1、IMAGE GUIDEDTHERAPIESMedia BriefingS p o n s o r e d b y t h eRadiological Societyof North AmericaBrain Aneurysms Successfully Treated Without Open SurgeryV A S C U L A R D I S E A S EJacques E.Dion,M.D.Emory University HospitalS p o n s o r e d b y t h eRadiological Societyof North AmericaBrain Ane
2、urysms Successfully Treated Without Open SurgeryJacques E.Dion,M.D.,FRCP(C)Professor of Radiology&NeurosurgeryDirector,Interventional NeuroradiologyEmory University HospitalAtlanta,GAHistory of Coilingn1987-1989:Dr Guido Guglielmi(University of Rome)visits Dr Viuela(Interventional Neuroradiologist)a
3、t UCLA and research work on coiling concept startsn1989:Dr Guglielmi comes permanently to UCLAn1989-1990:Bench and animal researchnMarch 6,1990:First clinical use of Guglielmi Detachable Coil nFDA approval in 1995International Subarachnoid Aneurysm Trial(ISAT)of neurosurgical clipping versus endovas
4、cular coiling in 2143 patients with ruptured intracranial aneurysms:a randomized trialThe LancetVol 360,October 26,2002ISATnA 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 e
5、nrollment 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 out
6、pouching from an artery which predisposes its carrier to cerebral hemorrhage and stroke Images Frank H.Netter,CIBA Collection of Medical IllustrationsAneurysm DemographicsnAneurysms are found in 2-5%of the populationnThere are as many as 27,000 aneurysms that could be diagnosed and treated per year
7、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 FactsnFactors believed
8、 to contribute to brain aneurysms:nSmokingnHypertensionnTraumatic head injurynAlcohol usenUse of oral contraceptionnFamily history of brain aneurysms nOther inherited disorders:Ehlers syndrome,polycystic kidney disease,and Marfan syndrome Aneurysm FactsnSymptoms of ruptured aneurysms:nThe worst head
9、ache of your lifenLocalized and intense headachenNausea and vomitingnStiff neck or neck painnBlurred or double visionnPain above and behind eyenDilated pupilsnSensitivity to lightnLoss of sensation Aneurysm TherapynSurgical clipping(approximately 60-65%in the United States)nEndovascular coiling(appr
10、oximately 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 coilingnAfter the release of the ISAT results,the percentage of aneurysm patients treated with coiling in England went from 40%to 90%Aneurysm Cli
11、ppingnDone under general anesthesia through a craniotomy(hole in the head)nThe brain is gently retracted in order to gain visual access to the aneurysmnA clip is placed at the neck of the aneurysmn1 week in the hospitaln1 month recoveryANEURYSM COILING nA minimally invasive procedure usually perform
12、ed under general anesthesia by an interventional neuroradiologistnA 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 potholenThe catheter is then
13、 removed and the small groin incision covered with a Band-AidnFor an unruptured aneurysm,the patient is discharged home within 24 to 48 hours Pros and Cons of CoilingPROSnMinimally invasive nShort recoverynSafer than surgerynCheaper than surgery CONS nShorter track record nPossibly less durablenRequ
14、irement for follow-up angiography The FuturenIncreased percentage of patients treated with coiling,in large volume referral centersnUse of adjunctive maneuvers increases the percentage of aneurysms treatable with endovascular techniquesnIncreased efficacy of coiling therapy(new,bioactive materials,t
15、issue healing strategies)nDevelopment of non-invasive follow-up techniques with CT or MR scanningnBetter educated population will actually demand availability and discussion of both endovascular coiling and surgical clipping optionsStent+CoilWide neck mid basilar aneurysmStent+coilsHydrocoilMatrix B
16、ioactive CoilTake Home PointsnEndovascular 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 PointsnThe ISAT study recently demonstrated a substantially b
17、etter 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 PointsnAll patients with aneurysms should be informed of the availabil
18、ity of both endovascular coiling and surgical clipping by a neurosurgeon and an interventional neuroradiologistnThe death and complication rate for aneurysm therapy is dramatically reduced in high volume centers that offer both surgical clipping and endovascular coiling Information and LinksAmerican Society of Interventional andTherapeutic Neuroradiology(ASITN)
