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Brain Aneurysm: More Than Just a Headache

Online Health Chat with Andrew M. Bauer, MD and Ryan McTaggart, MD

Wednesday, April 9, 2014


Headaches are a fairly common occurrence but experiencing a sudden, severe headache could be a sign of a more serious, life-threatening condition. Up to six percent of the population could be living with an unruptured brain aneurysm, while an estimated 300,000 people will experience a brain aneurysm within the next year. The key to overcoming a brain aneurysm is early detection and interventional treatments.

A brain aneurysm is an abnormal bulge in a brain artery that develops where the blood vessel wall is weakened. It is not clear why brain aneurysms form, but researchers believe smoking, severe traumatic head injury, family history, Ehlers-Danlos syndrome, polycystic kidney disease, Marfan syndrome, infections and high blood pressure are factors that contribute to their development. Anyone over 25 years old is at risk of having a brain aneurysm, but they are most commonly found in people between the ages of 40 to 60 and more so in men.

There are several scans that can help detect a brain aneurysm, but it is most often discovered after it has already ruptured. There are usually no symptoms prior to this incident and if undetected, the aneurysm can rupture and leak blood into the pace around the brain, causing a stroke. Signs of a ruptured brain aneurysm include severe headaches, stiff neck, drowsiness, nausea, vomiting, mental confusion, and dizziness.

Brain aneurysms can be prevented through lifestyle changes. Not smoking, exercising daily, eating a balanced and low fat diet, getting help for drug and alcohol abuse, and controlling high blood pressure are some of the preventative measures that can be done to avoid developing a brain aneurysm.

About the Speaker

Ryan McTaggart, MD is an associate staff physician at Cleveland Clinic Florida-Weston Department of Radiology and the Cerebrovascular Center. Dr. McTaggart’s specialty interests include brain (cerebral) aneurysm and their microsurgical treatment, arteriovenous malformation, carotid and intracranial angioplasty and stenting, carotid artery disease and stenosis, cerebrovascular disease, dural arteriovenous fistulas, stroke, and other cerebrovascular disease states and treatments.

Dr. McTaggart completed fellowships in interventional neuroradiology and diagnostic neuroradiology at Stanford University Medical Center, in Palo Alto, Calif. He completed his residency in diagnostic radiology at Warren Alpert Medical School of Brown University Rhode Island Hospital, in Providence, RI after completing an internship in general surgery at University of California-San Francisco School of Medicine, in San Francisco. Dr. McTaggart completed medical school at Columbia University College of Physicians & Surgeons, in New York.

Let’s Chat About Brain Aneurysm: More Than Just a Headache

Moderator: Let's begin with your questions.

Characteristics of Aneurysms: Size and Location

LCF: What size aneurysm is considered more dangerous than others?

Ryan_McTaggart,_MD: Size and location are important. We stratify aneurysm rupture risk into those aneurysms measuring less than 7 mm, 7-12 mm, 13-24 mm, and 25 mm and larger. Aneurysms in the front of the brain (anterior circulation) are at less risk for rupture than those in the back of the brain (posterior circulation). In very general terms, once an aneurysm hits 7 mm in size in the anterior circulation we start to worry. Aneurysms in the posterior circulation are at greater risk for rupture so we worry about them when they are smaller than 7 mm. For example a 13-24 mm aneurysm in the anterior circulation has the same five-year rupture risk as a 7-12 mm aneurysm in the posterior circulation, which is 14.5 percent (or roughly three percent per year).

Posterior Aneurysm Symptoms

Ann: Upon receiving the results of CT scan to rule out stroke, I learned that I have a brain aneurysm in the back of my brain. My doctor said that this is not uncommon. Are there symptoms I should be aware of, in case it becomes problematic?

Andrew_M._Bauer,_MD: The recommendations depend entirely on the location of the aneurysm, its size, your age and other risk factors. Small aneurysms we generally watch with serial CT scans. However, if it is indeed in the "back of the brain" or posterior circulation, we would be more likely to recommend treatment if it is possible. Aneurysms generally don't cause any symptoms unless they are very large (then they may cause headaches or sometimes stroke-like symptoms). Ruptured aneurysms classically give you the "sudden onset of the worst headache of your life". If you ever get something like this, you should seek medical attention immediately.

Aneurysm and Arteriovenous Malformation

Margaret: I had an arteriovenous malformation (AVM) that bled in 1988 and was removed. I was diagnosed with three small aneurysms in November 2013. I would like to know about the time factor for an aneurysm's bleeding. The AVM was diagnosed in 1971, and I hope to be that lucky with the aneurysms. Other than the headache, what other signs or symptoms can I look for or expect?

Andrew_M._Bauer,_MD: Aneurysms in patients with AVMs are slightly different than normal sporadic aneurysms. Generally, these are related to the high blood flow that is going to the AVM. Sometimes, after I treat an AVM, the aneurysms actually go away on their own. Given the long period of time between your AVM surgery and the diagnosis of the aneurysms, I would have to think that these are not related. I generally watch very small aneurysms with imaging yearly. In someone with your history, I would likely watch every six months for at least a year or two. I worry more about patients with a strong family history of aneurysms or patients who have multiple aneurysms. The risk of rupture of an AVM is roughly four to six percent per year, while the risk of rupture of a small aneurysm is far less than one percent per year. Whether these should be treated or not, depends on their size, location, and your age. The aneurysms will not cause you any symptoms unless they rupture, and in that case they will cause you a headache ("the worst headache of your life"). However, you had a ruptured AVM, you may have already experienced this before.

Margaret: I am 68 years old and fairly healthy, despite the AVM and stroke in 1988. I will see Dr. Aziz in November for a CT scan and office visit. Do you think I should see him before then?

Andrew_M._Bauer,_MD: I think November is reasonable. There really isn't any science to when or how we make our follow ups. I tend to scan yearly for a few years until I am getting comfortable that the size is stable, and then lengthen it out to every two to three years or five years in some patients.

Aneurysm Recanalization

val: Please discuss the possibility and percentage of recanalizations after the aneurysm is repaired using coil embolization (five years or 10 years out).

Ryan_McTaggart,_MD: Aneurysm recanalization depends on multiple factors including the size of aneurysm, the size of the neck of the aneurysm, the amount of coils originally placed within it, whether a stent was used, etc. Recanalization will typically occur within five years. Even if a recanalization occurs, they don't always need to be treated. As technology has advanced recanalization is becoming less of a problem and flow diverters may even eliminate it.

Incidence of Future Aneurysms

jimed: I had surgery for a brain aneurysm on the right side front of the head. What is the likelihood of me getting an aneurysm in another part of my brain? I am 78 years of age.

Ryan_McTaggart,_MD: When was your original surgery? The answer, in part, depends on the time interval between that surgery and your current age—as well as your risk factors for aneurysm formation hypertension, smoking, etc.

Hereditary Brain Aneurysms

nicki: I would like to know if brain aneurysms are hereditary. My father died of one. My mother had one that left her paralyzed on the right side, but did not die until two years later of a heart attack. Because of these occurrences, my brother was tested, and was found to have one. He had surgery for it. My father's aunt had one. Am I the next one to have one?

Ryan_McTaggart,_MD: A lot of what we know about screening for aneurysms comes from the Familial Intracranial Aneurysm (FIA) Study that was published in the Journal of Neurosurgery in 2008 and in Stroke 2009. Patients in that study had relatives with intracranial aneurysms and patients that had hypertension and/or smoked were screened with MR angiography. Those patients had a greater frequency of brain aneurysms and a higher rupture risk than patients without a family history. Based on your description your family meets FIA criteria, and I strongly recommend you have a screening magnetic resonance angiogram.

Cormorant: I have three aneurysms (ascending aorta, descending aorta and at the diaphragmatic hernia (hiatal hernias). I am 62 years old, exercise regularly, never smoked, eat healthy and do not have high blood pressure. I am five foot two inches tall and weigh about 124 pounds. I do take statins as naturally my total cholesterol is slightly above 200 although my HDL is also high. I get classic migraine headaches and have arthritis. My father's family had various forms of heart disease. Is it possible that I could also have a brain aneurysm? How should I have this checked out, (if you think I should have it checked out? What can I do, if anything, to prevent it from bursting?

Ryan_McTaggart,_MD: It is very reasonable that you are concerned. A lot of what we know about screening for aneurysms comes from the Familial Intracranial Aneurysm (FIA) Study. Patients in that study had relatives with intracranial aneurysms. Patients that had hypertension and/or smoked were screened with MR angiography. Those patients had a greater frequency of brain aneurysms and a higher rupture risk than patients without a family history. There is no study I know of that addresses a patient like you, and there are no official recommendations saying you should be screened.

Coiled Aneurysm

needtono: I had a brain aneurysm in May 2004 in the basal area of the brain that was coiled. Six months later, I had a follow up cerebral angiogram that showed all was well. After rehabilitation I was able to return to work with no lasting effects. Should I have any more follow-up angiograms or some other type of examination after a 10-year period? Also two other members of my family have had aneurysms as well.

Ryan_McTaggart,_MD: There is no agreed upon follow-up screening program for coiled aneurysms. It depends on whether a patient has one aneurysm or multiple aneurysms and other factors that have a relationship with recanalization and durability.

It is typical to do a follow-up angiogram at six months. I like to also obtain an magnetic resonance angiogram (MRA) at the same time, so I have a noninvasive test to match exactly what I saw at the time of the angiogram. I will then follow with MRA at a frequency that depends on what my suspicion is for recanalization is (aneurysm size, neck width, initial packing density, if the patient smokes, etc.) It sounds like your living family members should be screened for intracranial aneurysms. MRA will suffice to detect new (de novo) aneurysms you might form, which is rare in adults.

Headaches After Cervical Fusion Surgery

lin: I suffer from chronic back pain and have had three cervical fusions. I never had headaches until a little over a year ago. I had a CT head angiogram done and they found a tiny aneurysm. When I asked about it, they said not to worry and that many people have these and just don't know about it. Is this something that should be followed up periodically? I have an appointment coming up for my headaches. They are horrible and are almost constant. Sometimes it just hurts to hold my head up. My vision has decreased, my neck and shoulders hurt, and I also have some nausea. It even hurts just touching the top of my head. Light and sound does not bother me. Nothing seems to relieve the pain. Since they are constantly present, I doubt they are due to the aneurysm, but should I be concerned? I am trying to make it to my appointment without going to the ER first for this.

Andrew_M._Bauer,_MD: I am sorry to hear about this. I expect that your neck and head problems are more likely related to your previous cervical surgeries and problems there. Aneurysms do not tend to cause headaches unless they are ruptured, very large or closely related to the bone of the skull base. They do not cause the type of headaches you are describing. In my practice, I follow very small aneurysms (less than 7 mm) with periodic imaging (either CT angiography or MR angiography) likely on a yearly basis for a little while and then extending it out if there is no issue. If it grows, it would be an indication to treat. Very small aneurysms have a very low rupture risk, likely far less than one percent per year. Growing aneurysms have a risk slightly higher than this, somewhere around 2.5 percent per year.

Magnetic Resonance Angiography

Vaughan: I have had two magnetic resonance angiography scans (as inpatient procedures with an interventional radiologist) of my three aneurysms in the past three years. My aneurysm is on the left front, right front and very low in the back of my head. I am 73 years old. I am concerned with continuing them because of risk involved in the procedure. I was unaware that the test itself was risky. What is the risk of further angiograms vs. risks of rupture?

Ryan_McTaggart,_MD: MRA is a safe procedure performed in an MRI machine. Are you asking if you should have a catheter-based cerebral angiogram? If so, it would depend on the exact size and location of the aneurysms you describe, your general health, and the qualifications of the person suggesting that you have the angiogram, etc.

Imaging Aneurysms

Rse: I have a bicuspid aortic valve (BAV) with a mildly dilated aorta. I also have Ehlers-Danlos syndrome. Recently I had two episodes of vision loss in my right eye diagnosed as amaurosis fugax. They did a brain magnetic resonance angiogram (MRA) that showed two normal right middle cerebral arteries with hypoplastic right A1 ACA segment, but no aneurysms. I have been told to stay on one 81 mg aspirin a day. Recently I woke up with a terrible headache in the middle of the night. I took two aspirin and just sat upright in bed for about 10 minutes. It finally passed. It really scared me because it was so intense. I was out of state so I called the doctor and they said if I had it again to go in, but I have not. Is this a concern and should I have more testing done? If so, what kind? I have had the carotid artery test which was good. I know that BAV and hypoplastic A1 segment puts me at a greater risk of aneurysms. Could there be small aneurysms that are not being detected?

Ryan_McTaggart,_MD: Your question is a great “lead-in” statement about how do you image aneurysms. You can image aneurysms with MR angiography (MRA) with no radiation, CT angiography (some radiation) and conventional (catheter-based) angiography (some radiation). By far conventional catheter-based angiography is the best test for cerebral aneurysms followed by CTA and then MRA. MRA typically has trouble with aneurysms smaller than 2 mm, but an argument can be made against detecting something that small because the rupture risk is small. We typically use CTA and MRA as screening tools and then formally characterize aneurysms being considered for treatment with catheter-based angiography. New (de novo) aneurysms form far more commonly in children than adults, so if you have had a negative MRA you should be reassured. A follow-up study may be indicated based on your risk factors but there is no good data to say what the time interval should be.

Antiplatelet Medications and Aneurysms

cami: For people with underlying vascular disease (vasculitis, fibromuscular dysplasia (FMD), etc.) and known aneurysms, what is the “trade off” on being on anticoagulation (aspirin, Plavix® (clopidogrel), Coumadin® (warfarin sodium) or heparin) therapy? It seems like a “catch 22”— either you keep the pressure down in hopes of preventing rupture, or you take your chances of bleeding to death if it does rupture? Does that change whether you would recommend interventions such as stenting?

Ryan_McTaggart,_MD: There is no study that prospectively compares people with ruptured aneurysms on anticoagulation and antiplatelet therapy vs. those that are not. However, researchers (most recently the group at Boston University) have looked at the patients that presented with aneurysmal subarachnoid hemorrhage (SAH) on these agents and found no increased risk. It makes sense that you would bleed more on these agents. In general terms, the protective effect of the drug probably outweighs the risk of an aneurysm bleeding while on it. In fact, there is some data to say you are less likely to rupture an aneurysm on aspirin, but the data is controversial.

Interventional Radiology and Endovascular Procedures

LucyintheSkies: What types of procedures does an interventional radiologist perform in regards to aneurysms?

Ryan_McTaggart,_MD: Interventional neuroradiologists perform endovascular procedures (procedures from within the blood vessel) to either definitively (curatively) treat aneurysms or adjunctively (in combination with another procedure) treat aneurysms. These endovascular procedures include coil embolization (definitive), balloon-assisted coil embolization (definitive), stent-assisted coil embolization (definitive), flow-diversion (definitive), balloon-test occlusion (adjunctive, and prior to vessel occlusion or surgical bypass) or parent vessel occlusion (definitive). In addition, patients that present with aneurysmal subarachnoid hemorrhage may develop vasospasm (spastic irritation of the blood vessels by the blood that initially leaked from the aneurysm). The interventional neuroradiologist may be required to treat the vasospasm with intra-arterial vasodilators and balloon angioplasty (usually more durable). People who treat aneurysms endovascularly may be called interventional neuroradiologists, endovascular neurosurgeons, neurointerventional surgeons or interventional neurologists.

Treatment of Small Aneurysms

Jimtr: In 2008, doctors found that I have an unruptured aneurysm in the Circle of Willis measuring 6.5 mm long by 3 mm high. My follow-up scans in 2009, 2010 and 2011 showed no change. No scans have been done since, and no other aneurysms were found. I am a 75-year-old male. My cholesterol is under control with medications. I am also on Proscar® (finasteride) and 81 mg aspirin. Do not smoke or drink, but drink 10 eight-ounce cups of caffeinated coffee per day. I have mild sleep apnea, and a CPAP (continuous positive airway pressure) device was prescribed, but I do not use. I do mild exercise consisting of yoga and walking 90 minutes per day seven days per week. I have no family history of aneurysm. Please comment on any of above and advise whether watchful waiting is recommended.

Andrew_M._Bauer,_MD: It sounds like you are doing all the right things in terms of your health. This aneurysm is small by our standards. Generally, for aneurysms less than 7 mm watching them with serial scans is reasonable depending on the risk of treatment. The risk of rupture is not zero, but it is less than one percent per year. I usually watch them with CT scans yearly for a few years, then stretch them out to every two to three years once we have established that there has been no change. It does not sound like you have any high risk features (previous rupture, family history, etc.) that would make me more concerned.

Niko: I have a unruptured right distal middle cerebral artery aneurysm (4 mm distal to middle cerebral artery [MCA]) at M2-M3 branch junction on right). This was found when I went to the hospital with double vision and they did a MRI. Since I have patent foramen ovale (PFO), paroxysmal supraventricular tachycardia (PSVT) and an irregular heart, is it best just to wait and see rather than try to repair it? I have a lot of pain in my neck and the back of my head, but they have not found a cause for this.

Ryan_McTaggart,_MD: Many aneurysms are discovered incidentally as your aneurysm was. Your aneurysm is in the front of the brain (anterior circulation) and measures less than 7 mm. Based on our best data from the International Study of Unruptured Intracranial Aneurysms (ISUIA) your rupture risk is 0.069 percent over five years. Assuming you have no family history of ruptured intracranial aneurysms it would be a good choice to follow this aneurysm and watch it with MR angiography or CT angiography. Please keep good control of your blood pressure and do not smoke.

Niko: You said that you do not usually operate unless an aneurysm is 7 mm. Mine is 4 mm, and they said that anything over 4 mm they would consider going in. Could this be because mine is in a small vein rather than a large artery? Also, I heard they are using glue to treat wide-mouth aneurysms when coils will not work.

Andrew_M._Bauer,_MD: The general rule is not to operate on aneurysms measuring smaller than 7 mm, which comes from the ISUIA study. While the cutoff they used in the study was 7 mm, a more recent study used 10 mm. Both studies showed that the risk of rupture of these aneurysms was very low, but not zero! I do treat aneurysms less than 7 mm fairly often, and I have seen small ruptured aneurysms as well. The aneurysms we are talking about are always on arteries, not the veins. I always consider treatment if the risk of treatment is low. Ideally, you want the risk of treatment to be lower than the risk of rupture. There are a few types of glue (Onyx®) that can be used for treatment of aneurysms, but I would only consider this in special circumstances. It is rarely used in the United States today.

MagTed: I was diagnosed with a cerebral aneurysm that was confirmed by magnetic resonance angiography (MRA) in December 2013. I had the test due to headaches from a fall that I sustained in September 2013, but I was told the fall was not the cause of the aneurysm. I was advised that surgery was not indicated due to the risk of surgery being greater than the rupture and to follow with an MRA in one year. In March 2014, I had a second opinion and the conclusion was the same—only follow up should be done every six months. I had an episode of dizziness, but took Benadryl® (diphenhydramine) and it subsided in a few days. I was told by both doctors that severe headache would be the symptom of rupture. I am fairly healthy 76 year old with a history of hypertension. I am on medication and my blood pressure is 120-130/70-86. I have a history of pulmonary embolus (PE) 10 years ago and deep vein thrombosis (DVT) in my left calf in June 2013. My clotting factors have been negative. I would like your opinion.

Andrew_M._Bauer,_MD: Very small aneurysms (less than 7 mm) have a very low risk of rupture (less than one percent per year). I generally follow this size of aneurysm yearly for a few years, and then extend this follow-up to every two to three years if there is no growth. Growth might be an indication for treatment. I watch more frequently in patients who have a strong family history of aneurysms or subarachnoid hemorrhage, or those who have had previous aneurysms. At your age of 76, the cumulative risk of rupture over the rest of your life is quite low, and certainly surgery and recovery are more difficult as we age. It sounds like you're doing an excellent job with the control of your medical risk factors.

Treatment of Aneurysms in Posterior Circulation

grandnana: My 42 year-old daughter was diagnosed with an aneurysm of the P2 segment of the left posterior cerebral artery measuring 0.8 cm in the AP direction, 0.6 cm from left to right, and 0.7 cm in the craniocaudal direction. The aneurysm appears focal and fusiform, but may have a saccular component. She was evaluated at Rush University Hospital in Chicago. Prior to her angiogram both the coil procedure or a stent placement were discussed. However, after the angiogram the doctors are recommending waiting for six months and retesting. The doctor is concerned about the risks and it sounds like he has done only one other procedure in this area. Does this sound reasonable?

Andrew_M._Bauer,_MD: Aneurysms in the posterior circulation (posterior cerebral artery counts here) can be a bit tricky. This is near the brainstem, so if there are any complications, the consequences can be quite devastating. The treatment depends entirely on the anatomy of the aneurysm. We worry a little more about these because they have a slightly higher risk of rupture than aneurysms in the anterior circulation. Fusiform generally means that the entire vessel is abnormal, and this often requires some complexity to the procedure. Stenting can be quite successful and the newer stents are easier to use for a specific purpose and possibly better at treating these. The surgical options generally require a bypass procedure where we use a blood vessel from the scalp to supply the artery with the aneurysm (in this case the posterior cerebral artery) so the segment of the artery with the aneurysm can be sacrificed without the patient having a stroke. This is a technically challenging procedure that should be done by someone experienced with these types of issues. Given her age I would likely recommend treatment one way or another, but would need to see the angiogram to determine exactly what would need to be done.

grandnana: You said that you felt you would most likely recommend treatment. Have you treated aneurysms in this area and how many have you treated?

Andrew_M._Bauer,_MD: I have treated aneurysms in the posterior circulation before. First, they make up only about 10 percent of all aneurysms, so they are not common. The largest number of cases that was ever published in the medical literature is about 1,700 aneurysms over the entire career of three very busy neurosurgeons. The options for your daughter depend entirely on the anatomy of this particular aneurysm. Surgically I would say I treat between five to 10 of these per year. Dr. McTaggart, who does endovascular management, probably does more than this when you consider normal or "berry" aneurysms. Endovascular management of these is very common. The "fusiform" nature of the aneurysm that you mentioned though is what makes it a little tricky. Most of the aneurysms we treat in the posterior circulation are berry aneurysms. The fusiform ones are more rare, I would say we see about five per year at Cleveland Clinic.

yol: I am 59 years old and a nonsmoker. When my aneurysms were found in 2005, it was for checking into the reason for a headache that I seriously thought I was not going to survive. I have not had one like that again. However, I have not been offered magnetic resonance angiography (MRA) nor cerebral angiogram. The CT scans clearly state that the aneurysms are in the posterior, Circle of Willis, carotid artery and communicating artery.

Ryan_McTaggart,_MD: I recommend you seek consultation with either myself or one of my colleagues. I am happy to review your existing imaging with you and help you determine how best to proceed. At the age of 59, you need a clear plan of action.

Pipeline™ Embolization Device

Weather Guy: How many Pipeline™ embolization procedures have been conducted at Cleveland Clinic? What, if any, complications have occurred? What are the possible side effects, and what is the risk probability for this procedure? How long is the procedure and what is the recovery time?

Ryan_McTaggart,_MD: I recently joined Cleveland Clinic from Stanford University and can only comment on my own experience of 35 procedures at both institutions. The Pipeline™ Embolization Device (PED) is one type of flow diversion device, but is the only one currently FDA approved. Aneurysms that are not candidates for traditional open surgery or coil embolization are considered for Pipeline™ reconstruction. Major morbidity and mortality (illness and death) from the procedure is about 10 percent according to the published medical literature, but my own experience is less than that. The PED demands good judgment and experience (you have to be certified to use it). While a surgeon can perform a perfect procedure with this device, there are still risks that are associated with placing a bare metal stent of this kind in patients (clots can form on it) as well as patient’s prescribed dual anti-platelet therapy (bleeding complications can occur). At Cleveland Clinic we do special platelet function testing (with the gold standard test of platelet aggregometry) to be sure patients are responding to the dual anti-platelet medications, and less likely to form clots when the device is placed. We aim not to overmedicate patients who are at risk for bleeding. The procedure typically requires an overnight stay in the intensive care unit (ICU), so frequent neurology checks can be performed. Discharge is usually the day after the procedure. The procedure can vary from one to four hours depending on the difficulty and number of Pipeline™ devices required for the aneurysm repair.

Onyx® HD-500

aslycy: Do you recommend the Onyx® HD-500 procedure for a 7 mm aneurysm?

Ryan_McTaggart,_MD: I do not use Onyx® HD-500 and it is only rarely used. I have not really found a compelling reason to ever use it.

Side Effects of Surgery

marilyn: I was misdiagnosed for five months with a leaking brain aneurysm. I suffered excruciating pain during that whole timeframe and became bed ridden. My brain aneurysm finally ruptured in May 2012. I should have died, but didn't. After five hours, I was at a second hospital that finally put a hole in my head and transported me by Life Flight me to Indianapolis. I have coils and shunts. I have developed neurological problems (twitches and jerks) that are worse when I am stressed. Is this common? Also, my head still hurts where the surgery was. It sometimes feels tight. Is this common? This was behind and below my right ear. I supposedly have a second located directly in the center of my brain that they are monitoring. Is this common? I don't smoke or drink. I cannot find anything that tells me why this is happening and how to prevent them. Do I need to avoid stress?

Andrew_M._Bauer,_MD: It sounds like you have had a rough course. Although I don’t exactly understand your history, let me try to answer your questions. The twitches and jerks could be from a number of different things. After severe injury, some patients develop jerks we call myoclonus. I am not sure if that is what you are describing or not, but it may be able to be helped by a good neurologist. After surgery it is common to have unusual sensation around the site of the surgery, this often represents the healing process. I am not entirely sure about the pain. If you have a second aneurysm, the decision to treat depends entirely on the location, size and risk of treatment. I am fairly aggressive in patients that have had one ruptured aneurysm about treating the others. This could potentially be done with either surgical clipping or endovascular coiling. If they decide not to treat your aneurysm, I would recommend following very close and treat if there is any change in size. I don't know specifically why this has happened to you. The associated risk factors that we know for sure are smoking and genetics. Most of the aneurysms that we see though are sporadic and are just there for an unknown reason. Stress avoidance is always good, but sometimes impossible—especially in your situation, but probably does not play any major factor in forming aneurysms or their rupture.

Osteopathic and Chiropractic Manipulation

jkoe: Is osteopathic manipulative treatment (OMT) advised for alleviating headache pain while considering a subarachnoid hemorrhage (SAH) as a diagnosis in the emergency room?

Andrew_M._Bauer,_MD: If subarachnoid hemorrhage is being considered as a possibility, I would hold off on any manipulations of the neck until it is ruled out. Sometimes subarachnoid hemorrhage can come from injury to the vertebral or carotid arteries in the neck, and these types of injury can be exacerbated by chiropractic or osteopathic manipulations.

Exercise with Aneurysms

cami: I am a very active 32-year old who is a 115 lb. athlete and a nonsmoker. In 2006, I was diagnosed with intimal and medial fibromuscular dysplasia (FMD) in just about every arterial bed, including unruptured aneurysms and cerebrovascular and carotid disease. I was diagnosed at Cleveland Clinic. My question has to do with activity level—I love bootcamp classes and crazy circuit workouts, but find myself timid and scared to do too much that causes an increase in cerebrovascular blood pressure. In other words, I am concerned about exercises that involve anything with an up and down or quick side to side movement of my head or a decline. Is that intuition founded? Are there any other activity modifications or restrictions that you would recommend to reduce the risk of rupture?

Ryan_McTaggart,_MD: I saw a patient just like you recently and advised her to continue to exercise and maintain an active healthy lifestyle and do what she enjoys doing. There is no data to say patients should do this and not do that. Do what you feel comfortable doing. Also, refer to our Health Chat from April 10 on FMD at


Moderator: I am sorry to say that our time with Dr. Andrew Bauer and Dr. Ryan McTaggart is now over. Thank you for sharing your expertise and time to answer questions today.

Andrew_M._Bauer,_MD: Brain aneurysms are complex to understand and often even more complex to determine the proper treatment sequence. Complicating the situation further, you would likely get different opinions about the proper treatment by talking with different physicians, depending on their comfort level with the different options. The most important thing is to be satisfied that you understand what the physician is saying to you, and that it seems like a reasonable plan for you. There are often many different options, but usually the physician you are talking to will be leaning toward one or the other. It is also important to remember, that sometimes we can make certain disease processes worse in the course of treatment. This is particularly true of things like aneurysms that in general, have a reasonably low rate of rupture. The benefits of treatment must outweigh the risks. Both surgery and endovascular management are excellent therapies for these lesions when used in the proper circumstances. All of you are already ahead of the game, seeking opinions on chats such as these.

Ryan_McTaggart,_MD: Brain aneurysms can form in patients with normal blood vessels and in patients with abnormal blood vessels. Patients with normal blood vessels who develop aneurysms are patients who have chronic hypertension, smoke, atherosclerosis, heart conditions, trauma or dissections (tears) in the blood vessels. Faulty genes may produce abnormal vessels predisposed to aneurysm formation as seen in patients with genetic disorders and in some families. Brain aneurysms are worrisome because of the high morbidity and mortality associated with their rupture. Only a minority of patients survive without any disability. The treatment of brain aneurysms is complex and the decision of when and how to treat is also complex and is based on aneurysm factors (the size, location, shape of the aneurysm, rupture status, etc.) and patient factors (general health, family history, clinical history, personal beliefs, etc.). My goal is to spend time learning about each patient and educating the patient so he or she can make the best decision. At Cleveland Clinic we work as a multidisciplinary team to offer you the best choice for your aneurysm. Your treatment options may include surgical clipping, endovascular coiling, stent-assisted coiling, balloon-assisted coiling, flow-diversion, vessel sacrifice or monitoring. Furthermore, the care we provide goes well beyond the actual procedure, and is often as important as or more important than the procedure itself. I would encourage any of you with aneurysms or questions about aneurysms to seek us out. This web chat does not substitute for a formal consultation and I would welcome the opportunity to be your doctor. At Cleveland Clinic we always aim to help patients do the right thing for them and the right way.

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To make an appointment with Dr. Andrew Bauer, or any of the other specialists in the Cerebrovascular Center at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at

To make an appointment with Ryan McTaggart, MD, an interventional radiologist or any of the other specialists in the Department of Radiology at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at

For More Information

On Aneurysm
On Cleveland Clinic

Cleveland Clinic’s Neurological Institute is internationally known for superior diagnosis and treatment of neurological disorders ranging from the common to the most complex, as well as for its major contributions to the understanding of aneurysms and cerebrovascular disease. Our highly skilled physicians are pioneers in the development of endovascular therapy and minimally invasive techniques to treat a wide variety of cerebrovascular conditions that often require unique, individualized approaches.

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Reviewed: 04/14

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