Defusing a ticking time bomb in the brain

SINGAPORE - Believe it or not, stroke can happen to young people - and a brain aneurysm is often behind it.

Unfortunately, most people are not aware of its existence until it strikes for the first time.

Simply put, a brain aneurysm is a small, localised bulge of a blood vessel in the brain.

Smokers and those with long-term uncontrolled hypertension are more likely to get it.

It also runs in families. In fact, it is estimated that at least one or two out of every 100 people have an aneurysm in their brains.

The risk runs the highest among those aged 40 to 60.

This happens because blood vessels get diseased. And when they do, they do so mainly in two ways: They narrow due to fat deposits along the vessel walls, causing a heart attack; or they balloon up and grow larger in diameter, causing an aneurysm.

These aneurysms are most commonly seen in blood vessels linked to the brain.

Some of them remain small and stable in size.

However, in a significant group of patients, they grow with time, especially among those with hypertension. And one day, the aneurysm may rupture, just like how a balloon will burst if we keep blowing air into it.

The worst headache

Only a small number of those with an aneurysm in their heads display specific neurological symptoms.

Most people find out only when the aneurysm bursts, causing the worst headache of their lives.

A significant number of them would not survive this episode, while others end up with severe disabilities from which they would never fully recover.

The good news is, things have been changing over the past few years in Singapore.

Just a few years ago, I treated patients with ruptured aneurysms as an emergency. But these days, I treat a significant number of people electively (non-urgent) for unruptured aneurysms.

A magnetic resonance imaging (MRI) or computed tomography (CT) scan is all you need to pick up a significant aneurysm in the brain.

Better technology and awareness have certainly been the main reasons behind this trend.

This is all great news for patients. Elective treatment, especially in high-risk patients, saves lives and prevents a potentially debilitating stroke.

Last month, I had two patients from Russia who travelled here to get their brain aneurysms treated electively after undergoing CT scans at tertiary hospitals in South Korea.

Treatment for brain aneurysms has become very specialised, thanks to advances in minimally invasive endovascular techniques.

First, a small incision that measures less than 1cm is made at the groin. Surgeons can then reach any vessel in the brain through a blood vessel in that area. The aneurysm can therefore be treated directly without opening the skull.

It is fantastic technology that was not available 20 years ago.

Nowadays, in my experience, most patients who had elective treatment for brain aneurysms can walk home within one or two days.

Just like how stents have revolutionised the treatment of blood vessels of the heart, the minimally invasive approach has worked wonders in treating patients with brain aneurysms.

A question that patients often ask is, at what size should an aneurysm be treated?

While an aneurysm that has grown up to 1cm in length requires urgent treatment, it can also be potentially lethal even if it measures just a few millimetres.

One of the unique things I have seen in my practice over the past few years has been the way these aneurysms behave among local patients.

Many of their aneurysms rupture when they reach around 5mm in size.

Some have aneurysms that rupture even when they measure just 2mm to 3mm in size.

Yet, I did not come across this trend during my 11 years of training in Britain, Canada and the United States. There, most of the ruptured aneurysms were much larger.

In fact, my former colleagues and I almost never offered elective treatment to patients until their aneurysms were 7mm in size.

The local trend of aneurysms bursting at smaller sizes is likely a reflection of the overall smaller body size of Asians, compared to Caucasians.

A similar trend has been well described in studies done in Japan.

As every person is different, customised treatment is needed for it to be effective.

It is always better to defuse the ticking time bomb in the brain before it is too late.

manish_taneja@rafflesmedical.com

Dr Manish is an interventional radiologist at Raffles Neuroscience Centre, Raffles Hospital. He has a wide range of experience in all radiologically guided minimally invasive procedures. He also has special interests in diagnostic neuroradiology and vascular imaging.

This article was first published on July 10, 2014.
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