It is fatal, could affect anyone, and yet very few have heard of or understand it. In the US alone, around 6 million people have a brain aneurysm and as many as 1 in 15 people could develop this dreadful disease. Half of ruptured aneurysm victims die within minutes of a massive hemorrhage and, of the 50% who survive; half will suffer delayed death while the remaining survivors, depending on the level of the hemorrhage, usually live with severe long-term deficits (data from the Joe Niekro Foundation).
Cindy is one of those who compose the latter group of survivors. Her ordeal with a ruptured cerebral aneurysm happened in the Philippines where conditions for emergency treatment and care are often less favorable compared to the US. This is her story.
Day 00, March 2, 2009: It happened in seconds and without warning. It has been a pleasant, normal day at our farm some three hours away from our main residence in Davao City. It was around 10:00 pm and we were having a leisurely time after attending to the needs of a group of guests who were now having some fun on their own in another section of the farm. We were alone, having a small chat on a bench outside our cabin when our two dogs got restless so she stood up, got some dog food, and then stooped down to place the food inside the cage. It was as she stood up when she became unsteady and complained of a sudden severe headache. Persistently health-conscious and a nurse by profession, Cindy never had health issues or any known history of hypertension or major diseases so I did not expect anything serious. Back on the bench, I massaged her head and nape but she weakly requested to be brought to the hospital complaining that the pain was unbearable and she felt like her head was about to explode.
When we got to the local doctor a few minutes later, she was already half-conscious, her eyes were half-closed, and she was vomiting. The doctor, initially suspecting cardiac arrest, sent us to a local hospital where, after initial assessments, a specialist diagnosed a strong possibility of a ruptured cerebral aneurysm. A computed tomography (CT) scan was needed to confirm the initial diagnosis and the hospital had this facility but the nearest brain surgeon was practicing in General Santos City (GenSan), the next city about an hour away. So Cindy was transported by ambulance to GenSan to ensure that a surgery can be immediately undertaken by the brain surgeon if a ruptured aneurysm was confirmed. By this time, Cindy was already under life support, 70% of her breathing was administered by a respirator and she was having seizures and stiff involuntary movements mainly in her right extremities. While a doctor and two nurses were monitoring her vital signs, I had to apply pressure on her arms and legs to control the spasms as the ambulance sped through the now dark and deserted highway.
Day 01, March 3, 2009: After a CT scan and several tests at Saint Elizabeth Hospital in GenSan, almost five hours after Cindy felt the severe headache, it was confirmed that she indeed had a ruptured aneurysm. She was admitted to the ICU. Very carefully and in layman’s terms, the brain surgeon and a neurologist carefully explained Cindy’s medical condition to me and our three kids.
A Balloon in the Brain
From the doctors’ explanation I understood that Cindy’s aneurysm was congenital. Since birth, a major artery that supplied blood to her brain had an abnormally thin wall at a certain section inside her skull. The thin wall, because of the constant blood pressure, gradually swelled over the years into a balloon-like bulge. The presence of aneurysm is difficult to detect since its symptoms (fatigue, loss of perception or balance, speech problems, double vision) may not be pronounced and can be suspected to be due to unrelated causes. This blood-filled “balloon” ruptured and caused a massive cerebral hemorrhage which increased the pressure around the brain tissues, caused the seizures and involuntary movements I witnessed, and affected major bodily functions including breathing. The resulting blood clot around the brain blocked some ventricles thus causing the accumulation of fluids (brain water) and aggravated the increased pressure inside the skull. Because of these disruptions, the brain may shut down and then Cindy will succumb to comatose or death in a matter of hours. At that time, Cindy was doing only 30% of the breathing, the rest was being done by a respirator. The doctors declared that she only had a 20% chance of surviving this fatal condition.
I frantically tried to understand the possible treatments for Cindy’s condition. Simply put from the surgeon’s explanation; there are only two ways to treat a ruptured aneurysm. The older but allegedly more reliable method is called surgical clipping which involves opening a portion of the skull (craniotomy) and closing the ruptured aneurysm by clipping its base. On the other hand, the more recent and minimally invasive technique is called “endovascular coiling” or “coil embolization” where a catheter is passed into a major artery in the groin, through the aorta, into the brain arteries, and finally into the aneurysm itself then platinum coils are fed into the aneurysm through the catheter. The platinum coil fills up the ruptured “balloon”, initiates clotting and thus plugging the leak in the artery. The risk level is said to be the same in both methods but only surgical clipping procedures can be done at the hospital where Cindy was confined.
High Level of Uncertainty
Day 02, March 4, 2009: It appears that Cindy was also subjected to another medical practice called “watchful waiting”. None of the above methods were administered to her from the time she was admitted into the ICU. The surgeon felt that, despite all the tests, there is still a very high level of uncertainty about the conditions inside Cindy’s head. Her already dismal situation can quickly drop to worst at any time and risks of undertaking a surgery outweighs the desired benefits. Of course, it was very difficult for me and the kids to understand this approach. To us, Cindy’s life was like a lighted candle that was rapidly getting shorter with every minute that passed.
Day 03, March 5, 2009: Unconvinced that watchful waiting was the best way to manage Cindy’s case; I went to Davao City (our home city) to get a second opinion from another brain surgeon at Davao Doctor’s Hospital. This hospital has competent medical specialists, more modern and complete facilities, and a good track record in handling cases similar to Cindy’s. But another issue comes into the picture if Cindy was to have treatment at Davao Doctors – travel. The inside of Cindy’s head was so fragile at this time that even a small disturbance from the travel can trigger seizures, comatose or another bleeding. The blood clot presently controlling further bleeding can be dislodged and a second, usually fatal haemorrhage can occur. The second expert opinion I got was to allow the morbid “watchful waiting game” to continue for another three days before transporting Cindy to Davao. We had no choice but to trust the judgement of these surgeons and pray that they recommended the right action. Only time will tell.
Day 06, March 8, 2009: Cindy’s condition actually showed some signs of improvement. She has been unconscious at the ICU since day 1 but there were brief moments on the sixth day when she showed signs of being awake and her dependence on the respirator for breathing was now down to 50%. It was a good sign and we thought that she might have felt that she was about to go home. But the extremely high risk associated with the two-hour trip to Davao was still a very grave concern.
Day 07, March 9, 2009: It was only on our faith in God and that small sign of improvement where we clung to when we moved out of Saint Elizabeth Hospital towards Davao City just a few minutes after midnight (I chose this timing so that the weather will not be hot and traffic along the route will be minimal). I joined the medical team in the ambulance and positioned myself above Cindy’s head to help cushion it in case of bumps on the road while the kids, who I tried to prepare for any eventuality during the trip, did their prayers in a van following behind us. The atmosphere inside the ambulance was tense during the first half of the trip but, thankfully, Cindy’s vital signs remained stable and, with great relief, we arrived at Davao Doctor’s Hospital without any incident.
Day 08, March 10, 2009: My primary concern, now that Cindy will be subjected to a surgical procedure soon, was to make sure that the operation addressed as many of the problems as possible. In my mind, coil embolization was appealing because of its minimally invasive procedure but it only closes the ruptured aneurysm and does not address the problems with the blood clots and hydrocephalus or accumulation of fluids around the brain; whereas a craniotomy and surgical clipping can potentially address all these three issues. My fear was that if we subject Cindy to coiling embolization, another surgical procedure might be needed to remove the blood clots and fluids around the brain and that might be too much for her to handle. The brain surgeon agreed to schedule a surgical clipping operation as soon as the condition was right.
Day 15, March 17, 2009: Though Cindy remained unconscious at the ICU, she has been receiving continuous medications to improve her condition and prepare her for a surgical clipping procedure which was scheduled on this day. However, upon assessment by a number of specialists, the operation was not given clearance because she still had fever and some pulmonary infections.
Main Problem Solved
Day 17, March 19, 2009: While waiting for Cindy’s condition to improve, her managing physician decided to conduct another set of tests to determine the status of the hydrocephalus and blood clots. The tests showed that medications have successfully dissolved the clots and flushed out the unnecessary fluids around the brain. It was great news. Now we can agree to a coil embolization!
Day 21, March 23, 2009: Twenty one days after the rupture, time has finally come to fix the aneurysm once and for all. The team of specialists has confirmed that a coil embolization procedure can now be undertaken with the least possible risk to Cindy’s condition. She was brought to the operating room at 2:00 pm and, for 3 hours, family members and friends waited and prayed at the waiting area until the surgeon called me into the operating room; directed me to the screen which showed Cindy’s arteries and the path that the catheter followed; pointed to the various frames which recorded the process as the aneurysm got filled by platinum coils; then declared that Cindy was safe and the operation was a success. She was later returned to the ICU for further intensive care.
The Road to Recovery
Day 32, April 3, 2009: Cindy’s condition continued to improve after the operation and she was moved out of the ICU into a private room. She was having more frequent “waking moments” and her dependence on the respirator has totally ceased although feeding her solid food was still not advised.
Day 38, April 9, 2009: A physical therapist has started working with Cindy to revive her motor skills particularly in her right extremities which seem to be the most affected by the massive disruption inside her brain. Although she still cannot communicate, she can now take a few solid foods and even showed excitement when I and the kids joined her during meals.
Day 47, April 18, 2009: Forty-seven days after she had a ruptured aneurysm, Cindy was finally discharged from the hospital and we went home to the welcoming arms of family members and friends who were overjoyed and thankful that she had survived the ordeal. She was still in a wheelchair and we still needed to work with speech and physical therapists to help her recover her normal functions and minimize the deficits but we were confident that she will be able to overcome this part.
A Second Life
Day 1095, March 03 2012: It is the birthday of our eldest daughter, Nikki, today and on that tragic day three years ago when it was confirmed that Cindy had a ruptured aneurysm. But the day is bright and glorious and the atmosphere is a lot more festive on this day, far from the cloud of gloom and distress that enveloped the whole family three years ago. Cindy is now fully functional at home, in social functions and even in the farm where her long ordeal started. She still has a slight limp on the right leg and occasional lapses in speech and memory but she continues to amaze us with instinctive reactions to situations and sudden spontaneous recollection of things. Even her doctors and therapists comment that, compared to other patients who have gone through the same ordeal, she appears normal – “as if nothing had happened” was the common comment. Indeed, the meager 20% chance of survival she had in March 2009 has been fully reversed. She is now 100% alive and, as a bonus, she came out from the experience with such cheerful, child-like innocence that made her more endearing to people around her with each passing day.
- Women With Brain Aneurysms At No Greater Risk Of Rupture During Pregnancy And Delivery (medicalnewstoday.com)
- Bringing Hope to Brain Aneurysm with Interventional Neurology (enbloommedia.com)
- No increase in brain aneurysm rupture risk during pregnancy and delivery (eurekalert.org)