What is a brain aneurysm? [Music playing] [Text on screen: Ohio State Health & Discovery Health Talks] Gail Hogan: Welcome to Health Talks. I'm Gail Hogan, and today we're talking about brain aneurysms, what they are and what you need to know. Dr. Patrick Youssef is here to share what to watch for and how the experts at Ohio State can help. [Text on screen: Gail Hogan Host Health Talks] Gail Hogan: Dr. Youssef, thank you for being here. And what is a brain aneurysm? [Music fades] [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: Well, thank you for having me, Gail. So an aneurysm is an outpouching of a blood vessel wall. Typically, they tend to be on the arteries. They can be anywhere. They can be in your aorta. They can be in your heart. They can be anywhere. But when we're talking about brain aneurysms, they tend to be in the intracranial circulation and they tend to be bulges or weak spots on the blood vessel wall. An aneurysm itself isn't the most dangerous thing in the world. It's when it ruptures that patients can have fatal consequences. Gail Hogan: So how do you know if you have one? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So if an aneurysm isn't ruptured, it's really hard to know if you have one. Most of them are asymptomatic. If they do become symptomatic, it's when they become giant, and they tend to compress the tissue around them, including the brain and the nerves around them. So patients will tend to have their eyelids droop, or they'll have difficulty opening their eyes, their pupils might be really expanded, or they might have trouble using part of their face. When an aneurysm ruptures, then it becomes absolutely clear. Patients complain of the worst headache of their lives. Typically, they feel like a bomb exploded in their head or something along those lines, and they grab their heads and double over in pain. Gail Hogan: What do you do? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So when that happens, the first thing you do is you call 911, and you immediately get to the hospital. The patient comes to the hospital, we provide supportive care, and then we do our studies to see if there is an aneurysm. If there is an aneurysm, fixing it becomes of vital importance. So if you imagine the aneurysm as a leaking part of the blood vessel, fixing it to stop the leak is the key to fixing and long-term success of an aneurysm. So there's multiple different ways to fix an aneurysm, including classically we open up the skull, we find the blood vessel and where the aneurysm is located, and we put a little titanium clip on the base of the aneurysm. So if blood isn't filling the aneurysm, blood can no longer leak from the aneurysm. Conversely, we can also do interventional procedures where we go in through the blood vessels of the body through a single needle puncture and we put catheters up into the aneurysm, and then we can put different devices in the aneurysm or around the aneurysm to also secure it from bleeding. Gail Hogan: It is amazing what you can do. What are the outcomes? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So initially, patients who have poor outcomes from aneurysms, about a quarter of them don't make it to the hospital in time. Gail Hogan: And that's key, right? Patrick Youssef, MD: Yes, ma'am. Gail Hogan: That's why you say call 911. Patrick Youssef, MD: Immediately, yes. And of the ones that get to the hospital, overall, about one-third will pass from the aneurysm and its effects. Earlier treatment is key. Because if the aneurysm is not treated and it ruptures again, it's almost nearly universally fatal. Of the patients remaining, about two-thirds do make a recovery from an aneurysm. Gail Hogan: Do we know what causes a brain aneurysm? Patrick Youssef, MD: So there's several things that we've thought and we've looked into. One of them, there is a genetic predisposition to aneurysms that can be found in patients with diseases such as polycystic kidney disease or collagen connective tissue diseases like Marfan's or Ehlers-Danlos. For those without genetic factors... And we would know those were genetic factors because they would have multiple family members that would be afflicted with aneurysms. For those without genetic factors, then we start looking at habits and other things. Most aneurysms arise what we call de novo or new, and those aneurysms tend to arise in patients that are smokers, or they have high blood pressure not controlled with medication, or they use street drugs such as methamphetamines, crack or cocaine that cause really high and uncontrolled blood pressure. Gail Hogan: Does it have anything to do with age and gender, sex? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So for age, we tend to see patients who are a little bit younger. Actually in the 30 to 60 year age range are the ones that mostly get aneurysms that rupture. And women do have a little bit of a higher predilection of aneurysms to men for reasons that we are still researching. Gail Hogan: So you can't find an aneurysm until it bursts. Patrick Youssef, MD: Typically, when an aneurysm is found, it's either ruptured or a patient's come to the hospital and we're looking into their head for something else and we happen to find an aneurysm. There are not usually typical warning signs or heralding signs. There can be something we call a herald bleed, which is when an aneurysm leaks, but doesn't rupture all the way, and that will cause many similar symptoms to a rupture, but not quite as severe. Gail Hogan: You said one of the biggest symptoms, if not the biggest sign, is that someone complains it's the worst headache they've ever had. How do you know if it's not just a migraine, maybe you've never had one before, and so you think, oh, I have a new migraine, or it really is a brain rupture? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: For many patients, this can be indistinguishable. And that's why I always tell them err on the side of caution and please come to the emergency room, because a simple CAT scan will tell the difference. You cannot truly tell the difference if it is a severe migraine versus an aneurysm rupture. Gail Hogan: Can aneurysms appear in any part of the body? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: Well, Gail, sure. An aneurysm just means an outpouching of a blood vessel wall. So anywhere where you have a blood vessel or an artery, you can see an aneurysm occur. You can have them occur in the aorta, anywhere in the aorta. You can have them occur cardiac, in the heart. You can have them occur in the lungs. Anywhere where there's a blood vessel. You can even have venous aneurysms that are a different aneurysm type altogether. But the word aneurysm can appear anywhere where there's a blood vessel. And specific here we're talking about intracranial aneurysms, which is aneurysms in the circulation of the brain, which have a different risk profile and risk factors. Gail Hogan: Can stress cause a brain aneurysm? Patrick Youssef, MD: Absolutely. So the risk factors involved in a brain aneurysm include smoking, high blood pressure not controlled with medication, and street drugs, crystal meth, methamphetamines, those kinds of things. Stress potentially could create really high blood pressure. And if that's not controlled, that could contribute to the formation of an aneurysm. [Text on screen: Gail Hogan Host Health Talks] Gail Hogan: You mentioned stroke. What is the relationship between aneurysm and stroke? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So stroke is a complicated term. In medical terms, stroke, it means just an attack of the brain. So you can have a hemorrhagic stroke, which is bleeding on the brain, which is what happens when an aneurysm ruptures. An aneurysm rupture is technically defined as a hemorrhagic stroke. That hemorrhagic stroke can then lead to something we call vasospasm, because our blood vessels are well-designed to hold blood inside the blood vessels. When blood escapes the blood vessels and goes to the surrounding of the blood vessels, the outside of the blood vessels where the nerves are located, that can irritate those nerves. And when a blood vessel gets irritated, it clamps down. That can lead to what we call an ischemic stroke or a lack of blood flow to a certain part of the brain. And those are the strokes that we commonly think of when we think of the word stroke. Gail Hogan: And stroke always has to do with the brain, correct? Patrick Youssef, MD: Yes, ma'am. Gail Hogan: You mentioned a couple different treatments. So how does the patient then recover from these treatments? What happens afterwards? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: So when we open the patient's skull, the patient will have an open craniotomy. So they'll have your typical surgical scar or surgical incisional pain, and they'll be in the hospital for several days to weeks thereafter. Typically, after an aneurysm ruptures, the patient is in the hospital for a minimum of 14 days. And that's so that we can check for other things such as vasospasm or spasming of the blood vessels to try to prevent stroke regardless of how it's treated. When patients are treated with interventional procedures, it's just a needle stick in the skin and everything is done inside the blood vessel, those tend to have less pain and a fairly quicker recovery. But again, we're still looking at the 14 days to try to prevent or evaluate and treat vasospasm if it occurs. Gail Hogan: If you've had an aneurysm that's burst, it's treated, what's the recurrence rate? Is there one? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: Yes, ma'am. So it depends on the treatment modality. This is where the open surgical clipping does beat the interventional procedures because the risk of recurrence on an open surgical clipping is less than 1%. When you go in with the catheter and you treat an aneurysm with a catheter, regardless of what modality you use, whether it's coiling or flow diversion or flow disruption, you still have a recurrence rate anywhere between three and 12%. Gail Hogan: You talk about all these terms. It sounds like there's a lot of research going on in this regard. [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: There's a lot of research. There's a lot of research here happening at Ohio State University. We've been working on all facets of aneurysm care, including evaluating and diagnosing aneurysms in a more sensitive manner so we can try to catch them earlier. Once the aneurysm ruptures, we have different treatment modalities that we're looking into, including flow diversion and flow disruption, which are just coming on the market and emerging to be used in a ruptured aneurysm. And then afterwards we're working on more trials to advance the post care of aneurysms to try to prevent vasospasm or treat it more successfully, try to prevent stroke from occurring after the aneurysm and maximize the patient's recovery. Gail Hogan: So you are holding and hosting clinical trials? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: Absolutely. Here at Ohio State at any particular time, we have anywhere between seven and 15 clinical trials going on just on aneurysms alone. Like I said, some of the more recent ones we're using is on different devices with different properties to help fill up that aneurysm a little bit better, faster, safer, and allow for more maximal recovery. [Music playing] Patrick Youssef, MD: We're also trying new devices these days where we're not even going into the aneurysm to treat it, we're staying in the vessel that the aneurysm is located on and trying to place a flow diverting stent to try to prevent manipulating of that ruptured aneurysm. Gail Hogan: So what's the future? [Text on screen: Patrick Youssef, MD Neurosurgeon Ohio State Wexner Medical Center] Patrick Youssef, MD: The future is that we will get better at aneurysm treatments. Patients will have better outcomes. They will be safer. And hopefully in the not so distant future, we become better at detecting aneurysms so we can prevent these ruptures from occurring in the first place. Gail Hogan: Dr. Youssef, thank you very much. Patrick Youssef, MD: Thank you, Gail. I really appreciate it. Gail Hogan: And thank you for joining us for Health Talks. [Text on screen: Ohio State Health & Discovery Health Talks health.osu.edu] [Music fades]