Game of Thrones’ star suffered two brain aneurysms; Here’s what it means.

The long anticipated eighth and final season of the hit HBO series Game of Thrones (GoT) will finally premiere today.  As predictions and fan theories fly on how the popular show will end, one thing is for certain: actress Emilia Clarke, who plays Daenerys Targaryen, is a survivor on and off screen.

Clarke’s character, also known as the Mother of Dragons, is one of a few players who has survived for the final season of the TV drama. But in the real world, Clarke, 32, was in the battle for her life during the filming of the early seasons of GoT.

In March, the actress penned an essay for The New Yorker in which she revealed she suffered two life-threatening brain aneurysms – the first when she was just 24 years old.

“I was in the gym, and the most excruciating pain, like an elastic band just went like snap! in my head, like an enormous amount of pressure suddenly,” Clarke told CBS Sunday Morning correspondent Tracy Smith.

She had suffered a subarachnoid hemorrhage, “a life-threatening type of stroke, caused by bleeding into the space surrounding the brain,” Clarke wrote in her essay.

Emilia Clarke at the season 6 premiere of Game of Thrones. Source: Shutterstock.com

With nearly 30 accredited comprehensive stroke centers in the HCA Healthcare family, our median stroke response time was 25 percent faster than the standard national goal last year.

We sat down with Joseph Cheatle, a neurosurgeon at HCA Healthcare affiliate Grand Strand Medical Center, a newly designated comprehensive stroke center, to discuss the affliction that affects an estimated 30,000 people each year in the United States: a ruptured brain aneurysm.

Dr. Joseph Cheatle has served as a neurosurgeon for six years at HCA Healthcare’s Grand Strand Medical Center.

What is a brain aneurysm?

It is when an individual has an outpouching due to weaning of the arterial wall and what happens is, the person will have a higher risk of a kind of stroke called a subarachnoid hemorrhage, a bleed into the fluid filled area called the subarachnoid space.

What are symptoms?

The most common symptom is a sudden, severe “thunderclap” headache. It is often described as the worst headache anyone has ever had. It’s almost always a sudden headache, not gradual, and it’s quite severe.

Sometimes an individual will have vision changes, nausea and vomiting or present with weakness, numbness, tingling or even a coma. But a sudden, severe headache is the classic sign.

How common are brain aneurysms in someone of this age?

Brain aneurysms usually develop later in life, but it can happen in 20 and 30-year-olds. However, it is more common after 40 or the older one gets. Women also tend to have higher rates of aneurysms than men.

How is it diagnosed?

It is commonly picked up on a CT, or CAT scan. Very rarely does it have to be detected by a lumbar puncture (spinal tap) to get spinal fluid for diagnostic purposes.

What are the risk factors?

The most common modifiable risk factors are smoking and drinking, which come in at number one and two, respectively. High blood pressure is also a risk factor.

How is it treated?

An aneurysm can re-rupture so it’s important to seek emergency care at a facility where it can be treated. Treatment options include:

• a craniotomy – an incision in the scalp in order to open a window of the skull and dissect down to the blood vessels, which are at the base of the brain, and place a clip to close off the aneurysm.
• endovascular coiling – a minimally invasive technique, which involves a needle poke in the groin and, through catheters, feed up platinum coils inside the aneurysm to disrupt the blood flow. (Emilia Clarke wrote in The New Yorker that her surgeons performed this procedure the first time.)
  

  Emilia Clarke shared photos of her surgeries. Source: YouTube/CBS Sunday Morning

What are complications from a ruptured aneurysm or subarachnoid hemorrhage?

The re-hemorrhage rate is about 2-4% per day and 50% at six months. An individual also can develop hydrocephalus, an increased fluid in the brain. It oftentimes requires an external ventricular drain, which is a little tube that goes through the skull and into the brain to drain the fluids.

There’s also a risk of what’s called vasospasm. The blood vessels that live in the subarachnoid space react to the blood from the subarachnoid hemorrhage, causing the blood vessels to clamp down. This would cause a delayed ischemic stroke – the kind of stroke that most people think of – and could be a significant life-threatening problem.

The last complication is called cerebral salt wasting, where the brain reacts to the blood and causes the body to excrete too much salt. This can be a very significant and a life-threatening problem as well.

Patients are usually monitored in the neurosurgical intensive care unit (ICU) for up to two weeks after a subarachnoid hemorrhage. (According to reports, Clarke was discharged from the hospital one month after being admitted.)

Is it life-threatening?

There are three different outcomes for people who have suffered a subarachnoid hemorrhage. The most common complication is when the aneurysm ruptures, it causes bleeding into the fluid-filled space and a build-up of pressure on the brain stem. This can result in loss of consciousness or even death.

According to the Brain Aneurysm Foundation, brain aneurysms:

• kill 40% of the time, often instantly;
• result in 15% never reaching the hospital, and
• the 66% of those who survive sustain permanent brain damage.

Clarke shared she had a second aneurysm, which had not ruptured and was disclosed to her while in the hospital for her subarachnoid hemorrhage. How common is it to have two brain aneurysms? 

Brain aneurysm concept as a 3D illustration.

There is a chance of multiple aneurysms. Most people, like Clarke, will learn of other aneurysms at the initial presentation because the imaging will detect it. There are some very, very rare genetic diseases that increase the risk of multiple aneurysms.

Most people who have multiple aneurysms are aware of it and are oftentimes treated electively in the short-term after recovering from their subarachnoid hemorrhage. (It’s been reported that Clarke was treated for the second aneurysm two years after the first one burst. This time, surgeons accessed her brain through her skull.)

What’s the recovery process?

It’s a really long recovery. Most people are in the ICU for two weeks, and after that, it takes the brain a year to 18 months to heal. It’s not uncommon to have a year to a year-and-a-half to recover from subarachnoid hemorrhage.

Clarke is lucky, says Dr. Cheatle, but her story is far from unique. According to the American Heart Association, one in 50 people are living with an undetected brain aneurysm. The actress has since made a full recovery and is now raising awareness about the disease that sits silently until a rupture occurs.

She is looking forward to the future and the finale of Game of Thrones.

Talk to your healthcare provider or click here for more information about brain aneurysms.

Dr. Joseph Cheatle is a neurosurgeon affiliated with HCA Healthcare’s South Atlantic Division.