Vascular Pathologies
What are vascular pathologies?
Cerebrovascular pathologies include disorders of the blood vessels that run through or supply the brain, which may lead either to interruption of blood flow or to haemorrhage.
Some are managed primarily by neurologists, whereas others require urgent neurosurgical or endovascular intervention.
Ischaemic stroke
An ischaemic stroke occurs when blood flow to an area of the brain is interrupted, usually because of a blood clot.
The main treatment includes thrombolysis or mechanical thrombectomy and is usually overseen by a neurologist and an interventional neuroradiologist. In selected severe cases, where the infarction causes extensive swelling and threatens the patient’s life, known as malignant middle cerebral artery infarction, urgent decompressive craniectomy may be required.
This is a neurosurgical procedure in which part of the skull is removed to relieve pressure.
Haemorrhagic stroke
A haemorrhagic stroke is caused by spontaneous bleeding within the brain tissue, most commonly due to long-standing hypertension, although it may also result from rupture of an aneurysm or vascular malformation.
In cases of a large haematoma causing significant pressure on the brain, urgent surgical evacuation is often required in order to reduce intracranial pressure and protect healthy brain tissue.
Intracranial aneurysm
An intracranial aneurysm is a localised dilation of the wall of a cerebral artery, like a small balloon, forming at a point of weakness in the vessel wall. Most aneurysms remain asymptomatic and are discovered incidentally on imaging, but rupture causes subarachnoid haemorrhage, an emergency and potentially life-threatening condition.
Treatment includes either surgical clipping, in which a small metal clip is placed at the base of the aneurysm to exclude it from the circulation, or endovascular coiling, a less invasive technique in which the aneurysm is filled with fine platinum coils through a catheter.
Vascular malformations
Arteriovenous malformations are congenital abnormalities in which arteries connect directly to veins without the normal intervening capillary network, creating a risk of haemorrhage. Treatment may include surgical removal, embolisation, or radiosurgery, depending on their size and location.
Cavernomas are low-flow vascular malformations, often asymptomatic, but they may cause small recurrent haemorrhages or epileptic seizures depending on their location.
An arteriovenous fistula is a rarer, acquired abnormal connection between arteries and veins within the dura mater, which may cause pulsatile tinnitus, neurological deficits, or haemorrhage.
Carotid stenosis
Carotid stenosis is usually caused by atherosclerosis, that is, the build-up of lipid material within the arterial wall, and is associated with an increased risk of ischaemic stroke.
In cases of significant narrowing, carotid endarterectomy may be recommended, in which the atherosclerotic plaque is removed, usually in collaboration with a vascular surgeon.
Symptoms
Symptoms of vascular pathologies depend largely on the type and location of the condition. A sudden, severe headache, often described as the worst headache of the patient’s life, is a classic sign of aneurysm rupture.
Sudden weakness affecting one side of the body, difficulty speaking, visual disturbance, or loss of balance may indicate either an ischaemic or a haemorrhagic event. Epileptic seizures may be the first symptom of vascular malformations such as cavernomas or AVMs.
Diagnosis
Initial diagnosis is based on CT or MRI of the brain, while angiography, whether as CT angiography or digital subtraction angiography, helps provide detailed visualisation of the vessels and assists in planning the appropriate treatment.
Treatment approach
The choice of treatment depends on the type of vascular pathology, its size, its location, and the patient’s general condition.
Prognosis
Prognosis varies considerably depending on the type of pathology. An unruptured aneurysm discovered incidentally usually carries a good prognosis with appropriate surveillance or preventive treatment, whereas aneurysm rupture or extensive intracranial haemorrhage are emergency conditions with a more serious prognosis, largely dependent on the speed of the initial management.