‘So excruciatingly painful, I cried’: Without warning, blood vessel burst in 26-year-old Singaporean’s brain, leading to stroke

SINGAPORE — For some people, a headache might seem like nothing more than an inconvenience, a sign to take a break or to reach for some paracetamol tablets to ease the symptom.  
For 26-year-old Tan Cheng Hui, though, a headache one day led to an emergency and her doctor said she may have died if not for immediate treatment. 
On June 23 this year, she was on her way to meet her boyfriend at Orchard MRT Station when she experienced “a terrible pain” in her neck and what felt like the worst headache of her life.
It came out of the blue, quickly escalated into debilitating pain and was accompanied by stiffness on the left side of her body, dizziness and nausea that made her want to vomit.
“It felt like my brain was exploding,” she recalled. 
“Normally, I have a high tolerance for pain, but this attack was so excruciatingly painful that I started to tear up.”
At first, she tried to brush it aside thinking she was feeling stressful and it was an old shoulder injury resurfacing. 
“I thought it was another headache that would soon go away — until the ‘brain exploding’ sensation came on and something felt different due to the stiffness on the entire left side of my body.” 
Seeing that the pain was so intense that she started crying — something she hardly does — her boyfriend rushed her to the nearest emergency department.
There, doctors delivered a diagnosis that Ms Tan never expected at her age: She had a ruptured brain aneurysm, which led to a haemorrhagic stroke.
A bulge, likened to a bubble or balloon, had formed in a blood vessel in her brain and it had burst. 
Once a healthy and active woman who would trek, cycle and swim regularly, Ms Tan was unable to talk or walk for weeks after the ordeal. 
It took weeks of therapy to regain basic movements and speech, and even now, she continues to experience side effects and remains homebound on most days.
Having been building her career as a digital and culinary artist before her diagnosis, she now chose to share her experience to raise awareness that a brain aneurysm rupture is “something that can happen anytime to anyone”. 
“I was someone who had no medical issues such as high blood pressure, have no family history (of brain aneurysms) and do not smoke, but I still got this,” she said. 
In 2019, British actress Emilia Clarke who played Daenerys Targaryen on TV series Game of Thrones famously wrote a personal column in The New Yorker magazine, titled A Battle for My Life, where she revealed how she had a ruptured brain aneurysm at the age of 24 in 2011 after landing the role that changed her career.
She went on to have a second, more severe rupture in 2013 and took years to get back on her feet.
For Ms Tan, she is nursing the effects of the health crisis and asked to do an email interview because her speech is still in recovery and using predictive text helps her communicate more easily.
Neurosurgeon Teo Kejia, who was called to attend to Ms Tan at the emergency department, said that unruptured brain aneurysms often go unnoticed because they do not typically cause symptoms. 
The senior consultant of private clinic Precision Neurosurgery added: “Many unruptured aneurysms are discovered incidentally during imaging tests for other conditions. 
“However, as they grow larger, they can press on surrounding brain tissue and nerves, potentially leading to symptoms such as headaches, vision problems or facial pain.” 
Ms Tan recalled that things had not been smooth-sailing before her brain aneurysm. 
Last year, she broke her collarbone and dislocated her left shoulder after a box fell on her from a high shelf at her workplace. 
She underwent several months of physiotherapy to regain the full use of her shoulder.
“At the same time, I was also having a tough time as a freelance culinary artist and was constantly under stress due to work commitments. I used to get headaches quite frequently at the time.”  
That was why when the brain aneurysm ruptured, she thought it was just “another headache”. 
However, Dr Teo said that these events likely did not contribute to her aneurysm. 
“The cause of her aneurysm was likely idiopathic, meaning of an unknown cause or mechanism of apparent spontaneous origin.”
In other words, Ms Tan may never know what triggered this life-changing medical event. 
At the National Neuroscience Institute (NNI), around 300 to 400 cases of aneurysms are seen a year, with 120 to 150 of these being ruptured aneurysms. 
The prevalence of brain aneurysms in Singapore is estimated at 3.5 per cent, based on a study done by the institute in 2017. 
Dr Julian Han, a consultant with the department of neurosurgery at the institute, explained that this means out of every 200 people, seven have brain aneurysms. 
Each year, a quarter of the patients diagnosed with brain aneurysms are younger adults under the age of 50. This proportion has remained consistent, based on the institute’s recent data in 2023.
With brain aneurysms, what is worrying is that people may not even know they have it until the blood vessel ruptures, dramatically altering their lives in an instant. 
Bleeding in the brain can lead to complications including a stroke. 
This type of stroke, which is a form of haemorrhagic stroke, has a 30 to 50 per cent fatality rate, Dr Han said.
Patients who have had a ruptured brain aneurysm also have another risk of getting an ischaemic stroke in the first two weeks after the rupture, as brain blood vessels may constrict or get narrow, Dr Teo said. 
A “leaking” brain aneurysm may also occur, which is also known as a sentinel bleed or warning leak. 
This happens when a small amount of blood oozes out from the aneurysm into the surrounding brain tissue, and can cause a sudden severe and intense headache that persists over several days up to two weeks, Dr Teo added. 
Other warning signs include nausea and neck stiffness.
“The leak might resolve on its own, but it is a significant warning sign that the aneurysm could rupture in the near future. 
“Immediate medical attention is critical to manage the aneurysm and prevent a full rupture,” Dr Teo said.
Brain aneurysms can develop due to a combination of genetic, environment and lifestyle factors that weaken the walls of the blood vessels in the brain. 
They are more common after the age of 40, and women are at a higher risk than men, possibly due to hormonal factors, Dr Teo said. 
Other risk factors include genetics and family history, as well as blood vessel abnormalities present at birth. 
Chronic high blood pressure, smoking and alcohol or drug use also significantly increases the risk.
Can persistent or intense stress increase the risk? There may be a link. 
Even though chronic or high stress itself may not directly cause brain aneurysms, Dr Han said that it can contribute to high blood pressure, which is a key risk factor. 
“Stress-induced hypertension (high blood pressure) may increase the likelihood of an aneurysm forming or rupturing.”  
A brain aneurysm can sometimes be mistaken for other problems such as migraines due to similarities in symptoms. 
“In general, having chronic or daily headaches are not related to aneurysms,” Dr Teo said.  
He explained that migraines usually develop gradually, often brought on by precipitating factors. 
Severe throbbing pain or a pulsing sensation on one side of the head are hallmark symptoms of a migraine, which can last for hours or days. 
Other symptoms are nausea, vomiting, extreme sensitivity to light and sound. 
On the other hand, aneurysm-related headaches are sudden and extremely severe, without warning. 
Patients are mostly without symptoms until the aneurysm ruptures, Dr Teo said. 
“However, when it ruptures, it is usually associated with a sudden, acute and ‘thunderclap’ headache,” he added.
Thunderclap headaches is so named because it strikes suddenly like a clap of thunder and the pain of these severe headaches is likened to blinding pain after being hit on the head. The pain typically peaks within a minute, though it can also last up to five minutes.
Dr Teo said that those who experience the rupture will complain of severe, intense and unbearable headaches. 
“There might also be accompanying sudden vision impairment, neck stiffness and other neurological (symptoms).
“When such headaches occur, seek medical attention immediately.”   
After scans confirmed the rupture in Ms Tan’s brain, Dr Teo performed emergency brain surgery and made an opening in her skull to place a clip at the base of the aneurysm, blocking blood flow from going into the aneurysm. 
If Ms Tan had not sought immediate medical attention that day, the aneurysm in her brain could have potentially ruptured again — and Dr Teo said that this could lead to death.
A blood clot was detected and it may expand and press onto her brain if treatment was delayed, he added.  
Ms Tan recalled being in a daze, not knowing what was happening to her. 
“I found out about my diagnosis and condition only when I began to recover.
“I did not understand the severity of my situation at the time, but I now realise that I was very fortunate to have survived a rupture brain aneurysm,” she said. 
The doctors pointed out that not all brain aneurysms require treatment.
It depends on the size, location, shape and growth. 
The person’s age, related medical conditions, history of a ruptured aneurysm or strong family history will also be considered. 
Dr Han from NNI said: “Very clear reasons for immediate treatment are if it has ruptured, or if the aneurysm has grown large enough to press on surrounding structures to cause neurological symptoms.
“As for aneurysms that have been picked up but are not causing symptoms, a comprehensive risk assessment should be made by a specialist as to whether or not treatment is required.” 
The doctors also highlighted that the treatment of aneurysm has its risks and could potentially trigger a stroke. 
However, if treatment is not administered in a situation where it is deemed necessary (where benefits of treatment outweigh its risks), there would be a risk of aneurysm rupture, and the risk of stroke in such a situation is considerably high, Dr Han added. 
After surviving a ruptured brain aneurysm and subsequent stroke, Ms Tan was unable to walk or talk for a few weeks. Her memory was also affected. 
“I couldn’t recognise my own name or remember my mother’s and boyfriend’s name,” she said. 
“There were times I called my mother ‘my sister’ and I could not even name everyday items that I was using on a daily basis such as a watch or comb.”
Ms Tan underwent numerous therapy and rehabilitation sessions to regain her motor movements and speech. 
Messaging applications on mobile devices and online tools helped her to communicate with her loved ones. 
When she could not articulate her needs, she would point to images of the items she needed. For this interview, Ms Tan was able to type out her responses on her own.
It took her a month to be able to communicate verbally again and, around the same time, to regain her daily movements and motor function with physiotherapy. 
“I still have difficulty remembering things, as well as describing and verbalising the things I want and need. My mother and boyfriend have been very patient with me when it comes to my inability to communicate clearly,” she said. 
Even eating is not second-nature anymore because her jaw often “locks” — one of the after-effects of the surgery, Ms Tan said. And food has to be cut into smaller pieces. 
She can still eat food that she loves such as steaks.
As for her job, she has had to turn down work opportunities such as food styling because it is difficult for her to stand for long hours. 
Culinary artists, who prioritise creativity and artistic expression in dishes, often spend long hours in the kitchen preparing ingredients and styling food. 
“My backup plan is to pursue digital art, which I used to do while working as a culinary artist. When it’s time for me to return to work, I’ll definitely figure something out,” she said. 
These days, when she goes out, Ms Tan is usually accompanied by someone because her family is concerned that she might become dizzy and need help.
At this stage, her wishes are simple — ones that many healthy young people take for granted. 
“I’d like to be able to go out alone, travel on my own and become active again,” Ms Tan said, adding that she hopes to resume work when she is able to stand for extended periods. 
An adventurous person at heart, she dreams of regaining her independence so that she can try extreme sports such as skydiving. 
“I also hope to fully recover my language and verbal capabilities, and to be able to enjoy a good night’s sleep again.” 
Her message for young people is to listen to their body and their instincts when something feels off about their health. 
To those on a similar recovery journey, she said: “Recovering from ruptured brain aneurysm is not easy and can take longer than expected. Be patient with yourself during this process.” 
Dr Teo said he is optimistic that Ms Tan has a good chance of a full recovery. 
“In general, the younger a patient is, the higher chance of neuroplasticity (the brain’s ability to change and adapt due to experience) and hence, a higher chance of good recovery,” he added.