The New Yorker recently published a segment by Emilia Clarke, better known as Daenerys Targaryen from The Game of Thrones. She detailed her experience with two aneurysms and two separate subarachnoid hemorrhages. It is well worth reading. Read below for Dr. Adam. P. Smith’s perspective on cerebral aneurysms. Dr. Smith is a board certified neurosurgeon at Rocky Mountain Brain and Spine Institute.
Cerebral aneurysms are a weakness in a blood vessel’s wall within the brain. Thought to be present since birth, an aneurysm may start as a blister but can enlarge with time, and in certain circumstances rupture. About 5% of people have aneurysms and most probably do not know they have one. Many people probably live a normal life without any issue. About 20% of those who are diagnosed with an aneurysm have another. Depending on the aneurysm’s size, they may rupture, called a subarachnoid hemorrhage. When this occurs it may be fatal or result in significant sickness.
Unfortunately for Emilia, at the age of 24, she suffered a subarachnoid hemorrhage. Per her account, she had just finished her first season with Game of Thrones in 2011 when she experienced the typical, “worst headache of my life” while exercising. This type of headache description is the buzz phrase we neurosurgeons commonly hear in our subarachnoid hemorrhage patients. She was lucky, however, and was able to make it to the hospital. Over 1/3 of patients die before reaching the hospital, and over 50% die by 6 months.
When an aneurysm ruptures it often will stop bleeding temporarily. A clot forms over the pinhole site of rupture, but can bleed again. Therefore the first concern following a subarachnoid hemorrhage is treating the aneurysm so that it does not re-rupture. For Emilia, that involved a minimally invasive endovascular procedure in which small metal coils were placed in the aneurysm. An international study called the ISAT was published in 2002 comparing clipping versus coiling, which are the two common ways of treating an aneurysm. Survival at one year was better with coiling, but long-term risk of further bleeding was higher with coiling compared to clipping. Coiling may also require multiple procedures, while clipping tends to just require one.
Emilia’s recovery was slow with some transient neurologic deficits including speech problems. About 1/3 of subarachnoid hemorrhage patients survivors are left with neurologic deficits. About 2/3 have a reduced quality of life. Emilia was lucky and able to be discharged a month after she arrived at the hospital. The average hospital stay following subarachnoid hemorrhage as about 21 days.
During her angiogram (procedure to coil the aneurysm), it was found she had another unruptured aneurysm on the opposite side of her brain. As mentioned earlier, this can happen about 20% of the time. Unruptured aneurysms have been studied as well in the ISUIA 2003 study. Most aneurysms at time of rupture are less than 7mm in size, and these have virtually a 0% change of rupture over the next 5 years. Based on another 2007 study by Komotar et al, we often recommend any unruptured aneurysm that is causing symptoms to be treated. Asymptomatic aneurysm less than 5mm often are observed. Aneurysms larger than 5mm in younger patients should consider treatment. Emilia elected to observe this 2nd aneurysm.
In 2013 a repeat scan showed it enlarged. Emilia underwent another attempted endovascular coiling but this procedure was unsuccessful and may have caused the aneurysm to rupture. This can happen 2-3% of the time during endovascular treatment. She then required the aneurysm to be surgically clipped, which involves an incision on her head, making a hole in the skull, and placing a titanium clamp across the aneurysm. This led to another month long hospital stay with all the same risks and recovery. She eventually did very well.
Many patients are concerned about the cosmetic risks of a craniotomy. However, as in Emilia’s case, I doubt any of her fans could see any cosmetic changes. In fact, I am not sure any of her fans knew she had this procedure until now, and she has completed another 5 seasons of the show.
In the Game of Thrones, Daenerys Targaryen once said, “I spent my life in foreign lands. So many men have tried to kill me, I don’t remember all their names”. In real life, Emilia Clarke said, “Just when all my childhood dreams seemed to have come true, I nearly lost my mind and then my life.”
Emilia, just as many others, successfully survived aneurysmal subarachnoid hemorrhage. Treatment is multimodal, and while not all people would be able to return to a successful TV show, great neurosurgical care can lead to pretty good outcomes.
Click here to read Emily Clarke’s journey to getting the coveted role on the Game of thrones and her battle with aneurysms as narrated to The New Yorker.