Problem based learning cerebral aneurysm

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1. PBL PRESENTATION.
CEREBRAL ANEURYSM – A CASE STUDY.
BY:- HIMANSHU RATHORE & HARSHVARDHAN SINGH
TO:- VAKHTANG ROBAKIDZE

2. ABSTRACT.
This case study presents the clinical details, diagnostic
procedures, treatment options, and outcomes of a patient
diagnosed with a cerebral aneurysm. Cerebral aneurysms
are abnormal balloon-like bulges that form in weakened
areas of blood vessels within the brain. This case study
provides valuable insights into the management of
cerebral aneurysms, emphasizing the importance of early
detection, accurate diagnosis, and appropriate treatment
to improve patient outcomes.

3. INTRODUCTION.
A cerebral aneurysm (also known as a brain aneurysm) isa weak or thin
spot on an artery in the brain that balloons or bulges out and fills with
blood. The bulging aneurysm can put pressure on the nerves or brain
tissue.
If the brain aneurysm expands and the blood vessel wall becomes too
thin, the aneurysm will rupture and bleed into the space around the
brain. This event is called a subarachnoid hemorrhage (SAH) and may
cause a hemorrhagic (bleeding) stroke.
Rupturing brain aneurysm and SAH are life-threatening events.

4. CASE.
A 52-year-old male presented to the emergency department with a
sudden severe headache, nausea, and vomiting. Neurological
examination revealed no focal deficits, but a computed tomography
(CT) scan of the head showed evidence of SAH. He had intermittent
right-side headache for 5 years, and he complained left lower limb
numbness for 3 months. Physical examination found no sensory loss in
both upper and lower extremities. The patient had normal muscle
tone and deep tendon reflex. The patient had no history of
hypertension, diabetic mellitus, and coronary artery disease.

5. DIFFERENTIAL DIAGNOSIS.
Brain tumor: A brain tumor, particularly if it is located near blood
vessels, can mimic the symptoms of a cerebral aneurysm.
Headaches, neurological deficits, and other symptoms may be
present. Imaging studies, such as magnetic resonance imaging
(MRI) or computed tomography (CT) scans, can help
differentiate between an aneurysm and a tumor.
Arteriovenous malformation (AVM): AVM is an abnormal tangle
of blood vessels in the brain. It includes headaches and
neurological deficits. However, an AVM is a congenital
condition involving abnormal vessel formation.

6. Migraine: Migraine headaches can cause severe head pain. However,
migraines are typically recurrent and may be associated with visual
disturbances, nausea, and sensitivity to light or sound.
Cerebral aneurysm: A cerebral aneurysm, also known as an intracranial or
brain aneurysm, is a weakened or bulging area in the wall of a blood vessel
in the brain. It is often described as a "ballooning" of the blood vessel.
Cerebral aneurysms can occur in any part of the brain, but they are most
commonly found in the arteries at the base of the brain, known as the circle
of Willis.
Intracerebral hemorrhage: This condition involves bleeding within the brain
tissue, and it can produce symptoms similar to a ruptured cerebral aneurysm.
intracerebral hemorrhage is often associated with conditions such as
hypertension, arteriovenous malformation (AVM), or head trauma.

7. SYMPTOMS.
Sudden and severe headache (often described as the worst
headache of one's life)
Neck stiffness or pain
Nausea and vomiting
Sensitivity to light (photophobia)
Altered mental status or confusion
Seizures
Vision problems, such as double vision or blurred vision
Loss of consciousness or coma (in severe cases)

8. CAUSES.
Weakness in the blood vessel wall: Cerebral aneurysms often develop in
areas where the walls of blood vessels in the brain are weak. Weakness
can be congenital (present at birth) or acquired over time due to various
factors.
Genetic factors: Certain genetic conditions can increase the risk of
developing cerebral aneurysms. Conditions such as autosomal dominant
polycystic kidney disease (ADPKD), Marfan syndrome, Ehlers-Danlos
syndrome, and neurofibromatosis are associated with a higher risk of
aneurysm formation.
Family history: There is evidence to suggest that having a family history of
cerebral aneurysms increases the risk of developing one. If a close
relative, such as a parent or sibling, has had an aneurysm, your risk may
be higher.

9. Smoking: Smoking tobacco products, including cigarettes and cigars, is a
significant risk factor for cerebral aneurysm formation and rupture. The
chemicals in tobacco can damage blood vessel walls and increase the
likelihood of aneurysm development.
High blood pressure (hypertension): Chronic high blood pressure can
weaken the blood vessel walls, making them more susceptible to
aneurysm formation. Uncontrolled hypertension can increase the risk of
rupture once an aneurysm is present.
Age and gender: Cerebral aneurysms can occur at any age, but they are
more common in adults, particularly in people over the age of 40.
Additionally, women are more likely than men to develop cerebral
aneurysms.
Trauma or injury: Head trauma or injury, such as a severe blow to the head
or a car accident, can cause damage to blood vessels in the brain,
potentially leading to the formation of an aneurysm.

10. DIAGNOSTIC TESTS.
Medical history and physical examination.
Imaging studies:
a. Computed Tomography (CT) scan: A CT scan of the head is often the first
imaging study performed to assess the brain. It can detect the presence of
blood in the brain or subarachnoid space.
 b. Magnetic Resonance Imaging (MRI): An MRI may be ordered to provide a
more detailed view of the brain and blood vessels. It can help visualize the size,
location, and characteristics of any defect.
 c. Magnetic Resonance Angiography (MRA): MRA is a specialized type of MRI
that focuses on imaging the blood vessels. It can provide detailed images of the
blood vessels in the brain and help identify the presence of any abnormality.
d. Cerebral Angiography: Cerebral angiography is considered the gold
standard for diagnosing cerebral aneurysms. It involves injecting a contrast dye
into the blood vessels and taking X-ray images to visualize the blood flow and
identify any abnormalities or aneurysms.

11. Additional tests:
 a. Lumbar puncture (spinal tap): In cases where a subarachnoid
hemorrhage is suspected but imaging studies are inconclusive, a lumbar
puncture may be performed to analyze the cerebrospinal fluid for signs of
bleeding.
 b. Genetic testing: In some cases, genetic testing may be
recommended, especially if there is a family history of cerebral
aneurysms. Genetic testing can help identify inherited conditions that
increase the risk of aneurysm formation.

12. TREATMENT.
Observation and Monitoring: If the aneurysm is small, unruptured,
and not causing symptoms, the healthcare provider may
recommend regular monitoring through imaging studies, such as
CT or MRI angiography, to assess any changes in size or
morphology. This approach is often considered for aneurysms that
are low risk and in patients without any other medical conditions.
Surgical Clipping: This procedure involves a neurosurgeon making
an opening in the skull (craniotomy) to access the aneurysm. The
surgeon then places a small metal clip around the neck of the
aneurysm to stop blood flow and prevent rupture. Clipping is a
durable treatment option but requires open surgery and is
typically performed for aneurysms that are easily accessible and
have appropriate anatomy.

13. Endovascular Coiling: This is a minimally invasive procedure performed
by an interventional neuroradiologist. A catheter is inserted into an
artery, usually in the groin, and threaded to the aneurysm site. Small
platinum coils are then delivered through the catheter and placed
within the aneurysm, promoting clot formation and preventing
rupture. Coiling is an effective treatment option for many aneurysms,
particularly those that are small to medium-sized, have a favorable
shape, and are located in difficult-to-reach areas.
Flow Diversion: Flow diversion is a newer technique used for the
treatment of complex or large aneurysms. It involves placing a stent-
like device called a flow diverter in the parent artery near the
aneurysm. The flow diverter redirects blood flow away from the
aneurysm, promoting clotting and eventual healing. This procedure is
also performed by an interventional neuroradiologist and is effective
for certain types of aneurysms that may not be suitable for clipping or
coiling.

14. ENDOVASCULAR COILING.