Incidentally discovered aneurysm in the brain. Now what do I do?

One of the readers of my blog wrote in to me. Her question and my response to it follows.

Hello Doctor,

I am a 27 year old otherwise healthy female. I work as a nurse and I recently got an MRI MRA due to some mild dizziness I was experiencing at work. I was shocked to learn that I have a 3mm aneurysm arising from the anterior aspect of the supracliniod portion of the left internal carotid artery consistent with ophthalmic artery aneurysm. I would greatly appreciate any advice/opinions you could provide….thanks so much.

Dear E,

                              Thank you for writing in to me.  Aneurysms in the brain are at times (actually quite frequently) discovered incidentally. The usual setting is that the patient seeks medical attention for some non-specific complaints commonly headache or like in your case dizziness. The doctor orders a MRI of the brain and the “silent” aneurysm comes to medical attention for the first time.

The majority of small sized aneurysms are clinically silent. By that I mean they cause no pain , headache, weakness in the arms or legs.  A small sized aneurysm may remain clinically silent and only come to medical attention when it ruptures and causes bleeding into the brain. Aneurysmal bleed usually causes subarachnoid hemorrhage (SAH). The SAH may be massive and carries a high morbidity and mortality rate. Survivors are usually left behind with significant neurological deficits (disabilities).

It is usually a giant aneurysm (defined as one greater than 2.5 cm in diameter)  that causes mass effect and hence may present clinically with weakness if it presses on the motor tracts in the brain or with problems with vision (decrease in visual acuity or double vision) if it press on the optic or other nerves with control the movements of the eye.

Now what to do when an aneurysm is discovered incidentally as in your case? Though I have not examined you, it is more than likely that the aneurysm is not the cause of your mild dizziness. The risk of an aneurysm to rupture has been studied  and the results are mixed. Since any aneurysm no matter what the size has the potential to rupture, every patient needs to be assessed on an individual basis for this.  Studies have shown that small aneurysms can be “safety” watched. The usual cut-off size is about 7 mm, though there is a debate whether aneurysms smaller than 7 mm in size carry a lower risk for rupture. It is well accepted that aneurysms greater than 25mm in size should be considered for therapy (there are different ways aneurysms can be treated—surgical treatment Vs endovascular treatment Vs a combination of the two) after closely weighing the potential risks of the surgery against the benefits (how likely is the aneurysm to rupture in the near future).

So my advise to you is to follow up with your physician.  After reviewing your MRI brain and other studies such as MRA (magnetic resonance angiography), he shall determine the best approach going forward. If he decides to wait and watch, then likely you shall need serial MRI studies at some interval of time (every 3 months Vs every 6 months Vs every year). Again there is no hard and fixed rule about how frequently you shall need to be scanned, this too shall be determined by your physician.

If you have high blood pressure, it shall be wise to maintain good blood pressure control.

I hope I have been able to shed some light on your query. Please feel free to write in again.

Personal Regards,

Nitin Sethi, MD

Disclaimer and confidentality

It is the start of a New Year 2011 so I wanted to again post my disclaimer and a small comment about confidentality. As many of you know information once on the Internet may stay on Internet forever and can be assessed by anyone. So my advise to the readers of my blog is this: if you do write into me and post on this blog please change your name or use an alias. Also it shall be better if you do not use your email address.

Here is my disclaimer:

This blog is my own endeavor and project. Though I work in New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, the blog is in no way connected to the hospital.

The information provided in this blog should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 if you have a medical emergency.

Links to other sites are provided for information only — they do not constitute my endorsements of those  sites.

 Any duplication or distribution of the information contained herein is strictly prohibited.

 

 

Nitin Sethi, MD

Seizures associated with excessive alcohol intake-why me?

One of the readers of my blog asked a question about alcohol induced seizures. His question and my reply to it follows. I have removed the name to maintain confidentality as always.

QUESTION

Hi; I wanted to read up about alcohol induced seizures because I have a question(s) for you, but I guess I should give you a little background first. I have had 7 of them, never had a problem before. The first one I do remember…I was drinking heavily ( Vodka ) and had done some recreational drugs too. I was in the kitchen and my bottom jaw “stuck” out and my hands clinched tight! My brain said “lay down” so I did and that’s as much as I remember. My soon to be wife and my son told me that my lips turned blue, eyes rolled up and I “wet” myself.Needless to say they called 9-11 but I refused to go.The other 6 six I do not remember…although the last one happened in the street and I got 3 staples in the head as a result.My Dad was an alcoholic so I never really drank growing up.However,when my son’s mother and I split when he was 2 ( he is 16 now ) I started to drink more, I had socially here and there but not like this.The seizures started about 3+ years ago I would “guesstimate”.I tried rehab 3 times – no good.At my “peak” I was drinking a gallon of Vodka a day.( I am not making any of this up! ).I have had massive panic attacks,spent hours ( every 20 min.) over the toilet,my blood pressure was through the roof and on and on.The “nail in the coffin” for me was one day I had my “other half” leave work to bring me my fix because I couldn’t handle the with-drawls any longer that morning. I drank about a pint and had pain in my chest,irregular breathing and I honestly felt like I was going to die!!My neighbor took me to emergency.When my “other half” got wind of it and showed up I was in horrible shape. The Doctor told her my blood-alcohol was .335 and he wanted to know how come I was even still functioning.( I know nothing of the point scale but I assume that was pretty bad ).I spent 3 days there, 2 on a heart monitor.They gave me Valume ( I don’t think I spelled that right ) and I don’t know what else.I had been given Librium in the past but they did not give me any, nor did I have any seizures while I was there.I was however really scared.When I came home I swore to my family that that was it……..it will 2 years in April !!! I drink a lot of coffee ( w/milk and sugar of course )and I like my ice cream!I build and paint models to “occupy” myself around the house but I do still think about it ( drinking ) here and there.I’m really not to worried about starting again…all I have to do is think about what I put the people I love through and that pretty much ” kills ” any craving,but I am fully aware that I will always be an Alcoholic. I do have an excessive personality, I really can’t do anything in moderation and I have insomnia ( in other words I am VERY high strung to begin with ).I will say that life is sooooo much better now but I do have a couple of questions……Why all of a sudden?  20+ years of “partying” and then one night “boom”( or did I answer my own question? ).It did take awhile to get to a gallon a day ( a few years in fact ). On a bigger scale….what I really would like to know is am I done having them? I think about them once and awhile and it kind of scares me to think I could be out doing something and have another one.I abstain from alcohol and everything else, but I do miss being able to “socialize” like everyone else.I don’t mind when people drink around me, it doesn’t tempt me or anything ( plus I know what they are going to feel like later! ) but I guess I put myself in that “boat”. Am I done having them??? I haven’t had one since I stopped drinking although one night at work shortly after I stopped I did have some kind of “panic attack”( light head,scared,sweating,dizzy-I just went home ) been O.K since but that is what got me wondering if I am truly done w/them.( I cannot associate any pain or anything w/having them – just waking up disoriented in an ambulance or wherever else, but again….I am clean and sober and will stay that way so can I assume that there won’t be anymore?
And to anyone reading this….I am no expert on this and believe me, I don’t tell ANYONE how to live their life but -  if your to the point of having seizures from drinking like I did – time to quit the game and walk away! I was playing a game that almost cost me my life – wasn’t worth it!
Thank you for your time reading this and I look forward to your response.

ANSWER

Thank you for writing in to me. As the name of my post suggests the seizure/ convulsion in the above case is usually temporally associated with excessive alcohol use. I shall use your question to discuss alcohol induced seizures at length namely under the following points:

“I can drink but know exactly when to stop”: people frequently have this misconception (these are people who usually suffer from a drinking problem aka alcoholics but still feel they have their drinking under control). Now what is “excessive” for one may be the “norm” for another. So there is no hard and fixed limit about exactly how much alcohol can be “safely consumed” without provoking a seizure.  Some people can drink like a fish and still not suffer a convulsion and there are others who have suffered an alcohol induced convulsion after just a “few” drinks. In my experience some people are particulary good in knowing when to stop. They shall drink right up to the limit but then stop and “be okay”. That said I feel this is playing with fire and if you are drinking right up the edge, you are playing Russian roulette.  

Another misconception that I have encountered is that people frequently feel that if they drink top shelf vodka or scotch or more commonly wine they are immune from suffering the ill-effects of excessive alcohol intake aka a seizure. Again it is not the type of alcohol which is consumed that makes you prone to have a convulsion, it is the absolute amount consumed. So if you drink bottle after bottle of wine, you are just as likely to suffer a convulsion as when you consume excessive amounts of some bottle shelf vodka. Obviously it goes without saying that one can ‘safely” cosume more bottle of light beer than an alcoholic beverage with a higher quantity of absolute alcohol.

When a person has suffered a convulsion in the field is brought to the emergency room, doctors as a rule usually check the blood alcohol level. This gives a fair indication about exactly how much alcohol was consumed and helps us in determing if excessive alcohol ingestion played a role in the seizure. The absolute blood alcohol level though is just a number and other things have to be considered before a seizure is attributed to excessive alcohol inake:

how long ago was the last drink consumed?  (alcohol is rather quickly metabolized and hence one may obtain a falsely low reading if the blood level is checked after some time has lapsed since the last drink).

over what time frame was the alcohol consumed ?(you are more likely to suffer a convulsion if you consume excessive amounts over a very short interval of time–aka if you are binge drinking). The caveat to that is alcohol withdrawal seizure if which a person who is a chronic alcoholic abruptly ceases drinking and suffers a withdrawal seizure. This usually occurs 24-48 hours after the last drink was consumed.

whether the drinks were mixed? one is more likely to suffer a convulsion in the setting of consuming many different types of drink (vodka, rum, whisky, beer) in one sitting. Again my personal impression is that this is not because one consumed different kinds of drinks, it is because when drinks are mixed you are more likely to consume more alcohol and not get a warning about when to stop.

whether there was use of illicit drugs along with the alcohol? combining alcohol and illicit drugs like cocaine, heroin and even prescription drugs like Xanax (a common drug of abuse), valium, Adderall, anti-depressants such as Wellbutrin, and even some over the counter so called safe herbal medications to lose weight can build the perfect storm to provoke a convulsion.

whether there were other precipitating factors? factors like been sleep deprived, dehydrated, drinking on an empty stomach all help in adding their two cents to build the perfect storm leading to an alcohol induced convulsion.

is there an underlying tendency/predisposition to have a convulsion? this concept is a little difficult to explain but let me attempt to explain with an example. Let us assume you have underlying epilepsy. You are then more likely to suffer a convulsion in the setting of excessive alcohol use that say a person who does not have underlying predisposition to have a seizure. You may both consume the same drinks and the same amount of alcohol, still you remain at higher risk of suffering a convulsion than the other person.

I thank you for your question and wish you good health in the New Year 2011. It takes immense strength of character and determination to walk away a winner from an alcohol addiction.

Personal Regards,

Nitin Sethi, MD