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Vascular Diseases of the Brain

Aneurysm (Vessel Bubbles)

The diseases we call aneurysms are usually caused by the weakening of the arteries, in other words, weakening of the wall of the arteries due to many reasons and they have a bubble-like appearance. A cerebrovascular aneurysm may develop secondary to cigarette smoking, hypertension, diabetes, and atherosclerosis, but may also be associated with some hereditary diseases (such as polycystic kidney disease) that may occur in some patients. The most feared condition in patients with an aneurysm is hemorrhaging. In some cases, this may be due to a sudden spike in blood pressure or occur unexpectedly even during sleep. Brain aneurysms bleed into the brain and into the space surrounding the brain, i.e. the subarachnoid space, which is filled with cerebrospinal fluid. Therefore, this bleeding is called subarachnoid hemorrhage (SAH). It is usually life-threatening. Therefore, the necessary treatment and follow-up of patients diagnosed with an aneurysm must be performed promptly.

Symptoms
  1. Headache: Severe headaches may be observed especially in patients with bleeding.
  2. Mental fog and coma: This situation is observed in patients who have had bleeding and may be life-threatening. In some cases the patient may lose consciousness in seconds and go into a coma.
  3. Different types of paralysis, weakness in the arms and legs, speech disorders, urinary and fecal incontinence may occur due to hemorrhaging.
  4. Depending on the pressure of the aneurysm, the eyelids may fall and cross-eye may occur.
  5. Seizures (lower frequency of occurrence)
Diagnosis

Brain aneurysms bleed into the brain and into the space surrounding the brain, i.e. the subarachnoid space. It is an immediate and always life-threatening event. The patient is often admitted to the emergency room. The first examination requested is the Computed Tomography of the Brain (CT). Here, the location and the amount of bleeding, as well as other accompanying pathologies in the brain such as hydrocephalus can be detected. After the detection of the bleeding, CT-angiography or MR-angiography may be performed to look at the vascular structures. One of the most sensitive examinations in which vascular structures are evaluated is DSA (digital subtraction angiography). With this radiological imaging, the vessels that feed the brain (arteries) and let the blood out (veins and sinuses) can be seen in great detail and, if any, with vascular pathologies such as an aneurysm.

Treatment

In surgical treatment, the aneurysm is seen by opening the skull, the tissue is removed from the surrounding area, clips are placed on the neck of the aneurysm to prevent the blood from filling into the aneurysm and the bleeding. In endovascular therapy, the aneurysm inside the brain is filled with special metals by entering from the inguinal artery as in DSA application, to prevent the blood from filling in and avoid the bleeding. The type of treatment is selected after an evaluation based on the location and size of the aneurysm, the general medical condition of the patient, the patient’s preference, and other circumstances.

Follow-up

On the third postoperative month, angiography is performed to confirm the complete closure of the aneurysm. Then clinical follow-up is performed once every 3 months.

Arteriovenous malformation (AVM)

The diseases called AVM are caused by a direct connection between the arteries and veins without capillaries. Since it has a glomus-like appearance, it is also called a glomerulus. It is generally thought that AVMs are congenital and may grow throughout the patient's life. In AVMs, as well as in aneurysms, the most feared condition is the occurrence of bleeding. In AVMs, cerebral hemorrhage may be into the brain tissue, or more frequently, into the subarachnoid space which is filled with cerebrospinal fluid. Aneurysms can also be seen in conjunction with AVM. This situation is usually life-threatening. Patients who are diagnosed with AVM should consult with the neurosurgeon and have the necessary treatment and follow-up performed.

Symptoms
  1. Headache: Severe headaches can be observed especially in patients with bleeding.
  2. Seizures: Especially young adults may consult to the doctor with incipient seizures.
  3. Depending on the locations of AVMs, different types of paralysis cases, weakness in the arms and legs, speech disorders, visual disturbances, urinary, and fecal incontinence may occur.
  4. Mental fog and coma can be observed in patients with bleeding and may be life-threatening. Sometimes the patient can lose consciousness in seconds and go into a coma.
  5. Some patients have no complaints at all and are detected by chance.
Diagnosis

AVM bleeding occurs into the brain and into the subarachnoid space which filled with cerebrospinal fluid. Patients are usually encountered in emergency rooms, or sometimes in neurology clinics due to seizures, in outpatient clinics due to a simple symptom, or by coincidence. Both lesion and bleeding can be seen in CT or Brain MRI. CT-angiography or MR-angiography may be performed to see the vascular structures. One of the most sensitive examinations to evaluate vascular structures is DSA (digital subtraction angiography). With this radiological imaging, the vessels that feed the brain (arteries) and let the blood out (veins and sinuses) and AVMs can be seen with great detail and, if any, with vascular pathologies such as an aneurysm.

Treatment

AVMs are graded according to their locations and sizes. Those with lower grades can usually be surgically removed. Stereotactic radiosurgery may be applied on large and deeply located AVMs that cannot be removed by surgery. AVMs can be closed over time with radiation treatments such as Gamma knife or Cyber knife. In endovascular treatment, the AVM inside the brain is filled with special metals by entering through the inguinal artery and thus preventing the blood from filling in and the bleeding. This method can be applied on large and deeply located AVMs that cannot be removed by surgery. The type of treatment is selected after evaluations based on the location and size of the AVM, the patient's general health condition, the patient’s preference, and other circumstances.

Follow-up

On the 3rd postoperative month, angiography is performed to confirm the complete closure of the AVM. Then clinical follow-up is performed once every 3 months.

Cavernous Angioma (Cavernoma)

Cavernoma or cavernous malformation is a vascular anomaly of the brain. In this disease, there are anomalous and swollen veins whose appearance resembles that of a blackberry. Similar to other vascular anomalies, cavernomas may also cause bleeding, However, cavernoma hemorrhages are usually on a small-scale, are different from aneurysm and AVM hemorrhages, and appear in the form of blood leakage around the lesion. Massive bleeding is rarely seen.

Symptoms

The most common symptoms are headaches and seizures. Other complaints are relatively rare. Depending on the location of the cavernomas, different types of paralysis, weakness in arms and legs, speech disorders, loss of vision, etc. may occur. Although hemorrhages rarely reach life-threatening scales, cavernoma hemorrhages located in the brainstem may sometimes be life-threatening.

Diagnosis

Although CT is important for the evaluation of the bleeding, MRI is essential to diagnose the cavernoma. Angio methods have no use in diagnosing the cavernoma and are only used to distinguish it from other vascular lesions in suspicious cases.

Treatment

Patients who are diagnosed coincidentally and patients with mild to no clinical signs may be monitored by intermittent MRI. Surgical treatment should be preferred for cavernomas with bleeding. Surgical removal of the cavernomas is the first treatment option. The option of stereotactic radiosurgery may only be preferred to reduce the possibility of bleeding in cavernomas and to reduce the frequency of seizures in patients who are experiencing seizures. It does not eliminate the cavernoma. The type of treatment is selected after evaluations based on the location and size of the cavernoma, the patient's general health condition, the patient's preference and other circumstances.

Follow-up

MRI is performed on the patient in three-month intervals.

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