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IMAGE GUIDED THERAPIES Media Briefing June 19, 2003 S p o n s o r e d b y t h e Radiological Society of North America Brain Aneurysms Successfully Treated Without Open Surgery V A S C U L A R D I S E A S E Jacques E. Dion, M.D. Emory University HospitalS p o n s o r e d b y t h e Radiological Society of North America Brain Aneurysms Successfully Treated Without Open Surgery Jacques E. Dion, M.D., FRCP (C) Professor of Radiology & Neurosurgery Director, Interventional Neuroradiology Emory University Hospital Atlanta, GA History of Coiling n1987-1989: Dr Guido Guglielmi (University of Rome) visits Dr Viuela (Interventional Neuroradiologist) at UCLA and research work on coiling concept starts n1989: Dr Guglielmi comes permanently to UCLA n1989-1990: Bench and animal research nMarch 6, 1990: First clinical use of Guglielmi Detachable Coil nFDA approval in 1995 International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial The Lancet Vol 360, October 26, 2002 ISAT nA recent large prospective study of 2143 patients with ruptured aneurysms who could equally be treated with clipping or coiling had to be prematurely stopped short of planned enrollment of 2500 patients because the coiled patients suffered significantly less death and dependency as compared to clipped patients (6.9% absolute difference, 22.6% relative difference) and it would have been unethical to continue the study What Is An Aneurysm? A cerebral aneurysm is a bubble like outpouching from an artery which predisposes its carrier to cerebral hemorrhage and stroke Images Frank H. Netter, CIBA Collection of Medical Illustrations Aneurysm Demographics nAneurysms are found in 2-5% of the population nThere are as many as 27,000 aneurysms that could be diagnosed and treated per year in the U.S. nThey are more common in women (Sharon Stone had an aneurysm that was treated with coils by an interventional neuroradiologist) nThe annual rupture rate is approximately 1.5% nRupture of an aneurysm results in approximately 50% mortality and 25% stroke incidence Aneurysm Facts nFactors believed to contribute to brain aneurysms: nSmoking nHypertension nTraumatic head injury nAlcohol use nUse of oral contraception nFamily history of brain aneurysms nOther inherited disorders: Ehlers syndrome, polycystic kidney disease, and Marfan syndrome Aneurysm Facts nSymptoms of ruptured aneurysms: nThe worst headache of your life nLocalized and intense headache nNausea and vomiting nStiff neck or neck pain nBlurred or double vision nPain above and behind eye nDilated pupils nSensitivity to light nLoss of sensation Aneurysm Therapy nSurgical clipping (approximately 60-65% in the United States) nEndovascular coiling (approximately 30-35% in the United States) nIn certain countries such as Finland, Great Britain and France, close to 90% of aneurysms are treated with endovascular coiling nAfter the release of the ISAT results, the percentage of aneurysm patients treated with coiling in England went from 40% to 90% Aneurysm Clipping nDone under general anesthesia through a craniotomy (hole in the head) nThe brain is gently retracted in order to gain visual access to the aneurysm nA clip is placed at the neck of the aneurysm n1 week in the hospital n1 month recovery ANEURYSM COILING nA minimally invasive procedure usually performed under general anesthesia by an interventional neuroradiologist nA very small plastic tube (microcatheter) is threaded from the groin to the aneurysm in the brain, and fine platinum threads (coils) are inserted into the aneurysm to fill it from the inside, much like filling a pothole nThe catheter is then removed and the small groin incision covered with a Band-Aid nFor an unruptured aneurysm, the patient is discharged home within 24 to 48 hours Pros and Cons of Coiling PROS nMinimally invasive nShort recovery nSafer than surgery nCheaper than surgery CONS nShorter track record nPossibly less durable nRequirement for follow-up angiography The Future nIncreased percentage of patients treated with coiling, in large volume referral centers nUse of adjunctive maneuvers increases the percentage of aneurysms treatable with endovascular techniques nIncreased efficacy of coiling therapy (new, bioactive materials, tissue healing strategies) nDevelopment of non-invasive follow-up techniques with CT or MR scanning nBetter educated population will actually demand availability and discussion of both endovascular coiling and surgical clipping options Stent + Coil Wide neck mid basilar aneurysm Stent + coils Hydrocoil Matrix Bioactive Coil Take Home Points nEndovascular coiling of aneurysms is available in over 200 hospitals in this country nApproximately 200,000 patients in the world have benefited from endovascular coiling since its inception in 1990 Take Home Points nThe ISAT study recently demonstrated a substantially better clinical outcome (22.6% less death and dependency relative difference, 6.9% absolute difference) in patients with ruptured aneurysms treated with endovascular coiling compared to patients treated with surgical clipping Take Home Points nAll patients with aneurysms should be informed of the availability of both endovascular coiling and surgical clipping by a neurosurgeon and an interventional neuroradiol