“I immediately knew something was wrong. I get migraines. This was nothing like a migraine.”
October 28, 2022, was a fairly typical Friday for then 48-year-old Kim Bello. While working from home, she crumpled to the floor with a sudden, piercing pain she later described as “the worst headache of my life.”
Kim and her partner
“I immediately knew something was wrong,” she said. “I get migraines. This was nothing like a migraine.”
Bello collected herself enough to call her significant other, who had left minutes earlier. She told him she thought she needed to go to the hospital. After hanging up, she began vomiting from the overwhelming pain.
She continued to do so in the waiting area at the Center for Emergency Care at Penn Princeton Medical Center, a five-minute drive from their home. Once she was seen by a doctor and given medication to help ease her pain, she was scheduled for a CT angiogram, a test where dye is injected to highlight blood vessels and tissues in a designated area of the body. A CT scan is then taken to view the area.
Because the sudden onset of “the worst headache of my life” is how a ruptured brain aneurysm is frequently described, her doctor had an inside track on the potential cause of her pain.
Sure enough, the CT scan revealed a subarachnoid hemorrhage, which is bleeding between the brain and the thin tissues that cover and protect it. It’s usually caused by head trauma and/or a ruptured brain aneurysm.
Subarachnoid hemorrhages can vary in severity, and Bello’s appeared to result from a relatively small aneurysm. But it was still considered life-threatening. A very thin blood clot was acting as a tenuous plug. Even the most subtle spike in blood pressure could cause the aneurysm to rupture again, which is often fatal.
Bello was stabilized and moved aboard a helicopter that flew her to the Hospital at the University of Pennsylvania (HUP), where she would undergo a procedure with Penn’s cerebrovascular disease experts that saved her life.
Finding, and sealing, the rupture
As Bello was waiting to be moved to the helicopter, the gravity of the moment pressed down on her. She turned her head toward her significant other of nearly 10 years, who was standing beside her stretcher, and said, “I don’t have a will.”
She choked back tears at the memory.
“It’s going to be OK,” he reassured her.
At HUP, cerebrovascular neurosurgeon Visish Srinivasan, MD, assessed Bello for signs of swelling on the brain. Day had become night by this point. No swelling was detected, which meant an emergency surgery wasn’t needed. A minimally invasive procedure could wait until the morning. On various medications to help keep her stabilized, Bello drifted in and out of sleep that night in the intensive care unit.
In the morning, Srinivasan performed a diagnostic angiogram on Bello. Under general anesthesia, a catheter the diameter of a twig was inserted through a tiny incision in her wrist and threaded up her arm and neck to the carotid artery.
There are two main carotid arteries, one on each side of the neck, that supply oxygen-rich blood to the brain, face, and neck. In this instance, it’s helpful to think of them as highways with many exits that lead to large networks of local streets, or blood vessels. The blood flowing through these exits, or branch points, can generate a lot of force. And with enough force, the vessel can rupture.
From Bello’s carotid artery, Srinivasan traced an intricate path to her aneurysm. It was located in the anterior communicating artery, which, he said, is the spot where ruptured brain aneurysms most commonly occur.
Bello’s aneurysm was about two millimeters. “About as small as they come,” Srinivasan said.
He’s used her case to help dispel the myth that aneurysms below a certain size pose no risk of bleeding.
“It’s a lot less risk than an aneurysm that’s seven millimeters or more, but it’s definitely not zero,” he said. “Understanding that is why a surgeon who treats aneurysms, not just follows them, is best equipped to counsel someone who’s been diagnosed with an aneurysm.”
Srinivasan sealed Bello’s ruptured artery with tiny coils made of very fine platinum threads. Once sealed, there was no further risk of bleeding, he removed the catheter and a wristband was placed over her incision, which was fully healed within a couple hours.
A new threat
The procedure was a significant step, but Bello wasn’t out of the woods yet.
Her brain remained coated in a thin layer of blood from her ruptured aneurysm. In time–Srinivasan says it can take anywhere from a couple weeks to a couple months, depending on the extent of the bleeding–her body would naturally wash it away. In the meantime, it was going to be very irritating to her brain.
Bello said she felt an incredible pressure in her head, even as she continued taking pain medication.
She was also at risk of seizures and a stroke because of a condition that can be triggered by this irritation. A vasospasm is an extended constriction of an artery that reduces blood flow through the artery, meaning nearby tissues receive less oxygen than they normally would. Vasospasms can occur in different arteries, but they happen more often in some arteries, including the heart, fingers and toes, and the brain.
Bello was monitored in the intensive care unit for more than a week after her procedure. She didn’t experience any abnormal events then or after she was discharged. She remained on pain medication to help with her headaches, until three weeks after the procedure.
Before Bello was discharged, Srinivasan performed a second diagnostic angiogram, this time under light sedation, to ensure her aneurysm remained fully sealed and her arteries were “relaxed.” This would indicate she was no longer at risk of a stroke or seizure.
Srinivasan saw Bello three months, six months, and a year after her procedure at Penn Neurosurgery in Princeton. He said her aneurysm remained stable, and didn’t need to undergo more angiograms. However, every couple of years, she should undergo an MRI to scan for new aneurysms.
There is about a 20 percent chance Bello will develop another brain aneurysm at some point in her life, Srinivasan estimated.
“She’s got a lot of life still ahead of her, so there is a small and real chance,” he said. “But if that aneurysm is detected early–and we would catch it early by doing these screenings every two years–we’ll prevent it from causing a problem. And my hope is, we’ll have something easy and preventive to treat it, whether that’s a pill or a risk factor modification.”
Finding her stride
Virtually nothing about Bello or her lifestyle put her at risk of developing an aneurysm in the first place. Smoking and high blood pressure, for most people, are the two leading risk factors. Bello never smoked and did not have high blood pressure.
Srinivasan did discover some small variations in the way her arteries are shaped that may have contributed to a higher rate of force at the branch points in her arteries.
Still, Bello became very cautious in the months after her procedure, worrying she may cause a re-rupture or a new aneurysm to form. She took a long-planned sailing trip with her family just a couple months after she was discharged–with Srinivasan’s endorsement–but she was hesitant to resume her ambitious exercise regimen.
“If you know you have a medical condition, you usually start researching and processing it before you begin treatment, whereas this just happened,” Bello said. “I didn’t start reading stuff or processing what happened until after the fact.”
She regularly found herself becoming emotional over ordinary moments with her three kids, imagining how easily she could have been absent from them.
With therapy, Bello was able to regain her footing. Srinivasan’s reassurance at her six- and 12-month follow-ups also helped.
“He’s been wonderful,” she said. “He’s made me feel so comfortable. And he’s never in a rush. I’ve always felt free to ask any questions I may have when we’re together.”
Bello returned to work several weeks after her ruptured aneurysm. In the time since, neither she nor anyone else has noticed any deficiencies in her performance. In fact, she assumed even more responsibility.
When she reflected on that October Friday when everything abruptly changed, she said, “I guess I just drew the short straw.” But almost everything since then has underscored just how fortunate she is.