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Prakash Chandran (Host): Cerebral aneurysms can occur in anyone at any age. Though the consequences of a ruptured cerebral aneurysm can be severe, some small unruptured cerebral aneurysms may not bleed or cause problems to a patient. Here to talk more about cerebral aneurysms, symptoms, diagnoses, and to help us understand severity and treatment is Dr. Kunal Vakharia. He's the Assistant Professor of Neurosurgery at the University of South Florida.

Welcome to MD cast by Tampa general hospital, a go-to listening location for specialized physician to physician content and a valuable learning tool for world-class healthcare.

I'm your host Prakash Chandran. Dr. Vakharia, it's great to have you here today. Thank you so much for being here. I wanted to start with the basics. What exactly is a cerebral aneurysm?

Kunal Vakharia MD, MBE, MBA (Guest): Yeah, that's a good place to start. So, it's cerebral aneurysm is similar to other aneurysms that you have elsewhere in your body. So when you have a thoracic aortic aneurism or anything along those lines, it's basically a weakening of the artery wall. And so we have a similar situation that happens in the blood vessels in the brain. And typically when I try to explain this to patients, I kind of describe it in several different classifications, but mainly saccular aneurysms and fusiform aneurysms. That being said, saccular aneurysms are the ones that we most commonly hear about. They're the ones that are like berry aneurysms, weakened walls, blisters in the head that have the ability to bleed and cause significant subarachnoid hemorrhage. And those tend to be the most scary and also the most common. And then there's a smaller, subset, more like a large circumferential dilations of intracranial arteries. That means they don't actually have a neck. And those tend to be what we call fusiform or dolichoectatic aneurysms. And they can actually be one of the causes of strokes or even mini strokes and something I always watch out for as well when I see these patients.

Host: Yeah, that makes sense. So one of the other things I wanted to ask is who does this typically affect and what are the symptoms and risk factors that people should know about?

Dr. Vakharia: I mean, that's also a challenging question because I don't think it's fully understood across every population. When we talk about patients that are most effected, I know that there are clearly good populational studies done looking at patients from Finnish origin or Scandinavian origin and also Japanese origin. And those patients tend to have a higher risk just based on a higher predominance of subarachnoid hemorrhage and cerebral aneurysms in those patients. That being said, there are definitely risk factors be at either genetic or lifestyle modification factors that play a pretty big role in if patients can have aneurysms and also the risk of them bleeding.

So, the big ones are, genetic issues such as Ehlers-Danlos syndrome or polycystic kidney disease. And a lot of diseases or disorders that affect elastic tissue or adventitional tissue typically also affects the ability for aneurysms to form. And then the lifestyle modification factors, the four most common. And, although, I guess this isn't a lifestyle one, but it's more common in females. Definitely more common in patients that smoke cigarettes, patients who have significant atherosclerotic disease and also those who have high blood pressure.

Host: Now you started to touch on this earlier, but can you unpack for us some of the risks associated with cerebral aneurysms?

Dr. Vakharia: I typically tell patients and the easy rule of thumb is that if an aneurysm bleeds, I describe it in thirds, a third of patients make it to the hospital and do well. A third of patients make it to the hospital and have some sort of long-term deficit. And the last third of patients don't make it to the hospital.

And then I basically talk to them about really quantifying the risk of them having a bleed versus not. And I think that's where a large part of this conversation is and also a large part of the conversation nationally and internationally about which patients should we treat and how do we limit the risk of our treatment for these patients?

Host: So Dr. Vakharia can you briefly explain how a cerebral aneurysm is diagnosed?

Dr. Vakharia: A lot of these patients typically see either their primary care providers, a neurologist, or they come into the ER for the first time. And the most common thing and what everyone in medicine, usually studies for their board exam is a worst headache of your life, that thunderclap headache. But along with that, a lot of these aneurysms can have what we call sentinel bleeds, where a patient may have a small headache a couple of weeks before, and then have another headache that's also pretty significant. So, it doesn't always have to be that one-time headache. Patients have nausea, vomiting, changes in mental status, loss of consciousness, vision problems, either loss of vision, double vision, one eye is one pupil is bigger than the other. A lot of these symptoms can be related to depending on where the aneurysm is and how it's growing.

So, that's typically the first sign and the red flag that a patient needs to get a scan. All of that being said, most patients are diagnosed incidentally. For some other reason, they end up getting either an MRI or a CTA and it demonstrates an aneurysm and that's kind of where the challenge and whether or not we need to treat these aneurysms lie.

Host: Yeah, that's interesting. So, because most patients are diagnosed incidentally, it means that they've been living with it for a while. So at what point does it become time to get treatment?

Dr. Vakharia: Prakash, that's a great question, but also a question that's nearly impossible to answer again. It's a question for debate even now, because the challenge is there was a great study done in the 1999 and early two thousands that showed that the rate of rupture of small aneurysms is relatively low. And then that's a study called the ISU. And that study, the long form is the International Study of Unruptured Intracranial Aneurysms. And that study basically said, if you have aneurysms in what we call the anterior circulation coming off of the carotid artery, they have a relatively low risk of bleeding. And if they're less than seven millimeters, they have an even lower risk of bleeding, almost zero versus aneurysms that come off of what we call the poster circulation have a much higher risk of bleeding and that really steered the conversation into which one should we treat? Now the challenge is since that time, a lot of studies have come out, looking at the morphology, the anatomy of the aneurysms, and also looking at if there's enough hemodynamic pressure, even small aneurysms bleed.

And most of the patients we see nowadays are those small aneurysms that have bleeds that come into the hospital. So, I don't think there's a perfect answer on that. But I think understanding that there's a risk and if you have younger patients, they're taking that risk over a longer period of time, kind of helps delineate which patients should and should not get treated.

Host: Yeah, I can see why that's a tough question to answer. But if they do come in and they don't want to take that risk over time, can you talk a little bit about how these aneurysms are treated?

Dr. Vakharia: The old school mentality was that you want to get in and completely treat these aneurysms the first time around. And that, that still holds true to a certain extent. But I think that the world is slowly changing because endovascular therapies have really taken off and the technology has also significantly taken off.

So, I tell you that there are different options for treating it. And really the two mainstays, are endovascular therapy, meaning we go through the artery in the arm or the leg, we go up with a catheter and actually try to treat the aneurysm from the inside. And then there's the microsurgical aspect, which where we come from an open surgical perspective in the operating room, we're actually opening up part of the head going around the brain not through the brain and finding these aneurysms and putting a clip on them or doing a bypass and taking them out of the normal circulation and making sure that we have good flow to the rest of the brain. That being said, the endovascular tools have exploded in the last decade or so. And we have a lot of technologies even to treat smaller aneurysms, which makes the risk profile lower, but also means that they might have recurrence rates and things that we're still learning about in the future. And also why we keep a pretty close eye on these patients long-term.

Host: So I imagine that the ideal case scenario, is to do the endovascular or a minimally invasive approach, but at what point do you consider a microsurgical one?

Dr. Vakharia: There are definitely aneurysms that are high risk from a microsurgical perspective. And that's a reason for the boom in endovascular therapy and aneurysms that are in that posterior circulation, aneurysms of the basilar apex, or posterior communicating artery. Those typically tend to be most amenable to endovascular therapy.

The aneurysms that require a lot of endovascular, what I call gymnastics, meaning you have to have multiple devices, multiple catheters, take a long time within an artery and increase the risk of stroke because we're obviously in the vessel. And anything that we put in the vessel can create plaque and atherosclerotic issues as well as intimal damage and also platelet aggregation, all of which can cause stroke. And so when we get to the point at which we're doing a lot of gymnastics to try to treat these, sometimes microsurgical approaches tend to just be easier, simpler and more durable.

Host: Yeah, that makes a lot of sense. So, Dr. Vakharia, just before we close here today, is there anything else that you'd like to share with our audience here?

Dr. Vakharia: I think that the field of neurosurgery and the field of neurointerventional surgery are dramatically changing. And every day we learn that even diagnosing these smaller aneurysms and the risks that they portend to patients, particularly those with other risk factors, such as family history and smoking, has really shaped how we talk to these patients. And also the risk benefit profile of endovascular therapy has also changed how we talk to patients. And I think that's an evolving discussion, be it with patients and also with other clinicians that are referring these patients to us.

Host: Well, this has been a fascinating conversation, Dr. Vakharia. I really appreciate your time today.

Dr. Vakharia: Thank you.

Prakash Chandran (Host): Thank you for listening to MD health cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa general hospital, please visit C M E dot T G h.org.

Host: My name is Prakash Chandran and we'll talk next time.