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New Minimally Invasive Treatment Offers Alternative to Open Surgery
The Forum News
Published Wednesday, June 13, 2007
by Michael Williams, MD

David, a 52-year-old man, was at work when he experienced a sudden onset of the worst headache of his life. His coworkers called 911 and he was immediately transported to a local hospital. A CT scan of his brain revealed evidence of bleeding in his brain which is often associated with ruptured brain aneurysms.

He was transferred to LSUHSC in Shreveport and underwent a more detailed examination of the arteries in his brain by the staff of the Department of Neurosurgery. The CT angiogram revealed an aneurysm of the anterior cerebral artery as the cause of the brain hemorrhage.

A brain aneurysm is a balloon-like bulge in the wall of a brain artery. If this bulge tears and bleeds, nearby cells may be damaged. A brain aneurysm can occur in an artery wall that is weak or has a defect. An aneurysm is often associated with hardening of the arteries, high blood pressure, heredity, or a head injury. Symptoms of an aneurysm include severe headaches, such as David's, clumsiness, weakness on one side of the body, neck stiffness, nausea, vomiting, brief blackouts and vision or speech problems.

At this point, he had arrived at a crossroads in the latest in neurosurgical care of brain aneurysms. For the past thirty years, patients and physicians have had only one option which is traditional open brain surgery with placement of a titanium clip on the aneurysm to prevent further bleeding. Now, another option exists for patients with aneurysms that is much less invasive. The aneurysm can be closed from inside the blood vessel without open surgery, referred to as coiling.

Interventional Neuroradiology is a minimally invasive approach in the treatment of vascular diseases of the central nervous system. Many recent advances have occurred in imaging and devices to make these treatments possible. Conditions in the past that would have required surgical intervention such as aneurysms, vascular malformations, and fistulae of the brain, spine, head and neck can be considered for treatment by using an endovascular approach as opposed to open surgery.

The procedure of coiling the aneurysm involves placing a catheter into the artery supplying the aneurysm. Then a smaller catheter, called a microcatheter, is advanced through the arteries in the brain to the exact location of the aneurysm. Tiny, delicate metal coils are placed into the aneurysm which have been matched to the size of the aneurysm. These are placed until the aneurysm is totally closed to prevent further chance of bleeding, the same goal as traditional surgery.

The treatment decision of coiling or open surgery for each patient is based on many factors including aneurysm size, location and shape, as well as patient age and condition. In a recent study of ruptured brain aneurysms, patients who were considered good candidates for either treatment faired much better at one year with coiling as opposed to surgical clipping.

Both neurosurgical and endovascular specialists evaluated David, and coiling of the aneurysm was recommended due to the location of the aneurysm and its rupture. It was completely closed without complication, he was discharged and has made a full recovery. He is now six months out from his treatment and enjoying a new lease on life.

While many hospitals have a neurosurgeon capable of aneurysm clipping, very few have specialists with training in aneurysm coiling. The specialty of interventional neuroradiology is relatively new. Recent studies have indicated better outcomes in aneurysm treatment at hospitals performing high volumes of aneurysm treatment. Most people are not aware that a less minimally invasive treatment is an option and don't know to ask about the best possible treatment if they are not familiar with this specialty.

Other recent advancements have provided the opportunity for patients with blockages in arteries to the brain to be opened with angioplasty and stenting, much like is currently done in the heart. FDA approval of both carotid and intracranial stents has made it possible to perform procedures that open blood vessels in high-risk patients. This can prevent the occurrence of a stroke. These are usually found during workup for "mini-strokes," which are also called transient ischemic attacks. These are very serious and can be a warning sign of a stroke.

Treatments also have been developed to treat an acute stroke if patients seek medical attention within the first few hours of symptoms. Treatment may involve administering a clot-busting drug through the vein or may require an endovascular approach to remove the clot and reopen the blood vessel.

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