ANEURYSMS DIFFICULT TO DIAGNOSE, COMPLEX TO CURE

Abdominal aneurysms are four times more common in men than in women, and are most prevalent
in whites aged 50 to 80. Ruptured aortic aneurysms are the ninth leading killer of American men
over 55.
When an aneurysm hemorrhages, blood pours into body cavities. Tissues beyond the rupture are
deprived of blood and cannot function properly, causing shock and death if not treated promptly.
The larger the aneurysm, the greater the risk of rupture. A person with an abdominal aortic
aneurysm that measures over 21/2 inches in diameter (over 6 centimeters) faces a 50 percent chance
of dying within one year; 75 percent within two years; and over 90 percent within five years.
About a quarter of those with abdominal aneurysms experience pain in the abdomen or lower back
that may be mistaken for a kidney stone attack or a ruptured vertebral disk. But in most cases, there
are no warning symptoms.
The doctor may see or feel a throbbing, tender mass in the middle or lower abdomen during a
routine physical, or may discover the aneurysm by chance when ultrasound imaging is done for
some other reason.
Since abdominal aneurysms less than 2 inches (5 centimeters) in diameter rarely rupture, physicians
usually prescribe blood pressure-lowering drugs, such as beta blockers, to reduce the pounding of
blood against arterial walls. Patients with small aneurysms are monitored regularly with full exams
and imaging techniques.
When the aneurysm is large or when there are many, surgeons can replace all or most of the aorta
with Dacron tubing. J ere W. Lord J r., M.D., retired professor of surgery, New York University,
calls this "probably the most difficult operation a surgeon is required to perform on a human
patient."
Thoracic aneurysms may also be symptomless, and are sometimes discovered unexpectedly on a
routine chest x-ray. If symptoms do occur, they include pain in the shoulders, lower back, neck, or
abdomen. A dry, brassy cough that doesn't respond to cough medication is another warning signal.
The swelling aneurysm may press on the nerve that opens and shuts the vocal cords, causing
hoarseness, even loss of voice.
When blood works its way through a tear in the aorta's innermost wall and separates the layers of
the artery wall, creating a second channel, a dangerous complication known as a dissecting aortic
aneurysm results. The most common symptom is an excruciating tearing or ripping pain in the
chest, often mistaken for a heart attack. Unless the aorta is repaired immediately, most people with
a dissecting aneurysm die. About 60 percent of thoracic aneurysms dissect; abdominal aneurysms
rarely do. Dissecting aneurysms are more common in blacks than whites.
Atherosclerosis, or hardening of the arteries, which weakens artery walls, is a factor in 95 percent of
aortic aneurysms. High blood pressure may speed up damage to vessel walls. Aortic aneurysms may
also result from congenital defects, heredity, injuries, diabetes, and syphilis.
More than half of patients with one aortic aneurysm will develop another, so physicians use a
variety of tests, not available in the Duke of Windsor's time, to monitor patients: computed
tomography (CT) scans, ultrasound, echocardiography, or magnetic resonance imaging (MRI).
People who have Marfan's syndrome, a connective tissue disorder, tend to be particularly vulnerable
to aortic aneurysms because of weak arterial walls. About 10 percent of patients with aortic
aneurysms have Marfan's syndrome.
Berry Aneurysms
Aneurysms that balloon out to look like berries may form in congenitally weak spots in a ring of
arteries at the base of the brain known as the circle of Willis. All the brain's major arteries open into
this ring, which then circulates blood to the areas of the brain that control movement, sight, feeling,
and thinking. The circle of Willis guarantees the brain a continual supply of blood in the event that
one of these arteries, such as the carotid, is blocked.
Berry aneurysms have been aptly described as time bombs, because they are liable to burst at any
time, resulting in hemorragic strokes that affect 30,000 Americans each year. One-third of such
ruptures occur during sleep. About half of the people with ruptured berry aneurysms die
immediately. Many of the survivors die later from recurring hemorrhage or suffer irreversible brain
damage. Ruptured berry aneurysms are most common in people 40 to 60 years old, and in slightly
more women than men.
Before berry aneurysms rupture, some people get warning signs. Small amounts of blood may leak
from the aneurysm for hours or days, causing headaches, nausea and neck stiffness. Angiograms
can locate a suspected unruptured aneurysm.
Unfortunately, in more than 90 percent of cases there are no symptoms until the aneurysm bursts.
Rupture results in an excruciating headache, often accompanied by nausea and vomiting. Loss of
consciousness that follows may be temporary or may proceed to coma and death. Other symptoms
may include personality changes, blurred vision, paralysis on one side of the body, speech
impairment, seizures, and difficulty walking or talking, depending on where the rupture occurred
and the amount of bleeding.
In some cases, the ruptured artery stops bleeding by itself because swollen brain tissues in the area
press against the rupture or a clot forms and plugs the rupture. When a burst aneurysm is suspected,
the best diagnostic tool is the computed tomography (CT) scan, which locates the clot and indicates
the amount of blood spillage in the brain in 80 percent of cases. A spinal tap (lumbar puncture) will
confirm the presence of blood in the cerebrospinal fluid, the watery cushion that protects the brain
and spinal cord from shock. Angiograms are usually necessary to show how large and where the
rupture is located, and can pinpoint other aneurysms as well.
Neurosurgeons can open the skull and repair the aneurysm, in most cases, by placing a metal clamp
at its base. Ideally, this should be done within 48 hours after hemorrhage, because the rupture can
start to bleed again at any time. However, when surgery is performed by experienced hands within
one to two weeks after hemorrhage on patients in good neurological condition, mortality rate is 5
percent or less. Another danger with subarachnoid hemorrhage-so-called because the blood seeps
into the fluid-filled area around the brain called the subarachnoid space-is that an artery near the
ruptured aneurysm may constrict or go into spasm, causing another stroke. Nimodipine (Nimotop),
a calcium channel-blocking agent, has been shown to decrease the severity of neurologic damage
from spasm in people who have suffered a subarachnoid hemorrhage.
When a patient is very ill, surgery is postponed to allow brain swelling to go down, usually a matter
of weeks. Besides bed rest, the patient awaiting surgery may be treated with drugs to reduce severe
high blood pressure, corticosteroids to reduce swelling, and analgesics to relieve headache.
Unruptured aneurysms that cause pain or other symptoms by pressing on nerves in the brain should
be surgically removed. If they are detected, unruptured aneurysms that cause no symptoms should
also be removed if they are more than two-fifths of an inch (10 millimeters) in diameter. Sometimes
the tendency to have such aneurysms is inherited.
Medical management of people with a family history of aneurysms is controversial. "If your mother
and your sister and your aunt all had aneurysms, and you are one of the worried well, you might
want to have some tests," says neurologist Alexander W. Dromerick J r., M.D., Princeton University
researcher and fellow of the Hospital of the University of Pennsylvania. "MRIs are being used to
screen asymptomatic relatives, but nobody is quite sure how accurate they are. An MRI will pick up
large aneurysms, and some of the smaller ones, but will miss some. A CT scan will pick up
evidence of bleeding, but not usually an unruptured aneurysm. What we call the 'gold standard,' the
test against which all other tests are measured, is the angiogram. But there's a 1 to 2 percent chance
of TIAs [transient ischemic attacks, or ministrokes], stroke and death with an angiogram, and no
physician wants to expose an asymptomatic patient to this risk without good reason."
About 20 percent of people initially diagnosed with one berry aneurysm are found to have at least
one more. (Berry aneurysms are found in up to 4 percent of routine adult autopsies.) As in other
types of aneurysms, atherosclerosis and high blood pressure, which exerts pressure on weakened
areas, cause these areas to stretch like a balloon and eventually rupture. Heavy cigarette smoking
and cocaine use have also been implicated in aneurysm rupture.
Peripheral Artery Aneurysms
The third most frequent type of aneurysm occurs in the large arteries that run down the leg and in
back of the knee (the femoral and popliteal arteries). They chiefly affect men and usually result
from atherosclerosis, only occasionally from congenital weakness of arterial walls, injuries, or
bacterial infections. They can be felt as throbbing masses in the groin and behind the knee.
Behind-the-knee aneurysms rarely burst, but they may grow so large that they interfere with
circulation in the lower leg. Clots may also develop suddenly in the aneurysm, cutting off the
supply of blood to the lower leg and foot, possibly leading to and necessitating amputation. Such
complications can usually be prevented by replacing the affected part of the artery by a (saphenous)
leg vein, as in bypass surgery.
Diagnosis may be confirmed by angiograms, which give a picture of the arteries, or ultrasound,
which can determine the size of the arteries. The physician will also look for abdominal aortic
aneurysms in these patients, because very often patients have both.
Aneurysms in the groin rupture more frequently than those in the knee, but otherwise are subject to
the same kinds of complications. Risk factors for the development of peripheral aneurysms are high
blood pressure, high blood cholesterol levels, diabetes, obesity, lack of regular exercise, and the
chief culprit, smoking. Since these same risk factors are implicated in heart disease and stroke,
lifestyle changes to keep blood vessels healthy will have other health benefits, as well.