Doctors at the University of Maryland Medical Center are among the first in the country to perform a new procedure involving a stent, combined with coiling, to treat brain aneurysms. The treatment provides a non-surgical option for patients with "wide neck" aneurysms, who make up about 25 percent of the people with brain aneurysms. Those are weak spots in a blood vessel that balloon out and can rupture. When an aneurysm ruptures, it causes bleeding in the brain and a significant risk of death. With "wide neck" aneurysms, the bulge in the vessel has a wide opening where it attaches to the artery.
In recent years, doctors have been able to repair "narrow neck" aneurysms by inserting coils through a small catheter passed up through blood vessels in the brain. They fill the aneurysm with tiny, spring-like coils, re-directing the blood flow away from the weakened vessel wall. But before the new stenting procedure was developed, that therapy could not be offered to people with "wide neck" aneurysms because the coils would not stay in place with the wider opening.
"A stent is a very small, metal scaffold with lots of holes in it," says Gregg Zoarski, M.D., director of Neuroradiology at the University of Maryland Medical Center and associate professor of Diagnostic Radiology at the University of Maryland School of Medicine. "The stent provides a framework, bridging the wider neck, so we can insert the coils and keep them from falling out. Then the body's own natural healing abilities take over; blood clots on the coils, sealing off the weakened area, preventing a rupture."
One of Dr. Zoarski's first aneurysm patients treated with the stent-assisted coiling is 41-year-old Gerry Neal of Rosedale, Maryland. When she had an unusual pain on the right side of her head in August, she blamed it on the summer heat. The pain stretched from the back of her head to her temple and lasted for only a few seconds. When it happened several more times, Ms. Neal decided to see her doctor. An MRI showed the problem: a large aneurysm in her brain.
At that time, because her aneurysm had a wide neck, Ms. Neal was not a candidate for coiling. Previously, patients with a wide neck aneurysm would need brain surgery with a procedure called surgical clipping. It involves drilling into the skull and placing a clip over the neck of the aneurysm, effectively cutting it off from the circulatory system. Recovery time for this procedure is much longer compared to coiling.
"With coiling, patients usually spend about two nights in the hospital and can typically get back to work in about a week," says Dr. Zoarski. "On the other hand, surgical clipping involves five to seven nights in the hospital, and patients are out of work for six to twelve weeks."
But not all aneurysms can be clipped. In fact, doctors first tried clipping to fix Ms. Neal's aneurysm, but its location low on the skull base caused concerns during surgery. "Surgery wasn't easy," Ms. Neal says. "My head was shaved for the surgery, and afterward it swelled." She still has a scar on her head.
With the new stent-assisted coiling procedure, doctors do not need to enter the brain through the skull; instead, they enter the body through an artery in the groin. Using advanced computer x-ray scanners, skilled radiologists guide a micro-catheter (less than one millimeter in diameter) through the blood vessels to the site of the aneurysm in the brain. They then deploy the stent that spans the neck of the aneurysm and conforms to the shape of the artery. Small gaps in the stent allow doctors to feed the tiny platinum coils into the bulge of the aneurysm. The number of coils needed depends on the size of the aneurysm. The coils themselves are only a few millimeters wide.
The stent prevents the coils from falling out of the aneurysm. "If they fell into the blood vessel, they could block the carotid artery or a smaller branch and cause a stroke," warns Dr. Zoarski. "Placing the stent across the neck of the aneurysm increases the safety of the procedure and helps us to fill the aneurysm completely with coils."
If left untreated, an aneurysm can rupture causing a subarachnoid hemorrhage. It's a dangerous condition that affects about 30,000 people every year in the United States. In up to half of these cases, this type of hemorrhage can be fatal; patients who do survive often face severe disabilities. An estimated five million Americans have some sort of cerebral aneurysm, and up to one quarter of those may have a wide neck.
Many patients may feel like they have a time bomb in their heads, fearing the aneurysm could burst at any time. Ms. Neal admits she had a tough time in the beginning and cried when she learned her diagnosis. "My family was upset, thinking I was going to die," she says. But she kept a positive attitude. "I resolved to get through it. I resolved to smile and laugh more."
Now, after the stent-assisted coiling procedure at the University of Maryland Medical Center on December 20th, Ms. Neal is doing well. She went back to work about a week after the procedure. "People are amazed to see me back at work so soon," she says. "My daughter is relieved that I'm going to be okay; my son says he knew it all the time."
**Video available of procedure on beta tape.
RSS