A bolt from the blue

This image has been used for representational purposes only

I felt like a bomb had burst in my head," said Sara as she lay on a stretcher in the emergency room, keeping her eyes closed and requesting us to dim the lights. She didn't feel like talking. Her parents said she had been sitting on the couch after dinner, reading a book when it had happened. No high blood pressure, no diabetes, and no family history of stroke, they confirmed. She didn't drink or smoke. No real or even apparent stress. She was 35 years old and about to be married. May be that was stress enough, I postulated in jest to myself.

She had a throbbing headache and felt confused, but was conscious and able to follow simple commands briskly. She could raise both her arms and flap her feet up and down at the ankle, which confirmed she had no striking neurological deficit. Her neck was stiff, however, and she couldn't touch her chin to the chest, one of the signs of an aneurysm rupture in the brain (you don't need to try doing this at home; you are fine).

The CT angiogram confirmed our suspicion: There was a 9 mm aneurysm arising from the middle cerebral artery bifurcation that had exploded. There was a large blood clot around it that was causing a significant pressure effect on the areas of consciousness. The spaces or cisterns in the brain reserved for the clean flow of cerebrospinal fluid had been replaced by blood.

An aneurysm is caused by the weakening of the wall of an artery resulting in an abnormal bulge or distension of the vessel, which, when faced with undue hemodynamic stress, can rupture and result in life-threatening internal bleeding. Nowadays, most aneurysms can be treated via endovascular means using coils, stents, and flow diverters, but in this case, owing to the complexity of the aneurysm morphology and the large blood clot, we needed to open up the head. For the next 20 minutes, I explained the possible outcomes to the family, each worse than the other, and concluded with: "It's going to be a roller coaster ride for all of us."

We opened up the head in the usual fashion. The brain was taut and the entire surface, dark red, as if it were directly battered with a baseball bat. Brain relaxation is critical to the success of intracranial aneurysm surgery. Gently and meticulously, we teased the spiderweb-like layer separating the frontal from the temporal lobes, exposing the sylvian fissure and the middle cerebral artery. We then made an incision on the brain to reach the blood clot and slurped some of it out with a fine suction; I was reminded, once again, of how melodious the sound of aspirating a hematoma is. As this action relieved the pressure on the brain further, we made sure not to go anywhere close to the dome of the aneurysm from where the initial rupture had taken place.

Once we had identified the middle cerebral artery, we temporarily placed a 5 mm titanium clip to reduce the blood flowing into the aneurysm, softening it up a little so that we could dissect it around the neck and clip it, which is the final goal of the operation.

Several anticipatory manoeuvres are performed to ensure there is no intra-operative rupture of the aneurysm, a situation that sends the operating room into a tizzy. During this part of the operation, there is pin-drop silence. All you can hear is the eerie sound of the monitor with everyone in the room glued to the giant monitors relaying the operation back to them, ready to immediately switch to fourth gear if it ruptures. I have once seen blood hit the roof of the operating theatre after an aneurysm ruptured - not metaphorically, by the way.

We identified the bulge of the aneurysm. Great care must be taken to ensure that a complete inspection is made circumferentially, so that no unseen branch is accidentally included when clipping the aneurysm neck. We determined the size, length, and shape of the clip and gingerly approached the neck, placing a 9 mm curved titanium clip that obliterated the aneurysm. You could hear a celestial sigh in the operating room, the sound of everyone letting go of their held breath at once. We released the temporary clip, removed the remaining clot adherent to the dome, and punctured the aneurysm to confirm there was no residual bleeding. The brain finally looking peaceful.

She woke up fine the next day, completely alert, but a few days later, the artery went into a severe spasm and she slipped into a coma. We had to rush her back to the endovascular suite and inject vessel-dilating drugs to ensure circulation was maintained. We repeated this on two other occasions until she was awake and alert once again. She was discharged two weeks later, 12 kilos lighter.

In 2001, Hollywood actor Sharon Stone was standing behind her sofa when she experienced a similar "lightning bolt" that knocked her unconscious. She had a subarachnoid haemorrhage from a vertebral artery dissection, similar to an aneurysm, that left her debilitated for quite a while even after treatment. Many years later, after having completely recovered, she referenced that incident in an interview, where she said, "If you act like you know what you're doing, you can do anything you want - except neurosurgery."

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.

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