Bulges in brain arteries can sometimes be left alone

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A person who has medical imaging done of their head may be surprised to learn that they have a weakness or a bulge in a blood vessel in their brain called an intracranial aneurysm.

Usually these cause no symptoms. Rarely, they may rupture, causing life-threatening illness for people. In this situation, there are medical decisions to be made.

I'm talking with two neurology experts from Upstate for help understanding the options. Dr. Aravind Reddy is an assistant professor of neurology, and Dr. Hesham Masoud is an associate professor of neurology, neurosurgery and radiology.

Welcome to "The Informed Patient," both of you.

Aravind Reddy, MD: Thank you for inviting us.

Hesham Masoud, MD: Thanks for having me.

Host Amber Smith: So, Dr. Reddy, do you have any idea how common this is for someone to be found to have an unruptured intracranial aneurysm?

Aravind Reddy, MD: From reviewing the (medical research) literature, it looks like the incidence of it is maybe about a little bit less than 3%, about 2.8% of people. However, I do think there is a tendency that we're detecting more of these recently as we've been doing more non-invasive imaging, like MRIs (magnetic resonance imaging) and CTAs (computed tomography angiography), and we're doing them more commonly than we used to do, like 10 or 20 years ago.

And so we're detecting more of these than previously.

Host Amber Smith: So of the ones that are found incidentally, how many go on to rupture?

Aravind Reddy, MD: For the most part, unruptured aneurysms that we detect incidentally never rupture, so like more than 90% of them will never rupture.

That gives you a sense of how likely they might be to rupture.

Host Amber Smith: Did you find any characteristics that these patients have in common? I'm thinking about age or gender or anything distinguishing about these people that have undiagnosed aneurysms.

Aravind Reddy, MD:

For example, some conditions, familial conditions or genetic conditions, tend to predispose people to develop aneurysms.

Aside from that, it looks like ethnicity plays a part in this as well. Especially the Finnish and Japanese ethnicities seem to have higher rate of aneurysm and going on to aneurysm rupture, so there are some factors that kind of go into development of aneurysm, and then there's factors that can go into a risk for rupture of aneurysm as well.

Host Amber Smith: Well, Dr. Masoud, can we talk about once an aneurysm has been detected, what do you do to assess it and try to predict how dangerous it is?

Hesham Masoud, MD: I think it dovetails very nicely into what Dr. Reddy was discussing, which is a big part of the encounter is about counseling. What is an aneurysm, just from a general structural consideration, and then that helps facilitate discussions about treatment options, but all of that is couched in the context of a risk profile assessment with this umbrella that most aneurysms that are discovered incidentally do not rupture. And so you have that as sort of the umbrella of a counseling framework. Now, with that being said, we do have these tools that allow us to create sort of assessments of risk that are really just systemic ways of going through associative findings with ruptured aneurysms or aneurysms that have been found to go on to rupture, things about morphology (structure or form), or as Dr. Reddy was talking about, family history of certain genetic disorders that may have a broader expression on the body, including the arteries, and therefore having the formation and subsequent rupture of aneurysms.

So these considerations can be put into these scoring models, and then that gives you a general rule of thumb of, OK, well, this is X percent or Y percent. And for the most part, it seems to be informed by location -- is this in the front of the brain or in the back of the brain, and size, with larger being more associated with rupture.

The other consideration, in addition to what Dr. Reddy had laid down the framework of, is: Is this aneurysm causing symptoms outside of its expression of rupture, meaning the mechanical, physical ballooning of this aneurysm against neural structures nearby may cause symptoms, a classic one being double vision that occurs suddenly in an eye that looks down and out. The other one can be -- very rarely, Dr. Reddy and I have seen -- strokes from aneurysms. And that can happen in large, sort of vacuous, structures that can have clots swirl and form in the relatively stagnant part of blood flow, and then that whisks away little bits of clot that can find other fit in the arterial tree, up in the brain, and that can cause a small stroke. Now, if that's an aneurysm that is exerting that expression of symptomatology, that would be an indication for treatment. In the same way, an indication for treatment would be an aneurysm that ruptured.

And it would really be about this thing not re-rupturing or not getting worse, as opposed to it being about getting better from the consequences of the rupture. That's a separate care path related directly with the neurocritical care and considerations of what can happen as a consequence of having had something happen from an aneurysm.

The treatment related in rupture is really about, or symptomatology, is really about stopping this thing -- you know, putting out the fire -- then assessing the damage and dealing with the fallout.

Host Amber Smith: So someone who has an unruptured aneurysm, do they need to alter their behavior or be careful? I mean, they don't wear a helmet or anything, right?

Hesham Masoud, MD: No. And see, like Dr. Reddy was saying, you've got to remember, hey, at the end of the day, this is a low-probability event. Really, if you think about it in terms of just risk profile and risk management assessments, just on a regular paradigm, it seems like the numbers are relatively anxiety free. With that being said, anything to do with the body and certainly the brain can be anxiety provoking, so what I like to do is start with a risk profile, with some numbers, because it's nice to anchor in some relative quantitative analysis of where one fits, and that can be reassuring.

And then it can be about, OK, well, you're already at this low risk. How do you further lower your risk? And that's just good health care, meaning controlling your blood pressure. Big one: not smoking, because smoke is exquisitely damaging to the arterial vessels, and this is already about weakening blood vessels, so weakening it more is just going to lead to ruptures, and then, obviously, the stroke association as well, so things about, healthy eating, lowering blood pressure, engaging in healthy decisions in your diet, and smoking or lack thereof.

That's a big part of the counseling as well.

Aravind Reddy, MD: To build a little bit on what Dr. Masoud has said, some common questions that we hear from patients are, "Do I have to be careful about certain medications I take?" or "Am I safe to go under specific procedures or anesthesia?"

And with regards to this, for patients with unruptured aneurysms, for the most part, we recommend continuing, even on their blood thinner medications, any antiplatelet or anticoagulation. If they have a reason that they're taking those medications, generally it's safe to continue taking those medications, even with the aneurysm. And then, patients also have questions about anesthesia. " Am I safe to go under for a procedure?" And, in fact, from looking at the literature, it looks like it is safe to undergo general anesthesia even with these unruptured aneurysms. So those are a couple common questions that the patients have, and I think it's good for them to know how to approach those.

Now with regard to, like you were asking also about, like, should patient be wearing helmet? I do think, for small aneurysms, generally low-risk aneurysms, those precautions aren't necessarily needed, OK.

But in someone who's engaging in high-impact activity, and with larger aneurysm or with higher-risk aneurysm, that probably deserves treatment. They should probably avoid those kinds of activities until it's actually treated and taken care of.

At least I think that would be a reasonable recommendation.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with neurologist Aravind Reddy and neurologist and vascular interventional radiologist Hesham Masoud about intracranial aneurysms that have not ruptured.

Now, before we get into treatment options for the aneurysms that do need treatment, let me ask you about the people who can live safely with an aneurysm: How would they know if it's getting worse? Are there symptoms to kind of be on the lookout for, or do they come for checkups regularly?

Hesham Masoud, MD: Generally speaking, these unruptured aneurysms are asymptomatic, so the regular checkups are related to looking at the size of the aneurysm or the shape of the aneurysm for any changes that would then change the calculus that we had going into it. Meaning (that) if we had decided that we were going to conservatively manage this because the risk profile was such that it makes sense to watch it first, then it would be OK, as long as this thing meets our criteria, meaning it is of this size, has not changed in this shape and obviously isn't causing any symptoms, then we would continue to watch it at an interval of time.

Now, typically that means annually, then it gets spread out, and the longer you have something that's stable, the less likely you are to find something change with it over time. Now, with that being said, you never stop watching someone who's had an aneurysm, be that an aneurysm that's been treated already or an aneurysm that you're watching because it's small.

And the reason for that is the system that developed the aneurysm, meaning the arteries of the brain, may, further down the course of one's life, develop a small aneurysm. That may not be an actionable one, but it would be one to know, because this is part of the paradigm of the care. In the same way that as we age, our skin may wrinkle, our arteries may sag. That actually can happen, in a sense, where maybe that's the threshold that's met before an aneurysm can form, and that may happen further down the line.

Now these things are very low probability, but it is something that we know is part and parcel of the system.

So most of the care is surveillance, with imaging, and because of the rise of telemedicine, a lot of times people can get imaging, non-invasive imaging, locally, and then have a telemedicine checkup with the specialist, who says, hey, yeah, that aneurysm looks stable. We'll see your picture next year. If it rises to the level of a counseling that requires operative considerations, I like to do things in person, certainly before the day. But again, this is mostly a process of counseling and shared decision making, which is really similar to any kind of meeting can be conducted in several different instances, as opposed to one of a care that needs to be rendered at each individual appointment or an assessment that can only be done in person. It's an imaging-based assessment, so it allows for a lot of flexibility for people to get their care and really not allow the aneurysm to be a burden on them, at least operationally, in terms of their lifestyle.

I really want to kind of realign us into the overarching theme of these are relatively low-probability events.

Having an aneurysm does not necessarily mean a sentence of any variety. And most of the time when you do engage in health care related to an unruptured aneurysm, there's not much of an engagement. It's just a follow-up and a picture you take every year, almost like a yearbook.

Host Amber Smith: Well, let's talk about the treatment options for those few patients that do need some sort of treatment.

Is it medication based?

Hesham Masoud, MD: I like to anchor it that if you do well to lower your risk profile from a medical standpoint, blood pressure, not smoking, lower your cholesterol, do these things that allow for a healthy artery, then yes, I do think that medication can be part of it.

Now, that means blood pressure medication, cholesterol medication. Now, direct one-to-one for aneurysm treatment, no. A medication certainly at this time point has not been developed to directly address an aneurysm in the form of a therapeutic regressive structural effect. But, in terms of treatment, because this is a structural problem, the treatment has a structural consideration, right?

And what's the problem with the structure? Well, in most instances, we're trying to just make it so that blood can't get inside this weak dome that is liable to rupture because it's a weak dome. So that may mean filling it up with material that will clot off, such that blood can't enter into it. And over time, when something clots off, the body will cover it with a clean surface, and no more propagation of clot will form. And so the oldest way of doing that really was just to put a clothespin, almost, for lack of a better example, across the aneurysm ballooning. And that would, essentially, surgically exclude that ballooned part of the artery from receiving any blood. Now, to do that, you would have to obviously get access from outside to inside. This means breaking the skull barrier. This is a more invasive, open-surgical thing.

I'm an interventional neurologist, so what we do is minimally invasive therapies. And this is now the shift in terms of even endovascular neurosurgery, which is just another word for this approach to go through the arteries to treat, as opposed to going outside in, you go from inside.

So all arteries are in communication to each other, and therefore they can be accessed. Arteries in the limb can be accessed to get access to arteries all the way up in the brain. And we have incredible tools that are really manufacturing and engineering marvels in and of themselves, in our ability to utilize them with very basic physical maneuvers all the way up to the brain.

And then, for instance, fill the aneurysm with coils, which are metal alloys that are inert, that allow us to slowly fill the aneurysm up in a controlled fashion under X-ray guidance and then deploy it there, leave it behind. Over time it clots off.

There are devices which are called intrasaccular devices, sac meaning the inside of the aneurysm being the sac of the aneurysm. And so these devices, similar to a coil that you deploy inside the sac, you would have this one big cage that you can potentially just put in there or something that flowers out and then seals the neck of the aneurysm.

So these cool approaches that are now demonstrative of a way of treatment that is even more minimally invasive to the healthy structures. So it's like, oh, if we would just want to fill the aneurysm, so maybe we just need to take care of the neck, and everything else will involute, meaning shrink, over time.

And so these considerations of "less is more" is what you're seeing with this idea of the endosaccular device. And less-is-more approaches are great for ruptured aneurysms that are difficult to treat because of their morphology being aggressive.

I should mention also the stents. And so there are stents that can assist with holding up coils. We would call that a stent-assisted coiling type approach. And then there are stents which are almost like Chinese finger traps in how dense they are, and sort of springy, and you can deploy that inside the artery across the neck of an aneurysm, meaning across bridging the ballooning portions of the aneurysm, so you have healthy to healthy.

And then what happens is blood doesn't really have facility to naturally, path of least resistance, go inside the aneurysm. And so it diverts flow. That's why they call these things flow diverters. Because it's a stent, which has a woven design and a relatively increased amount of metal exposure, there are considerations of blood thinners.

And so a lot of times when we're talking about treatment, when we talk about treatment complexity, we're talking about, oh, the structure of the aneurysm is such that it would lend itself to device Y, X or Z. And oh, that may require the addition of X stents, and that may mean the duration of this blood thinner.

Now, it is important to note that a lot of times people are already taking blood thinners for another reason, especially in an elderly population. So now you're adding and you're stacking on blood thinners for an elective treatment. And so you really need to anchor that in a risk profileand a value added for the patient. So everything, again, going back to a risk assessment profile and counseling, a shared decision making with the patient.

Host Amber Smith: Now, this is still technically brain surgery. There's risks, right? .

What are the risks?

Hesham Masoud, MD: Yeah, this is brain surgery. Just the approach is different.

It's from the inside in. It's a more minimally invasive, less traumatic experience. The risks are inherent to that system, so if you block off an artery. While you're trying to just block off an aneurysm, that's going to have a consequence to that part of the brain. So strokes, meaning permanent disability, rupture of the aneurysm -- the aneurysm is a fragile structure; it may decide to rupture as you are now filling it, or pressure changes across it can cause that to happen. Then that rupture is now the consequence of an aneurysm rupture. Now, luckily, the chance of risk, of procedural risk related to the treatment of an unruptured aneurysm, is lower than that of a ruptured aneurysm. However, as an elective thing of the patient's walking in, this is about a probability event that may never occur. If I say, 60% chance it might not happen, you may be in the 60%. And so you're really doing something for a future that you really never know will be borne out, except when it's really symptomatic, really large, which a lot of times it's not clear like that.

So it is this back and forth of, "Oh, well, risk tolerance related to already I'm in a bad state because I've ruptured," in which case the amount of harm added by the procedure in terms of risk tolerance is less relative, versus, "Oh no, I'm doing this electively."

Yes, patients can succumb to the treatment of an elective aneurysm. That can happen. So it can carry the risk of up to death, because at the end of the day, this is brain surgery of a vital structure, the arteries that subserve the brain.

Aravind Reddy, MD: That's a great point, Dr. Masoud, and the difference between unruptured and ruptured aneurysms and how that affects the treatment pathways, I think, very significant. For example, in a patient who has an unruptured aneurysm, generally the procedure that we do is initially a diagnostic angiogram. So that is for usually purposes of diagnosis and planning for the procedure, and then, using that information, to plan for different treatment options and different potential devices or treatment approaches.

With a ruptured aneurysm, typically the diagnostic portion as well as the treatment are done together. And so, like Dr. Masoud was saying, some of the devices, stents and so forth, may be less desirable in that setting because of introduction of metal and need for antithrombotic (anti-clotting) medication in someone who's developed an intracranial bleed.

And so, for patients or for families, I think it's important to understand the different approaches that we have for ruptured versus unruptured aneurysms.

Host Amber Smith: So, Dr. Reddy, how do you help patients decide what to do? Because I imagine this must be an unnerving diagnosis, first of all, trying to convince them that most of them don't rupture, but you still have this deformity or whatever in your brain.

So how do you help them decide what they're going to do?

Aravind Reddy, MD: It's important to help the patients, make sure they have all the information that they need about their condition before they make any decision. But ultimately, it's a decision that comes from an informed patient -- very appropriate that we have that name of the podcast as well. So the way I would do it is, I would counsel a patient based off of the information that I have from the risk stratification, using those models that Dr. Masoud had mentioned earlier.

Based off of these, we can get an estimate of what is the likelihood for this aneurysm to rupture if it's an unruptured aneurysm? And based off of that, again, we compare that to the risks of a procedure. And these can vary a little bit based off of the shape of the aneurysm and the location of the aneurysm, how accessible it could be, and then also the risk factors that the patients themselves present in terms of their own medical comorbidities (conditions). So, based off of a consideration of all of those things, we can help the patient to make the best decision. "Is this a treatment that's going to benefit me, and do I understand the risks of it?"

Hesham Masoud, MD: Yeah. I really think that a lot of times, it becomes very difficult for patients to have certainty when navigating health care decisions related to risk, where the ultimate consequence is so heavy. Brain damage is scary. Anything related to the brain is really scary.

What I've found, a lot of times, and we do this on rounds a lot, is to try to address two things that I think as humans, we all have a natural inclination to want to know about, which is what, how and who else? So, what is this, how did this happen, and who else has this, meaning "What else can I expect? What other futures have panned out that maybe I can glean some insight from and therefore empower myself with some knowledge?" And so, drawing out something really speaks volumes to people's understanding, especially when you can pull it out.

We have technologies now that allow us to give 3-D representations of it, so people can really contextualize where it is, how large it is in physical space. And then, support groups, and support groups for people who have unruptured aneurysms, meaning not patients who've had the negative consequence, but also patients who've had the rupture and have come through it. Stroke patients include patients who've had problems with the blood vessels that have related ruptures, including aneurysms, and the predominant stroke patients of the clot. But, broadly speaking, stroke patients are the most resilient patients in health care, truly, and I may be biased, but obviously, these are people who have survived the scariest event for the most important organ that we have. And Dr. Reddy and I have been so privileged to be in clinical encounters with people who have just overcome so much.

And so, I think tapping into that wealth of strength can be really nice for an initiate into the world of having to deal with this new cognitive load. This is a really powerful group of people, and connecting people, I think, is part of it. So we do have support group informational stuff at our clinic, as well.

So counseling and then the networking, I think is a big, piece of it, to help people.

Host Amber Smith: And then again, the majority of the people who get this diagnosis will go on to lead a normal life, where this won't be an issue.

Hesham Masoud, MD: That's the umbrella, right.

But then again, you want to know what's going on, and people have that reflexive anxiety because of the value of the organ. So we try to temper that.

Host Amber Smith: Well, I appreciate both of you so much for making time for this interview.

Aravind Reddy, MD: Our pleasure.

Hesham Masoud, MD: Thank you for having us.

Host Amber Smith: My guests have been Dr. Aravind Reddy and Dr. Hesham Masoud. Dr. Reddy is an assistant professor of neurology, and Dr. Masoud is an associate professor of neurology, neurosurgery and radiology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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