Transcription:

Prakash Chandran (Host): Aneurysms can be serious, especially if they rupture, but you can also learn to live with an aneurysm, improve your risk through lifestyle changes or attempt to repair it. Here to talk to us about everything from symptoms and recognition to causes and treatment, is Dr. Bharath Naravetla, an interventional neurologist. This has McLaren's In Good Health, the podcast from McLaren. My name is Prakash Chandran. And so Dr. Naravetla, really great to have you here today. I wanted to just start with the basics. What exactly is an aneurysm?

Bharath Naravetla, MD (Guest): Thank you Prakash for having me here. In simple terms, an aneurysm is the ballooning out of the blood vessels in the brain.

Host: Okay. So the ballooning out of the blood vessels in the brain, and you know, one of the things that I've heard of is a brain aneurysm. Do aneurysms only happened in the brain?

Dr. Naravetla: Aneurysms can happen anywhere in the body, wherever there are the blood vessels. We hear the aneurysms of the aorta, which is the main blood vessel in the body. And we can see the aneurysms involved in the blood vessels in the neck and blood vessels in the abdomen, anywhere in the body. But we are in particular, we're talking about the aneurysms in the brain.

Host: Okay, understood. And when you say the ballooning out of that blood vessel, is that just a rush of blood that causes that to happen?

Dr. Naravetla: That's a great question. So the blood vessels are compared to, you know, the electric wires, like, you know, the blood is flowing through and there is multiple layers of tissue holding the pressure. Sometimes the gap happens between the layers of this tissue and the blood starts pounding through with that blood pressure what we normally have. And the very outer layer of this blood vessel is like an onion skin, like a elastic tissue. So it cannot hold the blood pressure. So what it, what happens is, you know, it starts like bulging out like a balloon. So like a balloon, initially it is tough to blow, but once we start blowing, you know, it becomes easier and easier to make it bigger.

Right? So the same thing happens here. Initially it is small in size and over a period of months and years with the constant blood pressure pounding through it, it starts getting bigger. And at certain point like balloons, you know, it can rupture at certain size.

Host: Okay, that makes sense. And you're starting to touch on this already, but do you have a good sense of what the main causes of an aneurysm are?

Dr. Naravetla: That's a good question again. So there are some genetic causes and then there are some non-genetic acquired causes for the aneurysms. So let's, if we want to talk about the acquired causes, you know, the most important two top causes are like smoking and the hypertension. Uncontrolled blood pressure is the main reason where the aneurysms can form. And the smoking is the most important acquired risk factor where we can modify. Meaning, like if we stop smoking, the risk starts going down and with the smoking, not only the aneurysm start coming up, but the rate of growth of an aneurysm is increased. And the rupture of the aneurysm, meaning the bursting of the aneurysmal wall happens even when the size is smaller, compared to the non-smokers.

So smoking and hypertension are two most important factors. And there are some other factors like, you know, excess alcohol consumption and, you know, drug addiction and all these things. But those two are the most important, whereas coming to the genetic factors, people with some kind of connective tissue disorders like Ehlers Danlos Syndrome, or adult polycystic kidney disease, where, you know, people can have cysts in their kidneys also. These are the people who are at increased risk of forming aneurysms in the brain. And the other one is like, like, you know, cholesterol can deposit under the skin layer and stuff like that.

Host: Okay, understood. So what are some of the symptoms of an aneurysm?

Dr. Naravetla: So aneurysm per se can cause some symptoms, but most of the symptoms from the aneurysm happens when the aneurysm ruptures. So when the aneurysm ruptures, what it causes is a type of a bleeding into the brain, called a subarachnoid hemorrhage. So this is one of the most devastating strokes a person can have.

The reason for that is if the aneurysm ruptures and causes subarachnoid hemorrhage, the chances of the survival is less than 50%. So half of them, they don't even make it out of the hospital. A good number of those people will die even before reaching the hospital. But most of those people die in the hospital, not only just because of the rupture, but there are a lot of complications happen from the subarachnoid hemorrhage.

Those complications are life-threatening and that is the main presentation. So coming to the symptoms, when the aneurysm ruptures or before it ruptures, people can have a sudden worst headache of the life. We call it a Thunderclap headache, and people can have nausea, vomiting. People can have photophobia, meaning intolerance to the light and can have like a neck stiffness, which is called a meningitis.

All these things can be, can happen, or some of them can happen in the patients who have the rupture of the aneurysm. If the aneurysm is not ruptured, it also can cause symptoms. Those are mainly because the aneuryms are like a space occupying lesions. You know, they become like larger, especially in the areas where there are the cranial nerves.

So the larger aneurysm can press on the cranial nerves, can cause double vision can have, can cause loss of vision, stuff like that. Other things, is a small blood clot can form within the aneurysm because the flow, the blood flow in the aneurysm is not straightforward. It's not linear. It swells right. You know, like a coffee cup where, you know if we swallow the cup, coffee in a cup, the periphery outside is moving, but right in the center, the coffee is not moving. So same thing can happen in the aneurysms. Blood can be like swirling around, but right in the center, blood may be stagnant. When the blood is stagnant, it tends to clot.

So small clots can form within the aneurysm and from time to time, they can get washed up into the bloodstream and can cause occlusion of the blood vessel, blockage of the blood vessel causing ischemic stroke. So any of these symptoms can cause, but the frequency of that is much less, much less devastating compared to the rupture of the aneurysm causing subarachnoid hemorrhage.

Host: Okay. And just from a more practical basis, if someone is experiencing more visual symptoms that you mentioned, like the nausea, severe headache or blurry vision is the thing to do to call 911 and to go to the hospital?

Dr. Naravetla: I mean in a part, yes. And in a part you know, could be no. The reason for that is the headache and, you know, some blurring of the vision and some nausea could be from migranes. If the patient is very frequently having these for a very long period of time, that is, that may not be likely from the aneurysmal rupture. But if the aneurysm ruptures, it definitely is going to cause a significant symptom. So it will manifest as a significant symptoms and the patient is not going to be like able to tolerate those symptoms. So in that case, they should call 911, especially when they have a different headache than what they used to have. Thunderclap headache, like a sudden worsening of the headache, they definitely should seek medical advice.

Host: Yeah. So, you know, one of the things I want to get into is the treatment for an aneurysm. And it sounds like, when the aneurysm ruptures, that's kind of, when it becomes serious and more life or death. So maybe let's talk about when treatments for aneurysms happen? Like, did they happen at that moment? Is there something done proactively? Maybe go into that.

Dr. Naravetla: Very good question. So what, the way I want to answer this is what we need to do. How frequent are the aneurysms and how frequently they are going to rupture. So when we look at the studies, there is about three to 6% of the population in America have aneurysms, meaning that's a lot of patients. But at the same time, only 30,000 cases are presented to the hospital with the rupture of the aneurysm. Meaning there are so many patients who have the aneurysms, but not every aneurysm is going to rupture. So what makes the aneurysm more likely to rupture? The most important and important point is the size of the aneurysm? Especially when the size is, you know, less than six millimeters, the risk of rupture is very low.

And the risk increases as the size increases. That's first point. Second point is when somebody has multiple aneurysms, the risk of rupture is higher. Third point is when somebody in the family had aneurysmal rupture or have more than one person in the first degree relatives have aneurysms, not necessarily ruptured, they are at a highest risk of rupture of those aneurysms, the patient is at the highest risk of rupture of an aneurysm.

So those are the situations where even before the aneurysm is ruptured, you know, if the size is more than six millimeters, six or more millimeters, have multiple aneurysms. Other risk factors, a family history of aneurysms, previous history of aneurysmal rupture, all these things, even though the aneurysm is not ruptured; we tend to offer fixing the aneurysm before it ruptures. In all practical purposes, if the aneurysm is at a risk of rupture, we should go ahead and offer them to have it fixed. Then comes if the aneurysm ruptures, the most important point here is first, you know, stabilize the patient and then, you know, contrary to the common belief that oh, aneurysm is bleeding.

No, it does not bleed continuously. What happens is, you know, it opens up and the blood gushes out, pressure equalizes, both inside and outside. And the blood flow stops. When the blood flow stops, it clots within the seconds. And that clot is a sealing that rupture, that rupture site. And blood is no longer leaking, but guess what happens? You know, within certain period of a time that blood clot gets dislodged or the pressure inside the aneurysm increases and it is going to rupture again, this is called a rebleeding. Rebleeding is the most dreadful complication of aneurysmal rupture, or ruptured aneurysm.

So our job is to fix the aneurysms. Once the patient is stable, fix the aneurysm before it reruptures. So, this is an emergency and we stabilize the patient and we fix the aneurysm before it goes into another state of rerupture.

Host: Okay. And, you know, just kinda more broadly, it sounds like you want to obviously treat an aneurysm before it ruptures, even though there's treatment for when it ruptures. It seems like you want to be proactive about this. So are there certain screening modalities that people should be aware of and when should they start being mindful of screening for aneurysms?

Dr. Naravetla: That's a very good question now Prakash. Most important factor where somebody needs to be screened for an aneurysm is if there is a family history, meaning if one or two, first degree relatives or more than two second, second degree relatives have aneurysms then definitely; if there is any suspicion, once they are like adult age or something, and if they are having any minor symptoms, they should go ahead and get checked.

That's first thing. Second thing is if someone let's say someone has headaches for like whatever, the period of a time, and the frequency has increased and suddenly there is a change in the headache, then those are the people they should be looked up for aneurysms.

Host: Okay. I see. And then, you know, in terms of the treatment before rupture, what does that look like? Is that medication, is that something like, minimally invasive? Talk broadly about that.

Dr. Naravetla: Right. So the medical management for unruptured aneurysms is like there. But if let's say if someone has a horrendously controlled blood pressure, meaning like completely like out of limits blood pressure and they found to have a small aneurysm. Now we control the blood pressure, like, you know, very nicely then that is automatically reduces the risk of further growth and reduces the risk of a rupture.

Let's say someone is smoking heavy and they stop smoking. The risk has mitigated, but that does not mean that the aneurysm, which has already formed, that there is not going to grow in size. So medical management, it can alleviate the risk of growth and rupture, but it is not guaranteed. So then comes, what is the definitive treatment?

Definitive treatments used to be two types, like open surgical approach where we, you know, cut open the skull and then reach the aneurysm, put a clip the aneurysm and then the endovascular approach, meaning the interventional procedures where the catheter goes through the groin or the wrist, and the catheter comes up through the blood vessels and reaches the aneurysm.

And then there are various modalities of fixing the aneurysm that way which include coiling, like a, put some platinum coils into the aneurysm where it seals off and clots off from the circulation from the blood vessel, or put a pipeline, kind of a flow diversion technique. There are pipeline and Surpass and FDD, and there are various modalities or various flow diversion devices available where you lay across the aneurysmal neck, where the blood is entering. So it decreases the flow of the blood into the aneurysm. Like, you know it, then the aneurysm slowly start shrinking and eliminate it from the circulation. Like how you take out the air from the balloon, it deflates, same thing. And then there is a newer techniques coming up now, you know, a mesh kind of a device, put into the aneurysm right at the neck, it prevents the blood from entering into the aneurysm and the aneurysm seals off. These are the endovascular techniques.

Previously, we used to think both are equally effective and equally safe, but the latest studies have showed that, you know, people who have the endovascular approach, the risk of the complications are less and the risk of death during the procedure is less. And not only that, the cognitive outcome and the likelihood of the patient doing better is much better with the endovascular approach, meaning the interventional approach. So we are slowly turning towards the endovascular approach from the open surgical approach.

Host: Okay, understood. I mean, this has been a fascinating conversation, Dr. Naravetla. Just as we start to close here, is there anything else that you wanted to share with our audience about aneurysms or how they might understand them?

Dr. Naravetla: So basically there are a lot of people with aneurysms out there. Not everyone is at a risk of aneurysmal rupture and cause a subarachnoid hemorrhage. So, living good healthy life. You know, quit smoking if possible, controlling the blood pressure is the key. And whenever there is a suspicion, whenever somebody has a Thunderclap headache and unusually change the headache from what they use to get, or any stroke like symptoms, you know, the acronym is BEFAST. Use that or any sudden vision loss or double vision, anything like that, people should go and seek the medical help and get checked out. And if there are aneurysm, if they found an aneurysm, then there are various treatment options available.

Host: Well, Dr. Naravetla I think that's great advice and the perfect place to end. I really appreciate your time today.

Dr. Naravetla: Thank you very much Prakash. Have a good day.

Host: That's Dr. Bharath Naravetla, an Interventional Neurologist at McLaren. Thanks for checking out this episode of McLaren's In Good Health.

Prakash Chandran (Host): to learn more about Dr. Narva UTLA, or to submit a question, please visit mclaren.org/ . And that is spelled N a R a V E T L a.

Host: If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

This has been another episode of McLaren's In Good Health. My name is Prakash Chandran. Thank you so much. And we will talk next time.