Stroke: Overview of Hemorrhagic Stroke and Ruptured Aneurysm
Guest: Dr. Raymond Turner – Neurosciences, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Raymond Turner, who is an instructor in the Department of Neurosurgery and Radiology here at the Medical University of South Carolina. Dr. Turner, in this podcast, let’s talk about aneurysms that occur in the brain. First of all, what is an aneurysm?
Dr. Raymond Turner: Thank you for having me, Dr. Austin. An aneurysm in the brain is a weak spot on a blood vessel, much like an outpouching of a garden hose, or a tire, that you can see. The problem with brain aneurysms isn’t so much that they occur, but when they rupture. When they rupture, nearly half the patients die before they make it to a hospital. And of those that make it to a hospital, half of them are severely disabled; they can’t return to work. So, an aneurysm in the brain, when it’s unruptured; or hasn’t bled yet, isn’t too much of a problem, and usually doesn’t have any symptoms associated with it.
Dr. Linda Austin: So, a person wouldn’t even know that they had such an aneurysm until it ruptured, correct?
Dr. Raymond Turner: That’s correct. Most of the patients that come to our clinic with an unruptured aneurysm have had an MRI or CAT scan for some other reason; headaches. They were in a car accident and had a head trauma, and this was found by accident.
Dr. Linda Austin: Those that do make it to the ER with a rupture, what are the presenting symptoms, usually?
Dr. Raymond Turner: The symptom of bleeding from an aneurysm is the worse headache of your life. It comes on all of a sudden. A lot of times, it’s followed by dizziness, confusion, or loss of consciousness. Patients often continue to have headaches from this bleeding episode for many months afterwards. So, the most common symptom is a severe headache; the worse headache of your life.
Dr. Linda Austin: Now, there are a couple of different kinds of stroke. We usually think of a stroke as occurring in somebody who may have hardening of the arteries; an older person, but the sort of stroke you’re describing now is a very kind of stroke, correct?
Dr. Raymond Turner: That’s exactly right. There are two types of stroke. One is where you’re not getting enough blood to the brain, or an ischemic stroke. The second type is when there’s bleeding into the brain, or hemorrhagic stroke. An ischemic stroke can be caused by all sorts of different problems, such as narrowing of the blood vessels in your head or neck, or having something dislodge from your heart and go up to your brain and block a blood vessel. The other type of stroke, a hemorrhagic stroke, can happen when a blood vessel breaks in the brain due to a blood vessel that’s abnormal or from an aneurysm; a weak spot, on the blood vessel. The patterns of blood in the brain are very different. Whether it bleeds into the brain or into the spaces around the brain helps us determine the source of the hemorrhage.
Dr. Linda Austin: What age, typically, are patients who have the hemorrhagic stroke; the bleeding stroke?
Dr. Raymond Turner: Most patients are a little bit older in life, 50, 60, 70 years old; just like the ischemic stroke group, generally the elderly population, retired population.
Dr. Linda Austin: What’s the youngest, though, that you’ve ever seen the bleeding kind of stroke occur in?
Dr. Raymond Turner: We’ve seen it in newborn babies. So, it can happen at very young ages, but it’s extremely rare.
Dr. Linda Austin: How about the other kind of stroke, the ischemic stroke? What’s the youngest you’ve ever seen have that sort of stroke?
Dr. Raymond Turner: The youngest person I’ve seen with an ischemic stroke was 12 years old. She injured her neck and the blood vessel broke and blocked off blood to her brain.
Dr. Linda Austin: I see. When a person comes to the hospital with that fierce headache, what is the first thing you, as a neurosurgeon; or the neurologist seeing that patient, would do?
Dr. Raymond Turner: The first thing we want to do is make sure the patient is stable; that their airway is protected, they’re breathing okay, and their blood pressure is okay. Once the patient is stabilized, we’ll get a CAT scan of the brain. Oftentimes, we don’t know that they’ve had a bleeding episode or if the headache is from some other cause.
Dr. Linda Austin: And your treatment, obviously, would depend on that?
Dr. Raymond Turner: That’s exactly right. The treatment for a headache depends on the source of the headache; whether it’s from a bleeding episode, a migraine, or another cause of headache.
Dr. Linda Austin: So, TPA, for example, would be used for an ischemic stroke. But, since it keeps the blood from clotting, it sounds like it would be the last thing you’d want in a hemorrhagic stroke. Is that right?
Dr. Raymond Turner: That’s exactly right. We don’t want to use any clot-busting medications in somebody who’s had a hemorrhagic stroke. As a matter of fact, we want to keep their blood pressure down to try to reduce the risk of them bleeding again. And we want to get them treatment as urgently as possible.
Dr. Linda Austin: So, if it is a hemorrhagic stroke, or bleeding, stroke, and you determine that by a CAT scan, what do you do next?
Dr. Raymond Turner: The next thing we’ll do is a special CAT scan, called a CT angiogram (CTA), and that’s going to show us the blood vessels of the brain. That will help us determine if an aneurysm is the source of bleeding, or a collection of abnormal blood vessels; called and AVM, or if it’s just a typical hemorrhagic stroke that we see in the elderly population, due to weakening of the blood vessels and abnormal blood vessels.
Dr. Linda Austin: And, how does that determination guide what you do for treatment?
Dr. Raymond Turner: We first need to determine if it’s a bleeding episode into the brain: Do we need to go in and take the blood clot out? Is it causing a lot of pressure on the brain around it? If it’s bleeding from an aneurysm, we need to secure the aneurysm so it can’t bleed again. And if it’s bleeding from another source, a lot of times we just need to supportively care for that patient, to get them through it, as that blood gets reabsorbed into the body.
Dr. Linda Austin: Now, if you decide to treat surgically, what are your choices?
Dr. Raymond Turner: Well, if it’s an aneurysm, there are two options. One is to make a small window in the bone and split the spaces between the brain; we’re not actually going through the brain, but around it, to find the blood vessel, or the aneurysm, that bled. Then, we can put a small surgical clip on it. By putting the clip on the aneurysm, blood can’t flow through it [the aneurysm] anymore. Therefore, it can’t bleed again. The other option is to go from within the blood vessel. So, we go into a small artery over your hip, take a small tube, or catheter, up to the brain, up to where the aneurysm is, and pack the aneurysm off from the inside. By packing it off with small platinum coils, blood can’t flow through the aneurysm anymore and, therefore, the risk of it bleeding again goes down dramatically.
Dr. Linda Austin: We did another podcast in this series. Dr. Turk did a podcast with me on coiling as a procedure. So, let’s focus a little bit more on clipping as a procedure. What would make you decide to use the clip, going from the outside? I guess if you think of a garden hose, it would be like putting a big clamp on the outside of the garden hose, as opposed to going through the garden hose. What do you think about, as a surgeon?
Dr. Raymond Turner: As somebody who can do both, I look at it the age of the patient, how sick or healthy they are: Can I get them through an open surgery safely? Or, can I get them through an endovascular, minimally invasive, surgery safely? I look at where the aneurysm is, how easy it is to get to from within the blood vessel or through an open surgical approach. I also consider the anatomy of the aneurysm itself: Are there blood vessels coming out of that aneurysm. And if there are, am I going to include those blood vessels by either putting a clip on the aneurysm or packing the aneurysm with coils? The last thing I want to do is give the patient more problems than they already have, so I want to do what’s going to be the safest, most effective, treatment for that patient.
Dr. Linda Austin: It sounds very complex, and it sounds like the kind of decision you have to make very quickly as well.
Dr. Raymond Turner: Yes. But, fortunately, here, at MUSC, we have a team of people that specialize just in this type of problem. We have doctors that are experts in just open surgical treatment of aneurysms. We have people that are experts in just treatment of aneurysms through the inside of the blood vessels. And we have people that do both. So, whenever a patient comes in with a bleeding episode, it’s an urgent decision that needs to be made but, fortunately, with technology nowadays, we’re able to discuss things as a team and come up with the best treatment option for that patient; whether it’s coiling the aneurysm or clipping it.
Dr. Linda Austin: Dr. Turner, I know that you’re relatively new here at MUSC, having come from Cleveland Clinic. We’re thrilled to have you here. You, obviously, bring a lot of skill and expertise to our neurosurgery team.
Dr. Raymond Turner: Thank you very much, Dr. Austin.
Dr. Linda Austin: Thanks for coming.
Dr. Raymond Turner: Thank you.
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