Aneurysms: So Hidden, So Deadly : Brain Ruptures, Often Misdiagnosed, Hit 30,000 Annually
William Huhta, 38, thought he was in the best shape of his life.
On Oct. 18, 1986, he competed in Kona, Hawaii, in the Iron Man contest--a rigorous athletic event that involves running 26.2 miles, biking 112 miles and swimming 2 miles.
Two weeks later, he ran a half-marathon. The next day, while working in his garden, Huhta felt a severe pain in the back of his head.
“It was different than a normal headache,” he said. “I was light sensitive and had no strength, no appetite. I took two aspirin, went to bed and stayed there for five days. I thought I had the flu.”
When Huhta finally returned to work, he couldn’t speak clearly. Concerned friends took him to the hospital, where he was diagnosed as having a ruptured cerebral aneurysm.
20% Die Immediately
Huhta was lucky. Each year about 30,000 people suffer from ruptured cerebral aneurysms. And according to Dr. Neil Martin, assistant professor of neurosurgery at UCLA Medical Center, “Twenty percent of those stricken with aneurysms die immediately. Thirty percent die within a couple of weeks, and fewer than half survive without disabling neurologic problems.”
Martin characterized a cerebral aneurysm as a “weakened spot in an artery in the brain that might gradually enlarge and rupture, causing bleeding into surrounding areas.”
Studies have shown that aneurysms are not hereditary in most cases, nor do they have well-established risk factors. They are most common in people 30 to 60 years old and strike men and women with equal frequency.
Indeed, in some cases, symptoms are so generalized that patients are misdiagnosed.
Called a Hangover
Barbara Pope and Dorothy Haryung are well aware of this situation.
The day before her 22nd birthday, Pope was getting ready for her job at a phone company.
“I had a killer headache,” Pope remembers. “It felt like someone hit me on the head with a baseball bat. I saw everything with a halo around it.”
After driving to work, Pope blacked out in her car for a minute or so.
“I woke up, got out of the car and walked about 10 feet. Then I saw the pavement coming straight at my face.”
A passer-by saw Pope fall between cars and summoned help.
In the emergency room at a small community hospital, Pope was told she had a hangover.
Two Surgeries
“I had had a couple drinks the night before,” she said. However, later that day, when Pope failed to wake up, her mother called their doctor.
Pope eventually underwent two aneurysm surgeries, one to repair the bleeding aneurysm and one to remove a second small unruptured aneurysm on the other side of her brain.
“I didn’t wake up until after the second surgery,” she said.
Another patient, Dorothy Haryung, was reading the morning paper and drinking coffee when she lost vision in her right eye and had a severe pain in her left temple.
“It came on very suddenly,” 69-year-old Haryung said.
She knew immediately what was wrong.
Specialists Argued Over Her
“Both my mother and grandfather had aneurysms. I certainly knew the symptoms.”
In the emergency room, Haryung was treated by an ophthalmologist and a neurologist.
“The ophthalmologist said there was a nerve involved and that I should take cortisone for a year. The neurologist thought it was carotid artery disease and wanted to do an endarterectomy. Both of them were fighting over me.
“I wouldn’t buy it.”
A few days later, Haryung’s husband took her to another hospital, where she was properly diagnosed and operated on.
Headaches Are Typical
Huhta, Pope and Haryung all experienced one key symptom of a ruptured aneurysm--a severe headache.
Said UCLA’s Martin: “A sudden, severe headache is always present. It is strongest on one side of the head or behind the eye or the back of the neck.” He said the symptoms are not vague, and the headache is abrupt and “can get better over hours or in one to two days.”
Moreover, the headache may be accompanied by nausea and vomiting, light sensitivity, a generalized aching and a stiff neck.
Many patients have no symptoms until their aneurysms rupture and they incur the abrupt symptoms listed above.
However, some physicians believe that almost 50% of patients have warning signs before their aneurysms rupture. These could be caused by a minor leak from the aneurysm or by the aneurysm pressing on surrounding structures in the brain. Early signs include a headache, weakness, a dilated pupil or a strange noise heard in the head.
Diagnosis Difficult
“Early diagnosis and detection of aneurysms is a real problem,” said Dr. Steve Giannotta, associate professor of neurosurgery at USC School of Medicine. “Sometimes the warning signs are so subtle that you can’t expect anyone to pick them up. Sometimes they are so non-specific that you can’t prove they are warning signs.”
Giannotta estimates that 5% to 10% of patients don’t receive immediate help because they are misdiagnosed. Martin and Giannotta agree that educating the public and physicians about the warning signs of aneurysms is an essential step toward early diagnosis.
If a patient is suspected of having an aneurysm, certain tests are performed in the emergency room.
“It is absolutely critical to obtain a CAT scan (computerized axial tomography scan),” Martin said. A CAT scan is a non-invasive procedure that provides three-dimensional views of the brain.
After the CAT scan, a lumbar puncture is performed. In this procedure, a small needle is inserted into the spinal canal and cerebral spinal fluid is withdrawn. If blood is present in the cerebral spinal fluid, it usually indicates a ruptured aneurysm.
Patients may also undergo a cerebral angiogram. Radiopaque dye is injected into the circulatory system of the brain, allowing physicians to view veins and arteries and pinpoint the location of an aneurysm. After a diagnosis, the patient usually undergoes surgery.
“Unless the patient is very ill, we operate with 24 hours,” Martin said.
Early surgery is advised to avoid risking the aneurysm rerupturing, for a second, major hemorrhage usually occurs within 24 hours to two weeks of the first rupture. And according to Martin, there is a 50% mortality rate with a second, major leak.
Sac Is Punctured
During surgery, physicians usually place a small clip on the neck of the aneurysm to block the blood flowing into it. The aneurysm sac is then punctured, like a balloon.
“Most aneurysms are treated without causing any neurological deficit,” Martin said.
At Los Angeles County USC Medical Center, where most aneurysm patients in Los Angeles are treated, Giannotta estimates he performs 60 to 65 aneurysm surgeries per year with a morbidity and mortality rate of 5%.
Yet for the many patients who survive the physical trauma of a ruptured aneurysm, there remains an even greater psychological trauma.
“For a long time my thinking was terribly slow,” Haryung said. “I couldn’t accept what happened to me because I didn’t understand it. The first nine months, I was really confused. I had a spiritual and mental confusion and also a visual confusion.” For instance, she “couldn’t distinguish planes.”
Pope also experienced difficult times after her aneurysm.
Trouble With Drugs
“Nobody told me what I went through,” she said. “I started freaking out. I got myself in a lot of trouble with drugs.
“It psychologically altered my way of thinking. I thought that it wasn’t something I should be forced to deal with.”
After his six-hour surgery, Huhta, the athlete, was more disturbed by physical than mental problems.
“My strength was gone. I couldn’t even walk. I had to learn how to walk and swim again.” Since that frustrating time, Huhta has run in six 10-kilometer races.
“I’m a real positive person and I think that helped pull me through,” Huhta said.
In addition to increased education about the warning signs of aneurysms, doctors also advocate developing methods for earlier detection as a way of decreasing the high mortality.
Some Early Treatment
“We’re starting to see more aneurysms diagnosed and operated on before they rupture,” Giannotta said. “We see people who have tests done for other reasons. The CAT scan and MRI (magnetic resonance imaging) are so good now, they pick up more things.”
MRI uses a magnet and radio pulse waves to image cross-sections of body tissue, producing sharp detailed pictures. Martin is encouraged by research involving electronic detection of aneurysms by the sounds they make.
“It would be safe and non-invasive,” he said. “I would recommend everybody have one during a routine physical.”
Because most who have cerebral aneurysms are otherwise healthy people, taking a few extra minutes during a physical exam might, indeed, add years to one’s life, by catching a condition that could be fatal.
