Ruptured Aneurysm

A ruptured aneurysm is a life-threatening medical emergency that occurs when a weakened, bulging section of a blood vessel bursts open and causes bleeding in the brain. This sudden event requires immediate medical attention and can lead to severe complications or death if not treated quickly.

Table of contents

• What Is a Ruptured Aneurysm?
• Warning Signs and Symptoms
• Serious Health Complications
• Who Is at Risk?
• How It Is Diagnosed
• Treatment Options
• Outlook and Survival
• Recovery and Living After Rupture

What Is a Ruptured Aneurysm?

An aneurysm is a balloon-like bulge or weakening in the wall of an artery. It forms when there is a weak spot in the blood vessel, and the constant pressure of blood flow pushes the weakened section outward, creating a blister-like bump. As the bulge grows, it becomes thinner and weaker, similar to how a balloon gets thinner and is more likely to pop as it fills with air.^[1]

When an aneurysm bursts or ruptures, it releases blood into the spaces around the brain. This space is filled with cerebrospinal fluid (a clear liquid that bathes and cushions the brain). As blood spreads and clots, it irritates the lining of the brain and damages brain cells. At the same time, the area of the brain that previously received oxygen-rich blood from the affected artery is now deprived of blood, resulting in a stroke (when blood flow to the brain is blocked or interrupted).^[4]

Most aneurysms occur on larger blood vessels at the fork where an artery branches off. Brain aneurysms can occur anywhere in the brain, but most form in the major arteries along the base of the skull.^[1][3]

Warning Signs and Symptoms

Most aneurysms do not have symptoms until they rupture. Rupture usually occurs while a person is active rather than asleep.^[4] When an aneurysm ruptures, it causes a sudden, severe headache. Some people describe it as the worst headache of their life, often called a thunderclap headache because it comes on suddenly and with extreme intensity.^[1][3]

If you experience symptoms of a ruptured aneurysm, call emergency services immediately. The symptoms include:^[1][3][4]

• Sudden onset of a severe headache, often described as “the worst headache of my life”
• Nausea and vomiting
• Stiff neck
• Blurred or double vision
• Sensitivity to light (called photophobia)
• Seizures
• Drooping eyelid and a dilated pupil (when the black center of the eye becomes larger)
• Pain above and behind the eye
• Confusion
• Weakness or numbness
• Loss of consciousness
• Cardiac arrest (when the heart stops beating)

Serious Health Complications

A ruptured brain aneurysm can cause serious health problems. When it ruptures, blood spills into the surrounding brain tissue. The blood can put excess pressure on brain tissue and make the brain swell.^[1]

The most common serious complication is subarachnoid hemorrhage, which is bleeding in the area between the brain and the thin tissues that cover and protect it. About 90% of subarachnoid hemorrhages are due to ruptured brain aneurysms. A subarachnoid hemorrhage is life-threatening with a 40% risk of death.^[1][4]

Enclosed within the rigid skull, clotted blood and fluid buildup increases pressure that can crush the brain against the bone or cause it to shift. Other complications include:^[1][3][4]

• Hemorrhagic stroke: Bleeding in the space between the skull and brain
• Vasospasm: This happens when blood vessels get narrower or clamp down and less oxygen reaches the brain. It usually occurs between 3 and 21 days after rupture. Irritating blood byproducts cause the walls of an artery to spasm and narrow, reducing blood flow to that region of the brain and causing a secondary stroke
• Hydrocephalus: This happens when a buildup of cerebrospinal fluid or blood around the brain puts increased pressure on it. Blockage of the normal cerebrospinal fluid circulation can enlarge the ventricles (fluid-filled spaces in the brain) causing confusion, lethargy, and loss of consciousness
• Rebleeding: If the aneurysm ruptures again
• Changes in blood sodium levels
• Seizures: A temporary, uncontrolled surge of electrical activity in the brain
• Delayed cerebral ischemia: One of the biggest causes of complications and death after a ruptured aneurysm. It can happen between 3 and 14 days after bleeding and causes major damage to the brain and nervous system
• Coma: A state of prolonged unconsciousness that can last days to weeks
• Permanent brain damage
• Death

Who Is at Risk?

Brain aneurysms can affect anyone and at any age. However, they are most prevalent in people ages 35 to 60. Brain aneurysms are more common in women than men, with about a 3 to 2 ratio. Women, particularly those over the age of 55, have a higher risk of brain aneurysm rupture than men (about 1.5 times the risk).^[1][7]

Up to 6% of people in the United States have an aneurysm in their brain that is not bleeding. Ruptured brain aneurysms are less common and occur in approximately 30,000 people in the United States per year. A brain aneurysm ruptures every 18 minutes. There are almost 500,000 deaths worldwide each year caused by brain aneurysms, and half the victims are younger than 50.^[1][7]

African-Americans and Hispanics are about twice as likely to have a brain aneurysm rupture compared to Caucasians.^[7]

Risk factors for aneurysm rupture include smoking, high blood pressure, drug or alcohol abuse, genetic (family inherited) factors, atherosclerosis (buildup of fatty deposits in arteries), and lifestyle habits.^[4]

How It Is Diagnosed

When a person is brought to the emergency room with a suspected ruptured aneurysm, doctors will learn as much as possible about their symptoms, current and previous medical problems, medications, and family history. The person’s condition is assessed quickly. Diagnostic tests will help determine the source of the bleeding.^[4]

Several screening tests and procedures are used to detect and diagnose ruptured brain aneurysms:^[4][8]

• Computed Tomography (CT) scan: A specialized X-ray that is usually the first test used to assess for bleeding in the brain. The test produces images that are two-dimensional slices of the brain. A CT scan is a noninvasive way to view the anatomical structures within the brain and to detect blood in or around the brain
• CT angiography (CTA): Involves the injection of contrast material (a dye) into the blood stream to view the arteries of the brain. It can create detailed images of the arteries and detect the presence of an aneurysm
• Lumbar puncture (also known as a spinal tap): An invasive procedure in which a hollow needle is inserted in the low back to collect cerebrospinal fluid from the spinal canal. The fluid is examined to detect blood from a suspected hemorrhage. If you have had a subarachnoid hemorrhage, there will most likely be red blood cells in the fluid surrounding the brain and spine
• Magnetic Resonance Imaging (MRI): Uses a magnetic field and radio waves to create detailed images of the brain. These images may be either two-dimensional or three-dimensional and can show if there is bleeding in the brain
• Cerebral angiogram: An invasive procedure in which a thin, flexible tube called a catheter is inserted into an artery and passed through the blood vessels to the arteries in the brain. A special dye injected into the catheter travels to arteries throughout the brain. A series of X-rays can then reveal details about the conditions of the arteries and detect an aneurysm

Approximately 15% of people with a ruptured aneurysm die before reaching the hospital. Despite the widespread availability of brain imaging that can detect a ruptured brain aneurysm, misdiagnosis or delays in diagnosis occur in up to one quarter of patients when initially seeking medical attention. In three out of four cases, misdiagnosis results from a failure to do a scan.^[7]

Treatment Options

A ruptured aneurysm releases blood into the subarachnoid space around the brain, creating a life-threatening type of stroke. Treatment focuses on stopping the bleeding and repairing the aneurysm. If an aneurysm ruptures, it can quickly become life-threatening and requires emergency treatment. Receiving emergency medical treatment within 24 hours gives the best chance of avoiding permanent complications.^[4]

Medical management of a ruptured aneurysm is orchestrated in the intensive care unit, with cardiac monitoring and placement of an arterial line (a thin tube inserted into an artery to monitor blood pressure). Medical approaches involve control of high blood pressure, administration of calcium channel blockers (medications that help prevent vasospasm), and prevention of seizures.^[14]

The main treatment methods for ruptured aneurysms include:^[4][10]

• Surgical clipping: An incision is made in the skin of the head and the skull is opened by removing a very small piece of bone in order to access the aneurysm directly. A small metal clip is then fastened to the neck of the aneurysm, stopping blood flow into the aneurysm. The bone is then reattached, and the incision closed
• Endovascular coiling: Currently the most common treatment for brain aneurysms. It does not require general anesthesia or opening of the skull. Surgeons access the aneurysm via a catheter inserted into arteries in the arm or groin. Treatment consists of inserting small metal coils into the aneurysm
• Flow diversion: A newer technology in which surgeons insert a stent (a small mesh tube) into the artery along the aneurysm, which significantly reduces and later blocks blood flow into the aneurysm
• Bypass surgery: May be used in certain cases to reroute blood flow around the aneurysm

Following surgical or endovascular aneurysm treatment, blood pressure is maintained at higher levels to diminish complications associated with vasospasm. If vasospasm occurs, it can be treated with induced high blood pressure alone to maintain blood flow to the brain. In select patients, medications delivered directly into the arteries or endovascular balloon angioplasty may be used to treat vasospasm.^[14]

Outlook and Survival

Ruptured brain aneurysms are fatal in about 50% of cases. Approximately 25% of people die within the first 24 hours, and 50% die within 3 months. Of those who survive, about 66% suffer some permanent deficit to the brain or nervous system.^[1][7]

As more time passes with a ruptured aneurysm, the likelihood of death or disability increases. Only about 6% to 17% of survivors return to work.^[1][15]

Up to 50% of people have permanent brain and nervous system changes that can affect their thinking and physical abilities. About two-thirds of people who experience a ruptured brain aneurysm have some brain damage.^[15][22]

Recovery and Living After Rupture

Recovery from a ruptured aneurysm can be a long and difficult process. The length of time and how much improvement will occur varies greatly from person to person. Many factors contribute to recovery time, such as where the aneurysm ruptured, if the patient experienced subsequent medical problems like vasospasm, and the kind of medical treatment they received.^[18]

It may take 6 to 8 weeks to recover from aneurysm repair surgery, and it can take months to years to regain lost function. In the best cases, patients may have minimal recovery times and no long-term effects. On the other hand, others may face longer roads with life-long challenges.^[18][22]

Brain damage may cause temporary or permanent complications such as:^[22]

• Depression and anxiety (experienced by about 1 in 5 patients)
• Headaches
• Memory loss or memory problems
• Speech problems
• Mood changes
• Personality changes or behavioral changes
• Trouble concentrating
• Trouble with balance or coordination
• Fatigue

The brain is one of the most resilient organs in the body, capable of adapting and reorganizing itself after injury. In areas where damage is too extensive for regeneration, the brain can reroute functions like speech or movement from the affected area to healthier regions. This remarkable flexibility enables new parts of the brain to take over tasks once managed by damaged sections. Recovery, however, is often a gradual process.^[18]

Survivors often face physical and emotional challenges in their recovery journey. Common physical changes may include incision pain or numbness from open surgery, slowed reaction times, groin pain from endovascular treatment, hair loss, fatigue, diminished sense of smell or taste, headaches, vision problems, lower back pain, and constipation.^[18]

Survivors of brain aneurysms often experience feelings of isolation. Many feel different and set apart from the rest of the world. Loss of control over emotions is common, meaning survivors may be prone to acting out in anger or frustration at a moment’s notice. Changes in self-esteem and self-confidence due to new physical and mental limitations are also common.^[16]

Finding a group that understands your emotions and the road through recovery is essential. There are many online support communities and physical support groups dedicated to making survivors feel accepted and part of a larger group. It is important to talk to family, doctors, and therapists about how you feel and how to adjust to the “new” you.^[16][18]

After hospital discharge, physical, occupational, and speech therapy should continue. Following definitive treatment of a ruptured aneurysm, serial imaging studies should be obtained as an outpatient to monitor the treated aneurysm.^[14]