I was once called to the emergency department to see a man in his early thirties who had collapsed on the tennis court while serving the ball. When I got there, he told me he was experiencing the worst headache of his life and was nauseated. Although the man was drowsy, he was still able to explain what happened. He had no muscle weakness or numbness. We immediately sent him to get a brain computed tomography (CT) scan. It showed that he had bleeding around the surface of the brain in an area called the subarachnoid space. By the time he got back from the scanner, he was not making any sense. Additional testing showed he had a brain aneurysm that had ruptured.

A brain aneurysm (also called intracerebral aneurysm) is caused by a bulge in an intracerebral artery. One type, a saccular aneurysm, looks similar to a balloon filled with water or air—except it is filled with blood. In another type, the fusiform aneurysm, the artery is weak in all directions and looks like a small sausage. The saccular aneurysm is much more likely to rupture, as it had in my patient, and cause subarachnoid hemorrhage (SAH).

In this issue of Neurology Now, actress Tamala Jones tells us about her experience with SAH. Although her road to recovery was rocky, ultimately she achieved good health. My patient did not do so well: he had severe long-term disability from his ruptured aneurysm.

Thankfully, the majority of aneurysms do not rupture—about 30,000 people experience a ruptured aneurysm each year.

Before an aneurysm ruptures, there are usually no symptoms and no prior warning unless the aneurysm is large enough to put pressure on the surrounding brain. When an aneurysm ruptures, the most common symptom is a sudden, severe headache with nausea, vomiting, and other neurologic symptoms such as a decreased level or loss of consciousness.

Unruptured intracerebral aneurysms are often found incidentally when a person has a brain imaging study done for other reasons. Much research in recent years has focused on predicting which aneurysms are more likely to rupture and which will not—even over a person's entire lifetime. This information is used to counsel people with unruptured aneurysms about whether they need to have a procedure to remove the aneurysm.

The biggest risk factors for intracranial aneurysm rupture are a family history of aneurysms, aneurysm size, and cigarette smoking. In fact, several studies have shown that if you have two or more family members with intracranial aneurysms, you should be screened with a brain imaging test to see if you have an intracranial aneurysm. As our story points out, small intracerebral aneurysms have a low risk for rupturing and are usually followed with repeat brain imaging to see if they enlarge. Larger aneurysms have a higher risk for rupture, and a procedure to destroy the aneurysm is generally recommended.

The reason why not all aneurysms are treated is that the procedures done to destroy the aneurysm have risks of their own. Cigarette smoking has many bad health effects, but anyone with an aneurysm should not smoke because of the increased risk of rupture.

If you or a family member has experienced a SAH or has an unruptured aneurysm that is being followed, please try to find out if there is a family history of aneurysm; if present, be sure to discuss it with your doctor.

Take good care,

Robin L. Brey, M.D.

Editor-in-Chief