis and treatment, Hughes did not suffer permanent neurological damage and is expected to make a full recovery. She missed out on the job, but she knows she can count herself lucky.
A brain aneurysm – also called a cerebral aneurysm – is a weak area on the wall of a brain artery that balloons out and fills with blood. A small aneurysm is under 11 millimetres in diameter, while a giant aneurysm is more than 25 millimetres.
An unruptured aneurysm may go unnoticed throughout someone’s lifetime, but sometimes an undetected aneurysm will burst, causing a subarachnoid haemorrhage (bleeding into the spaces around the brain).
The most common symptom is the sudden onset of a severe headache, which may or may not be accompanied by vomiting, seizure, visual impairment or loss of consciousness.
Although ruptured brain aneurysms are relatively uncommon – afflicting about 10 in 100,000 people in Australia each year – they are accompanied by a high rate of death and disability. According to the Australian Brain Foundation, recovery depends on the size and location of the aneurysm, age, general health and neurological condition after haemorrhage.
An unknown enemy
In Australia, Macquarie University Hospital consultant neurosurgeon, Dr Andrew Davidson (MBBS, MS, FRACS), says about one per cent of the population has an aneurysm and doesn’t know about it. In a population like Sydney, with more than four million people, he says there are an estimated 400 ruptures per year, and that 20 per cent of patients who present with a haemorrhage will have more than one aneurysm present.
“Ruptured aneurysms strike people in the prime of their life and can occur in young, active, healthy people with no underlying medical problems,” says Davidson. “Without treatment a ruptured aneurysm is fatal in two-thirds of patients. In my mind, it is certainly one of the most catastrophic things that can happen to your brain and one of the most difficult things to treat.”
Davidson says the three risk factors for aneurysms are female gender, cigarette smoking and hypertension, but that “we don’t know the underlying cause and for the vast majority of that one per cent of the population, they’re just bad luck”.
Studies have also looked at a genetic link. The Familial Intracranial Aneurysm (FIA) Study II, a collaborative study by neurologists and neurosurgeons from the United States, Canada, Australia and New Zealand, reported an increase in risk of aneurysm in family members of patients who’d had an aneurysm. However, Davidson believes these findings could be exaggerated.
“Family history probably increases your risk of having an aneurysm slightly, but it certainly increases your chances of having an existing aneurysm found,” he says.
The two procedures used to treat aneurysms today are endovascular coiling and surgical clipping. Coiling involves inserting a catheter into the artery in the groin and advancing it through to the brain, where a platinum coil attached to a microcatheter is inserted into the aneurysm to prevent re-bleeding and encourage clotting. In clipping, open surgery is conducted through the head to place one or more tiny clips across the neck of the aneurysm to stem the flow of blood and prevent re-bleeding.
Davidson says new technologies emerge almost every year to improve the effectiveness of both procedures, and standards in Australia and New Zealand are among the best in the world.
“Looking back 40 years, the most common treatment was to put somebody in the quietest room of the hospital, turn the lights off and tell the family not to bother them because any excitement would cause it to rupture again,” says Davidson. “There were only a select few surgeons operating on them 50 years ago.
“There are still many patients who don’t do well or don’t recover, but I’m pleased to say in our experience, it’s the minority. If they survive their initial haemorrhage and make it to hospital, the most likely thing is they will recover with normal or near normal function. More than 70 per cent of patients will be independent; it may not mean back to 100 per cent, but they’ll be able to look after themselves and live a normal or near normal life.”
What you can do
Cognitive or behavioural issues directly related to the part of the brain affected by the aneurysm can arise before or after surgery, but often are not apparent until a patient is back at home.
In these cases, a patient may be referred to a clinical neuropsychologist, who specialises in the assessment, diagnosis and treatment of psychological disorders associated with conditions affecting the brain.
Dr Jane Lonie, a clinical neuropsychologist at Macquarie University, says some of the issues that may arise include language difficulties, personality changes, problems with visuospatial function or memory impairment.
“What we tend to see happen is, it’s not until somebody has regained health in a physical sense that they become aware of some cognitive changes,” says Lonie. “It can be a year down the track.” She would like to see more patients referred for assessment pre- and post-operatively.
Davidson believes more awareness of the condition is needed and says if there’s one piece of advice he has, it is to go straight to an emergency room if you or someone you are with experiences a sudden “thunderclap headache”.
“People should not go to bed and sleep it off,” he says. “The greatest danger anybody faces is in the first 48 hours after rupture. Once someone survives their original haemorrhage, the greatest danger is the risk of that aneurysm bleeding again, increasing the risk of stroke and death. There are consequences that occur days or weeks down the track that we can prevent by early treatment.”
• Ruptured brain aneurysms are fatal in about 40 per cent of cases.
• There are almost 500,000 deaths worldwide each year caused by brain aneurysms and half the victims are younger than 50.
• Of those who survive a ruptured aneurysm, about 66 per cent suffer some permanent neurological deficit and up to 25 per cent die from complications within six months.
• Four out of seven people who recover from a ruptured brain aneurysm will have disabilities.
• Brain aneurysms are most prevalent in people aged 35 to 60, but can occur in children as well.
• Most aneurysms develop after the age of 40.
• An estimated 50 to 80 per cent of all aneurysms do not rupture during the course of a person’s lifetime.
• Women, more than men, suffer from brain aneurysms at a ratio of 3:2.
• The cost of a brain aneurysm treated by clipping via open brain surgery more than doubles in cost after the aneurysm has ruptured. The cost of a brain aneurysm treated by coiling increases by about 70 per cent after the aneurysm has ruptured.