Q & A with Alexander Khalessi

April 15, 2019 | Interview by Tiffany Fox

Brain of Thrones

Dr. Alexander Khalessi Explains TV Actress’ Life-Threatening Aneurysm

To “Game of Thrones” fans, she’s known as Daenerys Targaryen, Khaleesi of the Great Grass Sea, Lady of Dragonstone, Breaker of Chains, Mother of Dragons.

But actress Emilia Clarke can now add another title to her long list of honorifics: “Survivor of Two Life-Threatening Aneurysms.” In a recent article in The New Yorker, Clarke opened up about experiencing two subarachnoid hemorrhages (SAH), a type of potentially fatal stroke brought on by a ruptured aneurysm.

In this month’s Q&A, Neurosurgery Division Chief Alexander Khalessi, MD, explains the implications of SAH, the type of treatment Clarke received and the importance of receiving treatment at a Comprehensive Stroke Center. (And for the record, Dr. Khalessi is well aware of the name similarity between him and Khaleesi, and yes, he gets asked about it all the time.)

What exactly is an SAH?

Dr. Alexander Khalessi: A subarachnoid hemorrhage is a pattern of bleeding within the fluid space of the brain that is due to ruptured aneurysm, or a weakening of one of the arteries of the brain. The fluid spaces of the brain are covered with a thin film that approximates a spiderweb – that’s where the term ‘arachnoid’ comes from. A SAH has always been a trigger for neurosurgeons to look for a source of the bleeding because it often needs to be secured. Often the risk of that aneurysm rupturing a second time is the highest in the first 24-48 hours. That’s what makes it so important to identify and treat that aneurysm.

Why are aneurysms so dangerous?

AK: A ruptured aneurysm case is among the most serious conditions in any area of medicine, When an artery bleeds, it’s a high-pressure hemorrhage, and the skull is a closed system. The patient immediately suffers an intercranial pressure crisis that may be fatal. When an aneurysm ruptures in surgery, the patient is at risk of bleeding to death; all the blood coming out of the head should be going to the brain, so the brain, in the absence of blood flow, starts to stroke. As the brain starts to stroke, it swells. If an intracranial aneurysm ruptures during surgery, it is devastating to the patient and places significant pressure on the surgical team. We need to get it under control very, very quickly – in 30 seconds to one minute – or we can lose the surgical corridor. It’s therefore very important for us to try to create situations where our surgical trainees develop the reserve to stay calm and manage that situation.

What are the warning signs of an aneurysm?

AK: Unfortunately there are really very few. Typically when you have an acute expansion of an aneurysm, that often causes what’s called a sentinel headache. It’s classically described as the worst headache of your life -- a bad headache to the point of throwing up, often with changes to one’s vision. If an artery is diseased it might not be doing a good job of carrying blood where it needs to go so part of the brain is not receiving enough blood, that can also lead to neurologic deficits, such as weakness or numbness on one side of the body or difficulty with speech.

What is the mortality rate for SAH?

AK: Unfortunately with a SAH, about 40 percent of people will die instantly, because it’s a catastrophic event. A third will recover with maximal medical recovery, often requiring a hospitalization of a few weeks to a month, with some neurological deficit. A third, with maximal recovery, will recover altogether. A lot of the spirit of aneurysm treatment is to identify and treat those aneurysms before they bleed. If they do bleed, ensuring the patient immediately receives specialized neurosurgical and neuroICU care dramatically improves their chances of recovery.

How common are aneurysms?

AK: The true incidence is not well understood because a lot of aneurysms are picked up incidentally, meaning people have had their brains imaged for another reason and an aneurysm is found. We think the overall incidence might be as high as one percent in the general population, so it’s an extraordinarily common condition. In a country of 300 million people, roughly 30,000 aneurysms rupture in a given year.

How are aneurysms treated?

AK: There are two basic ways to treat aneurysms: Either in open surgery, where you put a clip on the aneurysm to exclude it from the circulation, or using catheters to fill the aneurysm with coils made of titanium or platinum. Think of these coils as about the thickness of a human hair. Typically for a one centimeter aneurysm, you’d put in 10mm by 30 cm coil. Volumetrically your goal is to fill a third of the volume of the aneurysm with coils without occluding the parent artery, and then the patient’s endogenous clotting mechanism will led the rest of the aneurysm to seal. Then there’s no more filling of the aneurysm, but good filling of the entire brain.

Is this the type of procedure that saved Emilia Clarke?

AK: Without question. She was treated in 2011, so she probably had conventional coiling and clipping. The pendulum has swung from what it was a few years ago: 50 percent open surgery, 50 percent catheter-based treatment. Now I’d say 75-80 percent of aneurysms can be treated with catheter-based technologies. You certainly can’t argue with her result. She had a good neurological recovery and they got her through a life-threatening event.

What can Emilia Clarke expect going forward?

AK: With multiple aneurysms she will need surveillance screening because she will have some baseline risk of developing de novo aneurysms that would need to be proactively treated. She’s obviously done well with the consequences of the hemorrhage itself, so she’s out of the window now where that would be an ongoing issue.

So, if you are one of the lucky ⅔ who don’t die from this…

AK: … with maximal care and follow up you can have a full and happy life. More so than in many conditions in medicine, for complex neurological problems, where you get care really matters. Because the stakes are quite high, the difference in outcomes can be dramatic. I think a key thing here at UC San Diego is we are the third Comprehensive Stroke Center in the country and one of the only healthcare systems that has two comprehensive stroke centers, at Hillcrest Medical Center and at Jacobs Medical Center. We also have the only NeuroICU staffed 24/7 by board-certified neurointensivists in San Diego County. It takes a whole team of people to manage these kinds of complex neurovascular problems effectively. A big part of my job is to figure out the right thing to do in a given clinical situation, and then once we know the right thing to do, make sure we hit that mark every time for everyone. That second piece means that we develop data in areas like hemorraghic stroke, and then design systems of care to be sure we can deliver that care in a highly reliable way. Coming up with secondary transfer protocols and making the anatomic diagnosis in real time is really important, and I feel quite comfortable we’re doing that at UC San Diego. If a member of our county has one of these diagnoses in the field, we work to make sure there’s not a ceiling to the care they have access to based on the vagaries of where an ambulance takes them.