On Saturday (4), ex-BBB Josy Oliveira died after suffering a cerebrovascular accident (CVA) during surgery to treat an aneurysm. The singer from Minas Gerais, born in Juiz de Fora, MG, was in an induced coma at Hospital Santa Catarina, in São Paulo.
Interventional neuroradiologist and neurologist Fabricio Buchdid Cardoso explained to G1 what is an aneurysm, how to identify it, treatment and stroke. Fabricio works at Hospitals de Clínicas Unicamp and at Centro Médico de Campinas, in addition to Instituto Neuron Campinas.
According to Fabricio, there are two types of stroke:
- hemorrhagic: where there is extravasation of blood in the artery that feeds the brain
- ischemic: where there is interruption of blood flow in the artery that nourishes the brain
Josy Oliveira, former BBB participant died after a stroke — Photo: Reproduction/social media
1 – What is a brain aneurysm?
Cerebral vessels are made up of arteries and veins, as are all the organs in the body. Arteries are made up of a larger amount of muscle in the wall than in veins, so they are more resistant. Cerebral aneurysm is a dilation in the artery wall due to a certain weakness, a muscular discontinuity in a certain part of the wall, which, over time, causes a dilation. This more fragile region is subjected to blood pressure that bulges, increasing in size, and becomes more and more fragile and irregular until the moment it bursts.
2 – Is there an age when it is more common, or predisposition?
He has no predilection for age. It is more common in young adults, but can affect all age groups, including children. In children, one of the main causes is post-traumatic, after accidents in which there is head trauma.
It is important to mention genetics in the case of predisposition, that is, when a person in the family is diagnosed with an aneurysm, parents, uncles, cousins, siblings and children must undergo exams.
There are risk factors, such as smoking, due to the fragility of the vascular wall caused by smoking, and kidney diseases such as polycystic kidneys, which can cause the formation of aneurysms in the brain or in other parts of the body.
3 – How can it be detected?
Many people throughout their lives can end up with a brain aneurysm that goes unnoticed, that is not ruptured. However, the aneurysm can be detected by examinations either in the phase when there is rupture or when there are still no symptoms.
- No symptoms: the patient may discover the aneurysm during routine examinations;
- With symptoms: the main symptom is a headache, sudden, intense and explosive headache and, according to neurologist Amaury Bara, also with paralysis on some side of the body or even a coma. Fabricio completes the explanation with “loss of strength usually in one hemibody, speech alteration, visual alteration, drowsiness, even coma, among others”;
- There are different degrees of bleeding, such as the Modified Fischer scale, which considers levels from 0 to 4. The higher the scale, the more severe and with risks of worsening.
The aneurysm can be detected by imaging tests that contrast the cerebral vessels, such as angioresonance (which paints the cerebral arteries), CT angiography (which injects a contrast that passes through the arteries) and cerebral angiography (a kind of cerebral catheterization through the groin or arm that reaches the artery of the neck — a direct contrast is injected into the arterial vasculature to allow detection via imaging).
4 – How is the treatment?
There are treatment criteria depending on the patient’s condition: surgery is with a “clipping” of the aneurysm, or endovascular, an embolization inside the artery. To define the best treatment, a series of tests is needed to determine whether the aneurysm is large or small. For aneurysms smaller than 5 millimeters there is a tendency to monitor annually; but if it is irregular, in bifurcations, either endovascular treatment or open surgery should be considered.
Open skull surgery: there is an exposure of the brain tissue until the arrival of the blood vessel in which there is the aneurysm. He is then given a metal clip to exclude the aneurysm from circulation, protecting the surrounding blood vessels and preventing occlusions and complications.
Endovascular: a catheter is placed in the groin (femoral) or arm (radial) artery and travels to the neck. Then, it performs a catheterization of the arteries until reaching the aneurysm. In the region, metallic devices are used, often the diameter of fishing wires, to enter the aneurysm and exclude it from circulation, often using platinum springs for this purpose; or other techniques available in the endovascular method.
This was the procedure adopted to treat Josy Oliveira, as her sister told the G1. Fabricio said there was a complication: “Metallic materials are placed inside a fragile artery and this may have generated a complication. There are strategies to contain the bleeding, but it is not always possible.”
Endovascular techniques have low complication rates, but, like any procedure, problems can occur, as in the case of Josy. These can be: aneurysmal rupture at the time of manipulation, vascular perforation, which can lead to hemorrhagic stroke, or arterial occlusion, which can lead to ischemic stroke.
5 – Stroke during the treatment of correction of a cerebral aneurysm
During corrective treatment of cerebral aneurysm, complications can occur and aneurysmal rupture with secondary hemorrhagic stroke can be a reckless complication. Intracerebral hemorrhage expands intracranial pressure. The skull, made up of bones, makes swelling of the brain difficult because it is a contained environment.
Associated with this, one of the complications is hydrocephalus: within the brain there are spaces in which there is production of cerebrospinal fluid, produced by the brain itself and which is contained in some pockets within the brain, called ventricles. In the case of intracranial hemorrhage, this makes it difficult for this fluid to be reabsorbed, that is, the fluid is produced more than it is reabsorbed.
This causes fluid to accumulate inside the brain and the ventricle to enlarge, which is called hydrocephalus. To try to control the complication, sedation is performed so that the patient has the lowest possible brain metabolism, intubated, in an induced coma. It may be necessary to apply medication into the vein to reduce swelling and place a drain to allow this excess fluid to lower the pressure.