October 14, 2019

Brain Aneurysms – Silent but Often Fatal

By Apostolos “Paul” Hiotellis, MD


Hypertension, diabetes and back pain are typical conditions for which patients see their primary care physician. Having a patient walk into your office with a cerebral aneurysm, however, may not be what you’re expecting that day.

Cerebral aneurysms are present in an estimated 2 to 3 percent of the population, 90% being saccular and the majority asymptomatic. According to the National Institute of Neurological Disorders and Stroke, most aneurysms go undiagnosed before they rupture; in 25 percent of cases that involve a rupture, patients do not survive the first 24 hours. Considering that nearly a quarter of patients don’t survive, it is critical to diagnose and determine the best course of action for individuals at the brink of a rupture. You may go your entire career and never encounter such a case, or you may find one by accident while testing for other conditions. 

For the percentage of patients with undiagnosed, ruptured aneurysms, recognizing the hallmark signs and symptoms is crucial for timely life-saving care. This includes an individual experiencing a sudden, severe headache, or the “worst headache ever.” 

According to the American Heart Association, misdiagnosis occurs in about a quarter of all patients when they initially seek medical attention, and it accounts for a significant percentage of poor outcomes among consecutive cases of symptomatic aneurysms.

Without knowing what causes aneurysms or when the bleed will occur, accurate early diagnosis of an unruptured brain aneurysm is critical to avoid initial hemorrhage, which may be fatal or result in devastating neurologic outcomes. 

In the absence of the statement “worst headache of their life,” piecing together the puzzle is a more complex process requiring not only symptoms but also history and risk factors. Seeing as the only definitive and diagnostic measures require costly testing, determining the presence of an aneurysm can be a daunting undertaking. However, it is a life-saving act for a patient close to a rupture. 

Recognizing the cases that present even subtlety could mean life or death. The details that come together as you speak to the patient, and as the diagnosis begins to take shape, include family history, illicit drug use, smoking, and age. All are risk factors that should lead to more aggressive measures.

Generally, screenings are not regularly performed, but certain risk factors could provide more considerable evidence that would convince a doctor to take that step. Those include Klinefelter syndrome, polycystic kidney disease, and familial intracranial aneurysms. 

In most instances, diagnosing a cerebral aneurysm doesn’t involve a face-to-face office interaction. Often you have an unexpected phone call, in which a patient describes lateral paralysis or thunderclap headache leading you to suspect a large unruptured aneurysm. The person’s prognosis largely depends on factors such as location, size, or shape, and any pre-existing neurological conditions. 

Every patient is as unique as the cerebral aneurysm, and in these life-threating events, deciding the best course of action quickly becomes of the highest importance.

Dr. Hiotellis is a Board certified family medicine physician at TPMG Denbigh Family Medicine. He takes a special interest in the treatment and management of diabetes, cardiovascular disease and preventative medicine.  mytpmg.com