Beware of Sudden and Severe Headache!

Beware of Sudden and Severe Headache!

Headache is a very common condition that nearly everyone experiences. However, if the headache you are experiencing is sudden and severe, it may actually be signaling another underlying disease. For this reason, if you are experiencing a headache that you might describe as ‘the most severe headache I have ever had in my life, as if a bomb is going off inside my head’, it is advisable to see a physician immediately… We spoke with Prof. Dr. Mustafa Bozbuğa about sudden and severe headaches, which can occur at any stage of our lives, and about brain aneurysms, one of their main causes, covering the things that are unknown and that people wonder about…

Beware of Sudden, Very Severe and Persistent Headache!

For us, a headache that starts suddenly, is very severe and does not go away is the leading sign of a serious brain hemorrhage known as Spontaneous Subarachnoid Hemorrhage (SAH). This type of hemorrhage has very serious consequences; however, it is a condition in which the chance of treatment and the success rate are high when intervention is timely. The headache, which the person experiences as more severe than any they have had before, may also be accompanied by neck stiffness, nausea, vomiting, impaired level of consciousness, weakness on one side of the body, sensory disturbances, speech disturbance presenting as loss of comprehension and/or expression, visual disturbances, epileptic (seizure) attacks, and any other neurological and non-neurological symptoms that one can imagine.

The richness of the clinical picture depends on the event developing suddenly, a large volume of blood spreading at very high pressure into the brain, spinal cord and nerves, and thus affecting the entire nervous system both volumetrically and functionally. Subarachnoid hemorrhage occurs in approximately 80% of cases as a result of the rupture and bleeding of a balloon-like bulge (aneurysm) in a brain artery. Subarachnoid hemorrhage caused by a brain aneurysm and its bleeding requires, for diagnosis and treatment, a high-equipment center and an experienced team consisting mainly of a neurosurgeon, an anesthesiologist and intensive care specialist, and a neuroradiologist. Good treatment starting from the very first moment ensures protection of the brain, and if the aneurysm is closed, it becomes possible to achieve good results.

What is an aneurysm?

Literally meaning dilation, a brain artery aneurysm refers to a permanent ballooning in the structure of a brain artery. Aneurysms in brain arteries are classified according to their causes, locations, relationship with the vessel, shape and size (saccular / fusiform; congenital / mycotic / traumatic / dissecting / atherosclerotic /…; narrow-necked / wide-necked / thin-walled / thick-walled; small aneurysm / large aneurysm / giant aneurysm / thrombosed aneurysm / and many other aspects). The aneurysms we frequently encounter in our clinical practice are the so-called congenital saccular aneurysms, which develop on top of certain congenital disorders with the addition of later factors that affect blood flow, are seen at the bifurcation points of arteries or the branching points of vessels, and are usually cherry-like in shape. The aneurysms that lead to the very serious clinical picture of spontaneous subarachnoid hemorrhage (SAH) are also of this type.

How and why does an aneurysm form in the brain?

The structure of brain vessels differs from the vascular structure of other organs. The layers of the brain vessel wall may be missing or weaker in some people. As a result, particularly at the bifurcation points of arteries or at vessel origins, an aneurysm forms when the vessel bulges out from the area where the muscle layer of the vessel wall and the elastic layer lining the inner wall are defective. The widely accepted view is that aneurysms form when acquired factors related to blood flow and processes affecting the structure of the vessel wall are added to the congenital weakness of the vessel wall; however, the exact cause is still not known.

In which age group are aneurysms more common?

Although congenital saccular aneurysms of brain vessels have a congenital origin, these lesions usually appear between the ages of 40 and 60, and very often present with SAH (spontaneous subarachnoid hemorrhage), a serious brain hemorrhage. Of course, we also see extreme examples; I remember an 11-year-old child who came to us with spontaneous subarachnoid hemorrhage and in whose angiography we identified 4 aneurysms. We also have patients in older age groups, for example those in their ninth decade (in their eighties). In short, although they can be seen in every age group, we can say that the onset of these lesions is concentrated in the fifth and sixth decades of life.

Risk Factors Can Trigger Aneurysm Formation!

Race and regional characteristics are important in the frequency of brain aneurysms; in some populations and families, the rate of aneurysms is very high. Therefore, we can say that genetic factors are important. However, although new genetic information related to brain aneurysms has been discovered in recent years, what these factors are and what their roles are has not yet been fully understood. About one in ten patients with a brain aneurysm and spontaneous subarachnoid hemorrhage has a family history; it is known that in these patients the clinical picture generally appears at younger ages and follows a more severe course. The likelihood of a brain aneurysm increases in some systemic connective tissue diseases such as Ehlers-Danlos syndrome, Marfan syndrome, pseudoxanthoma elasticum, neurofibromatosis, polycystic kidney disease and aortic coarctation.

Age and sex are also important factors. Although it is seen in all age groups, it is found at a slightly higher rate in women in the 40–60 age group. Among acquired factors, hypertension, diabetes, smoking, narcotics, alcoholism, infections such as inflammation of the blood/sepsis, and craniocerebral trauma (brain injuries), which affect the structure of the vessels and blood flow dynamics, play a role in aneurysm formation. In the natural course of brain aneurysms, more than 90% present with rupture and bleeding of the aneurysm. This is the very serious brain hemorrhage we call spontaneous subarachnoid hemorrhage (SAH). In this clinical picture, we need to treat the severe brain hemorrhage accompanying the aneurysm and the series of complications triggered by this hemorrhage. This very complex and difficult treatment must be carried out at a very well-equipped center, through a dynamic treatment by a team of “Neurosurgery/Cerebrovascular Surgery – Neuroanesthesiology and Intensive Care – Neuroradiology” that is experienced in brain vessel microsurgery and works in close collaboration.

Be Very Careful If These Symptoms Are Present!

In very few patients (fewer than 10%), the aneurysm mass may exert pressure on the surrounding brain structures, and related neurological findings may appear. These signs and symptoms include:

Visual disturbances,

Restriction of eye movements and, related to this, double vision,

Pain around the eye and/or in the face,

Speech disorders,

Loss of strength or sensation on one side of the body,

Walking disorders,

Dementia,

Affective disorders,

Headache.

If these findings are correctly interpreted by a physician and the necessary investigations are performed, there may be a chance to diagnose the aneurysm before it bleeds. Sometimes, an aneurysm may also be detected incidentally on imaging performed for other reasons. Diagnosing an aneurysm before it bleeds is a very fortunate situation for both the patient and the physician.

Which tests are used to diagnose aneurysms?

Throughout this dynamic process, it is necessary to continuously monitor, at the most basic level, the gross morphological structure of the brain, the composition inside the skull, the brain vessel tree and the pathological formations within this structure, the location, size and course of the hemorrhage, how the brain and vessel structure responds to this process, the blood supply and functional map of the brain, and the status of the vital functions and all other systems of the body. Many tests are performed for this purpose, and these provide complementary information. Computed brain tomography is useful for showing the hemorrhage, its effects and the probable etiological lesion; cerebral angiography (DSA) is useful for revealing in detail the brain vessel tree and the brain aneurysm or another vascular lesion (such as an arteriovenous malformation); cerebral magnetic resonance imaging (MRI) is useful for providing further information about brain imaging and brain functions; and the various interventional monitoring methods we use in the Neuro-Intensive Care Unit are also useful to us in tracking the whole body, and especially the vital functions, and keeping these values within optimal ranges.

What symptoms appear when a brain vessel aneurysm ruptures?

When a brain vessel aneurysm ruptures, clinically, spontaneous subarachnoid hemorrhage (SAH) occurs: headache (characteristics of the headache: sudden, of a severity never experienced before, not lessening in any way, persistent headache) is the cardinal symptom and is very valuable for diagnosis. This should be known not only by all physicians, medical students and healthcare workers, but also by all members of society. Because the sooner this condition is considered, the earlier it is diagnosed and the patient is taken to the appropriate center, the better the outcome will be to that extent. Until the patient is taken to the appropriate center, breathing and heart function must be secured, and the patient should be kept in a comfortable position.

During this process, the First Aid Health Team should be notified and the patient should be taken to a hospital under suitable conditions. The most important point here is that the hospital to which the patient is taken should be a high-equipment center with an experienced team specialized in this field. In patients with subarachnoid hemorrhage caused by aneurysm bleeding, contemporary treatment involves admitting the patient to the Neuro-Intensive Care Unit as early as possible (within minutes to hours), so that all vital functions are brought under control from the first minutes.

Thus, while the brain is protected and angiography of the brain vessels and all advanced investigations are completed, the patient can then be operated on by an experienced Cerebrovascular Surgery team, and treatments requiring high standards can be applied. The most important factors determining the outcome in the patient are the severity of the hemorrhage and the technical difficulties of the aneurysm causing it. Of course, patient-specific factors such as age, the patient’s vascular structure, general health status, and concomitant serious chronic systemic diseases such as hypertension, diabetes and chronic obstructive pulmonary disease also influence the course of the disease and the outcome.

How does the surgical process work?

Our approach in these patients is, following early diagnosis, to immediately admit the patient to the Intensive Care Unit and perform monitoring procedures that ensure all vital functions are continuously followed. In this process, evaluating the patient’s other systems, ensuring the best conditions for brain metabolism and blood supply and treatment, performing all necessary advanced investigations before surgery, and operating as soon as possible constitute one of the most important and decisive links in the chain.

In contemporary neurosurgery, these procedures are accepted and recommended to be carried out within the first 72 hours/3 days (and sometimes even within the first 96 hours/4 days). In our hospital, all these procedures can be completed within a few hours, and it is possible to take the patient to surgery within the first 6 hours. The primary goal of surgery is to close the aneurysm causing the hemorrhage with a millimeter-sized, mandala-like material made of a special alloy called a clip, and to do this without any damage to the normal brain vessels. In addition, clearing the hemorrhage, reviewing the brain vessel tree, and taking measures against possible complications that may arise during the process are also the main aims of surgery.

For these patients, a very specific, advanced follow-up and intensive treatment period in the Intensive Care Unit is essential after surgery as well. With this approach, early intervention is possible for the brain damage caused by the hemorrhage, the risk of re-bleeding from the aneurysm is prevented, and the process that began with the hemorrhage and, following a separate pathway, causes additional damage to the brain is interrupted, and other serious complications that may develop are eliminated before they occur. Thus, the main outlines of treatment consist of protecting the brain throughout this entire course and eliminating the event causing the hemorrhage.

What is the postoperative process like?

Length of hospital stay varies from patient to patient; however, it is not less than 14 days. The patient’s return to daily life depends on the patient. According to the data shown by all scientific publications in this field, some patients may retain severe neurological dysfunction despite the best medical treatment and surgery, while in some patients mild neurological dysfunction may continue. However, we are very happy that the result we most frequently see in our series is that the patient returns to their former normal life with a good psychocognitive and neurological status. This can be achieved approximately one month after the hemorrhage and surgery.

For which symptoms should a person who has had aneurysm surgery consult a physician without fail?

Since these patients are among the most severe and delicately balanced patients in Neurosurgery, we do not discharge them from the hospital until the patient’s neurological and other systemic condition has reached a stable and optimal level. When sending them home, we explain in detail what may happen and what they should do, we remain in contact with these patients, and we call them back to the hospital for check-ups at frequent intervals. Although not very frequent, headache, nausea and vomiting, changes in consciousness, seizures, weakness in the arms and legs, etc. are the signs and symptoms these patients must definitely report to us. However, a behavior pattern we see very often in practice is that these patients become almost dependent on us. Even after years have passed, and even in completely unrelated situations such as a flu-like infection, they feel the need to consult us. This allows many problems to be addressed before they even emerge.

What should the patient pay attention to?

The point that patients must never forget is this: a new page has opened in their lives, and even the smallest detail must not be disregarded when making plans, nor should the illness and surgery they have gone through be ignored. A regular life, a pursuit maintained with interest and love, always staying in contact with their physicians, and not neglecting their periodic check-ups are points we insistently emphasize.