Brain Aneurysms

Brain aneurysms, also known as intracranial or cerebral aneurysms, are dilations of the arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries along points of weakness in the brain. The majority of the aneurysms are berry (saccular) in nature and located within the anterior circulation of the circle of Willis. Unruptured aneurysms are typically asymptomatic, unless the aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms compresses surrounding structures. The majority of these aneurysms are detected on rupture and presentation of a subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH) ( SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH)). Rarely, they may be detected incidentally on brain imaging done for other reasons. Diagnosing an aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms is done via imaging with CTA or MRA. Management depends on the size, risk of rupture, risk of intervention complications, and individual preference. This may include risk factor modifications, surveillance with serial imaging, and interventional measures (such as surgical clipping or endovascular coiling). Ruptured aneurysms carry a high morbidity and mortality rate.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

A cerebral aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms is an abnormal, focal dilation of the artery wall in the CNS. 

  • Also known as cerebral or intracranial aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms 
  • Most occur at junction points of the major arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries of the brain (usually around the circle of Willis) 
  • Aneurysms can potentially: 
    • Compress adjacent structures 
    • Rupture and cause hemorrhagic stroke

Epidemiology

  • Worldwide prevalence: 3%
  • Mean age at presentation: 50 years
  • Women:men = 2:1 (> age 50)
  • Incidence of ruptured aneurysms: approximately 10 in 100,000 people per year

Risk factors

The following are risk factors for aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms formation:

  • Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics:
    • Increased risk in 1st-degree relatives 
    • Higher prevalence with associated disorders:
      • Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome
      • Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome
      • Coarctation of aorta
      • Autosomal dominant polycystic kidney disease Autosomal dominant polycystic kidney disease Polycystic kidney disease (PKD) is an inherited genetic disorder leading to the development of numerous fluid-filled cysts in the kidneys. The 2 main types of PKD are autosomal dominant polycystic kidney disease (ADPKD), which is often diagnosed in adulthood, and autosomal recessive polycystic kidney disease (ARPKD), which is often diagnosed antenatally or shortly after birth. Autosomal Dominant Polycystic Kidney Disease
  • Cigarette smoking
  • Hypertension
  • Estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries deficiency: menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause decreases collagen content of tissues

Pathophysiology

Classification and location

Cerebral aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms can occur at any point of weakness along the arterial circulation within the brain.

Saccular (berry):

  • Most common aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms 
  • Due to a thin or absent tunica media
  • Location:
    • Commonly at the bifurcations within the circle of Willis 
    • Most commonly in the anterior circulation (anterior communicating and anterior cerebral artery) 

Charcot-Bouchard (miliary):

  • Most common cause of intracerebral hemorrhage Intracerebral Hemorrhage Intracerebral hemorrhage (ICH) refers to a spontaneous or traumatic bleed into the brain parenchyma and is the 2nd-most common cause of cerebrovascular accidents (CVAs), commonly known as stroke, after ischemic CVAs. Intracerebral Hemorrhage
  • Microaneurysms in small, penetrating vessels (most commonly within the lenticulostriate branches of the middle cerebral artery → supply the basal ganglia Basal Ganglia Basal ganglia are a group of subcortical nuclear agglomerations involved in movement, and are located deep to the cerebral hemispheres. Basal ganglia include the striatum (caudate nucleus and putamen), globus pallidus, substantia nigra, and subthalamic nucleus. Basal Ganglia and thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus)
  • Strongly associated with chronic hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension

Fusiform:

  • Nonsaccular dilation of the entire circumference of the involved artery
  • Located mainly in the vertebrobasilar system
  • Associated predominantly with atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis

Mycotic: 

  • Rare
  • Secondary to infection of the vessel wall (e.g., septic emboli from infective endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis)
Arterial supply—circle of willis

Blood supply to the brain is derived from 2 sources, the internal carotid arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries and the vertebral-basilar system:
These 2 sources interconnect to form the circle of Willis, which is depicted here. Brain aneurysms commonly form at bifurcations, with the majority being saccular aneurysms occurring in the anterior circulation (junction of the anterior cerebral artery and anterior communicating artery). Other common locations include the middle cerebral artery and the junction between the internal carotid artery and the posterior communicating artery.

Image by Lecturio.

Pathogenesis

Saccular aneurysms:

  • Hemodynamic stress → endothelial dysfunction → breaks down the internal elastic lamina
  • Turbulent blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → fatigue of the internal structure
  • T-cell–mediated inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation changes the histology of the vascular wall
  • Both stress and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation → weak points → dilatation 
  • Aneurysm can either:
    • Rupture
    • Harden and stabilize
  • Large or growing aneurysms → compress nearby structures → mass effect symptoms
  • Factors that may trigger rupture:
    • Trauma
    • Physical exertion
    • Valsalva maneuver (prolonged or repetitive)
    • Uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or "uncontrolled" hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension

Mycotic aneurysms:

  • Arterial injury combined with bacterial seeding → infection of the intima
  • Inflammatory response → neutrophil recruitment
  • Matrix metalloproteinases → vessel wall breakdown
  • Bacterial seeding can occur through:
    • Bacteremia
    • Septic emboli
    • Spread from a nearby infection
    • Direct inoculation (e.g., trauma, percutaneous interventions, IV drug use) 

Clinical Presentation and Diagnosis

Clinical presentation

Unruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms:

  • Usually asymptomatic
  • Mass effect signs and symptoms could include:
    • Headache
    • Optic chiasm compression (cranial nerve (CN) II):
      • Bitemporal hemianopia
      • Loss of visual acuity 
    • CN III palsy:
      • Mydriasis
      • Ptosis
      • Ophthalmoplegia
    • CN V: facial pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 

Ruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms:

  • Headache:
    • “Thunderclap” 
    • Sudden and severe, peaking within an hour
    • Indicates subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH) ( SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH))
    • Can be the only symptom
    • Minority of individuals have a “warning leak” induced headache prior to SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH)
  • Associated symptoms:
    • Loss of consciousness 
    • Photophobia
    • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain or stiffness
    • Nausea and vomiting
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures (< 10% of cases) 
  • Charcot-Bouchard aneurysms may cause motor and/or sensory deficits (depending on location)

Diagnosis

Most brain aneurysms are found incidentally or present as SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH).

Unruptured (screening):

  • Indications:
    • Family history
    • History of an associated conditions (e.g., Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome)
    • Previous ruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms
    • Signs and symptoms of mass effect (e.g., CN palsy)
  • MRA or CTA: detects aneurysms ≥ 5 mm in size
  • Conventional angiography:
    • Done if high clinical suspicion (symptoms) with negative MRA or CTA
    • Can detect very small aneurysms
    • Higher risk of complications
  • Cultures should be obtained if a mycotic aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms is suspected.

Ruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms: 

  • Noncontrast CT:
    • 1st-line
    • For both SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH) and Charcot-Bouchard aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms
    • 100% sensitive if within 6 hours of symptom onset
  • If CT is negative but clinical suspicion for SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH) is high → lumbar puncture (LP)
    • ↑ Opening pressure
    • Xanthochromia
    • ↑ RBC
    • 95% sensitivity if within 12 hours of symptom onset
  • Locating the bleed source:
    • Intraarterial digital subtraction angiography
      • Preferred
      • Allows for intervention to be performed simultaneously
    • CTA or MRA (alternative)

Management

Unruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms

Management options are controversial and must balance the risk of rupture, risk of intervention, and individual preference.

  • Lifestyle modification: 
    • Smoking cessation
    • Hypertension management
  • Monitor with serial imaging for growth or new aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms formation
  • Interventional treatment:
    • Surgical clipping or endovascular coiling
    • Potential indications:
      • Life expectancy > 10 years
      • Size ≥ 7 mm
      • Size < 7 mm in younger individuals with a positive family history
      • Increase in size
      • Located in the posterior circulation
  • Mycotic aneurysms:
    • Antimicrobial therapy (based on culture data)
    • Surgical repair may be warranted.

Ruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms

  • Assess and stabilize:
    • Airway
    • Breathing 
    • Circulation
  • Neurologic ICU for:
    • Neurologic examination monitoring
    • Vital sign monitoring
    • Telemetry
    • Intracranial pressure ( ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)) monitoring
  • Blood pressure control (goal systolic blood pressure < 160 mm Hg)
  • Reverse any anticoagulation
  • Vasospasm prevention: nimodipine (medication of choice)
  • Seizure prophylaxis: levetiracetam (medication of choice)
  • Prompt neurosurgery consultation for possible surgical or endovascular intervention:
    • Surgical aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms clipping
    • Endovascular coiling
    • Ventriculostomy placement
    • Decompressive hemicraniectomy
Surgical-and-endovascular-treatments-for-cerebral-aneurysm-thrombosis-a-endovascular

Surgical and endovascular treatments for cerebral aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms:
A: Endovascular coiling of the aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms sac
B: Surgical clipping of the aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms neck

Image: “Surgical and endovascular treatments for cerebral aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms thrombosis” by Malebogo N. Ngoepe, Alejandro F Frangi, James V. Byrne and Yiannis Ventikos. License: CC BY 4.0, cropped by Lecturio.

Differential Diagnosis

  • Ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke: acute neurologic injury resulting from brain ischemia. Rupture of a Charcot-Bouchard aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms may initially present with the same focal neurologic deficits as those of an ischemic stroke; however, headache is more prominent in the Charcot-Bouchard type. The 2 types of ischemic stroke can be differentiated by noncontrast CT. Management is ideally with thrombolytic therapy to restore blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure if the time frame and clinical situation permits. Long-term rehabilitation with physical, occupational, and speech therapy are important after the acute event.
  •   Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the meninges Meninges The brain and the spinal cord are enveloped by 3 overlapping layers of connective tissue called the meninges. The layers are, from the most external layer to the most internal layer, the dura mater, arachnoid mater, and pia mater. Between these layers are 3 potential spaces called the epidural, subdural, and subarachnoid spaces. Meninges. The most common etiologies are bacterial or viral infection. Signs of meningismus after aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms rupture can mimic meningitis. LP and CSF analysis can help differentiate meningitis from an SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH). Management of meningitis includes immediate broad-spectrum antibiotics and supportive therapy to prevent complications. Specific treatment depends on the etiology of meningitis. Delay in treatment can lead to permanent neurologic defects and death.
  • Cerebral vein thrombosis (CVT): thrombosis of the cerebral veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins or dural sinuses. Cerebral vein thrombosis may present with a “thunderclap” headache, focal neurologic deficits, altered mental status, and SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH). CT or MR venography can provide the diagnosis. Management includes anticoagulation and supportive therapy.
  • Fibromuscular dysplasia Fibromuscular dysplasia Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory, medium-sized angiopathy due to fibroplasia of the vessel wall. The condition leads to complications related to arterial stenosis, aneurysm, or dissection. Fibromuscular Dysplasia: nonatherosclerotic, noninflammatory, medium-sized angiopathy due to fibroplasia of the vessel wall. The condition leads to complications related to arterial stenosis, aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms, or dissection. The clinical presentation can differ depending on which arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries are affected, but may include neurologic deficits from cerebrovascular involvement. The diagnosis is confirmed with imaging, such as CTA. Treatment includes lifestyle modifications, aspirin for stroke prophylaxis, and potential revascularization.
  • Migraine headache Migraine Headache Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache: primary headache disorder characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound and nausea and/or vomiting. A migraine attack might be preceded by a so-called aura—neurologic phenomena of visual, auditory, sensual, or motor quality. Migraine headache Migraine Headache Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache is a clinical diagnosis. Management strategies include abortive therapy, including NSAIDs and triptans Triptans Triptans and ergot alkaloids are agents used mainly for the management of acute migraines. The therapeutic effect is induced by binding to serotonin receptors, which causes reduced vasoactive neuropeptide release, pain conduction, and intracranial vasoconstriction. Triptans and Ergot Alkaloids to manage acute episodes, as well as preventive strategies to minimize morbidity and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain-related disability.

References

  1. Singer, R. J., Ogilvy, C. S., & Rordorf, G. (2021). Aneurysmal subarachnoid hemorrhage: clinical manifestations and diagnosis. UpToDate. Retrieved August 22, 2021, from https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-clinical-manifestations-and-diagnosis
  2. Singer, R. J., Ogilvy, C. S., & Rordorf, G. (2021). Aneurysmal subarachnoid hemorrhage: Treatment and prognosis. UpToDate. Retrieved August 22, 2021, from https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis
  3. Singer, R. J., Ogilvy, C. S., & Rordorf, G. (2020). Unruptured intracranial aneurysms. UpToDate. Retrieved August 22, 2021, from https://www.uptodate.com/contents/unruptured-intracranial-aneurysms.
  4. Spelman, D. (2021). Overview of infected (mycotic) arterial aneurysm. UpToDate. Retrieved October 21, 2021, from https://www.uptodate.com/contents/overview-of-infected-mycotic-arterial-aneurysm
  5. Malhotra, A., Wu, X., Gandhi, D., & Sanelli, P. (2018). The patient with thunderclap headache. Neuroimaging Clin N Am 28(3), pp. 335–351. https://doi.org/10.1016/j.nic.2018.03.002
  6. Liebeskind, D. S. (2018). Cerebral aneurysms. In Lutsep, H. L. (Ed.), Medscape. Retrieved October 21, 2021, from https://emedicine.medscape.com/article/1161518-overview#a5
  7. Jersey, A. M., & Foster, D. M. (2021). Cerebral aneurysm. StatPearls. Retrieved October 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK507902/
  8. Majeed, H., & Ahmad, F. (2021). Mycotic aneurysm. StatPearls. Retrieved October 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK560736/
  9. Gupta, K., & Das, J. M. (2021). Charcot Bouchard aneurysm. StatPearls. Retrieved October 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK553028/
  10. Chong, J. Y. (2020). Brain aneurysms. MSD Manual Professional Version. Retrieved October 21, 2021, from https://www.msdmanuals.com/professional/neurologic-disorders/stroke/brain-aneurysms

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