Decoding brain bleeds: evolving treatments promise encouraging results
A stroke takes place when the brain suffers irreversible damage due to a sudden interruption of blood flow. Strokes are predominantly of three types – ischemic strokes, intracerebral haemorrhages and subarachnoid haemorrhages.
An ischemic stroke is the blockage of blood vessels causing brain damage due to lack of blood flow. An intracerebral haemorrhage refers to bleeding inside the brain, usually resulting from the rupture of very small blood vessels due to high blood pressure. A subarachnoid haemorrhage refers to bleeding over the surface of the brain.
Least known, most devastating
A subarachnoid haemorrhage (SAH) is probably the least known stroke type because of its lower incidence compared to the other two, but it is also possibly the most devastating type of stroke. One of the most common reasons for a subarachnoid haemorrhage is a brain aneurysm occurring in the absence of any head injury. Before modern medical management, the mortality rates for an SAH were as high as 45% and many patients would remain disabled for life after experiencing one.
This condition gained a lot of attention recently when Game of Thrones star Emilia Clarke revealed that she suffered an SAH twice during the initial seasons of the popular show. She made a remarkable recovery both times and successfully completed all eight seasons of the show. Basic Instinct star Sharon Stone in her memoir ‘The Beauty of Living Twice’, has also written about her near-death experience when she suffered a subarachnoid haemorrhage in 2001. She recovered fully, but it took seven years, she revealed in her memoir.
Understanding brain aneurysms
A brain aneurysm is a balloon-like outpouching or protrusion affecting the blood vessels of the brain. A haemorrhage happens when the wall of the balloon becomes weak and ruptures.
Brain aneurysms usually go undetected until they rupture and cause a subarachnoid haemorrhage. When the haemorrhage occurs, patients develop sudden severe headaches often termed as “thunderclap headaches” or “the worst headache of life”. This is usually accompanied by nausea or vomiting. In most cases, the point of rupture becomes sealed temporarily after some blood leakage. However, in such cases, there is a high chance that the blood vessel may rupture again. When the amount of blood leakage is high, patients become unconscious and many unfortunately succumb even before reaching the hospital.
Aneurysms can also produce less intense symptoms such as vision problems, drooping of eyelids, mild headaches, etc. According to data from a large study published in The Lancet involving patients from multiple countries, the prevalence of unruptured aneurysm in the group was 3.2% without any other known diseases. The average age at aneurysm diagnosis is 50 years, and overall, it is more common in women.
Causes and diagnosis
The precise reasons behind aneurysm formations are still not fully clear. However, uncontrolled high blood pressure and smoking are known to be prominent risk factors for aneurysm development and rupture. In some cases, a family history of brain aneurysm also plays a significant role. Patients with polycystic kidneys or connective tissue disorders are prone to aneurysm development too.
When symptoms point to an aneurysm, the diagnosis is usually confirmed by a CT or MRI scan with an angiography. In high-risk patients such as those with a family history, periodic brain scans are recommended even in the absence of symptoms. Once the diagnosis is established, a catheter angiography is often required for treatment planning. Here, interventionists introduce a catheter (thin tube) into the blood vessels of the neck through a pinhole made in the leg artery or artery at the wrist. Detailed images of the aneurysm are then acquired in the specialised X-ray machine (cath-lab/angio-suite) after an injection of radio-opaque dye through the catheter.
Treating brain aneurysms
The treatment of an aneurysm depends on whether it was detected after minor symptoms, it ruptured or if it was a subarachnoid haemorrhage. In the case of a subarachnoid haemorrhage, treatment is done on an emergency basis. In other cases, it can be planned or elective treatment. Unfortunately, there is no medicine that can dissolve the aneurysm and heal the abnormal blood vessels.
Broadly, there are two ways in which an aneurysm can be treated: one, via opening the skull surgically and two, via a minimally invasive or endovascular route through a pinhole in the leg artery.
In open neurosurgical procedures, a metal clip is placed at the base of the aneurysm to prevent the blood from flowing inside the aneurysm. The most common endovascular option is coiling, where soft platinum coils are placed and aneurysm is packed.
While the first open surgical clipping dates back to 1938, it has only been three decades since coiling was used. Now however, coiling has been established as an option as well. The choice of whether clipping or coiling is better in a given case is decided based on the location and shape of the aneurysm.
Evolving science
The science of aneurysm treatment is changing rapidly now. Newer endovascular treatment options such as flow-diverters or flow-disrupters are emerging as promising treatment modalities with very high cure rates in difficult-to-treat aneurysms.
A subarachnoid haemorrhage due to a brain aneurysm used to be challenging for surgeons. However, medical science is advancing by leaps and bounds and minimally invasive procedures and sophisticated devices are now available to help doctors take on these conditions and treat them with encouraging results.
What this means for patients who suffer from strokes, is that there is hope. Getting help at the earliest through a proper diagnosis and right treatment is crucial.
(Dr. Vikram Huded is senior consultant and director of interventional neurology at Narayana Health, Bengaluru. vikram.huded.dr@narayanahealth.org)
Published – October 24, 2025 06:38 pm IST
