颅内动脉瘤的介入治疗

IMAGE GUIDEDTHERAPIESMedia BriefingJune 19, 2003,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 Hospital,S p o n s o r e d b y t h e,Radiological Societyof North America,Brain Aneurysms Successfully Treated Without Open Surgery,Jacques E. Dion, M.D., FRCP (C)Professor of Radiology & NeurosurgeryDirector, Interventional NeuroradiologyEmory University HospitalAtlanta, GA,History of Coiling,1987-1989: Dr Guido Guglielmi (University of Rome) visits Dr Viuela (Interventional Neuroradiologist) at UCLA and research work on coiling concept starts1989: Dr Guglielmi comes permanently to UCLA1989-1990: Bench and animal researchMarch 6, 1990: First clinical use of Guglielmi Detachable Coil FDA 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 LancetVol 360, October 26, 2002,ISAT,A 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,Aneurysms are found in 2-5% of the populationThere are as many as 27,000 aneurysms that could be diagnosed and treated per year in the U.S. They are more common in women (Sharon Stone had an aneurysm that was treated with coils by an interventional neuroradiologist)The annual rupture rate is approximately 1.5% Rupture of an aneurysm results in approximately 50% mortality and 25% stroke incidence,Aneurysm Facts,Factors believed to contribute to brain aneurysms:SmokingHypertensionTraumatic head injuryAlcohol useUse of oral contraceptionFamily history of brain aneurysms Other inherited disorders: Ehlers syndrome, polycystic kidney disease, and Marfan syndrome,Aneurysm Facts,Symptoms of ruptured aneurysms:The worst headache of your lifeLocalized and intense headacheNausea and vomitingStiff neck or neck painBlurred or double visionPain above and behind eyeDilated pupilsSensitivity to lightLoss of sensation,Aneurysm Therapy,Surgical clipping (approximately 60-65% in the United States)Endovascular coiling (approximately 30-35% in the United States)In certain countries such as Finland, Great Britain and France, close to 90% of aneurysms are treated with endovascular coilingAfter the release of the ISAT results, the percentage of aneurysm patients treated with coiling in England went from 40% to 90%,Aneurysm Clipping,Done under general anesthesia through a craniotomy (hole in the head)The brain is gently retracted in order to gain visual access to the aneurysmA clip is placed at the neck of the aneurysm1 week in the hospital1 month recovery,ANEURYSM COILING,A minimally invasive procedure usually performed under general anesthesia by an interventional neuroradiologistA 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 potholeThe catheter is then removed and the small groin incision covered with a Band-AidFor an unruptured aneurysm, the patient is discharged home within 24 to 48 hours,Pros and Cons of Coiling,PROSMinimally invasive Short recoverySafer than surgeryCheaper than surgery,CONS Shorter track record Possibly less durableRequirement for follow-up angiography,The Future,Increased percentage of patients treated with coiling, in large volume referral centersUse of adjunctive maneuvers increases the percentage of aneurysms treatable with endovascular techniquesIncreased efficacy of coiling therapy (new, bioactive materials, tissue healing strategies) Development of non-invasive follow-up techniques with CT or MR scanningBetter 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,Endovascular coiling of aneurysms is available in over 200 hospitals in this country Approximately 200,000 patients in the world have benefited from endovascular coiling since its inception in 1990,Take Home Points,The 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,All patients with aneurysms should be informed of the availability of both endovascular coiling and surgical clipping by a neurosurgeon and an interventional neuroradiologistT