1. 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

2. Brain Aneurysms Successfully Treated Without Open Surgery
V A S C U L A R D I S E A S E
Brain Aneurysms Successfully Treated Without Open Surgery
Jacques E. Dion, M.D.
Emory University Hospital
S p o n s o r e d b y t h e
Radiological Society
of North America

3. 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

4. History of Coiling FDA approval in 1995
: Dr Guido Guglielmi (University of Rome) visits Dr Viñuela (Interventional Neuroradiologist) at UCLA and research work on coiling concept starts
1989: Dr Guglielmi comes permanently to UCLA
: Bench and animal research
March 6, 1990: First clinical use of Guglielmi Detachable Coil
FDA approval in 1995

5. 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

6. ISAT
A recent large prospective study of 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

7. 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

8. Aneurysm Demographics
Aneurysms are found in 2-5% of the population
There 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

9. Aneurysm Facts Factors believed to contribute to brain aneurysms:
Smoking
Hypertension
Traumatic head injury
Alcohol use
Use of oral contraception
Family history of brain aneurysms
Other inherited disorders: Ehler’s syndrome, polycystic kidney disease, and Marfan syndrome

10. Aneurysm Facts Symptoms of ruptured aneurysms:
The worst headache of your life
Localized and intense headache
Nausea and vomiting
Stiff neck or neck pain
Blurred or double vision
Pain above and behind eye
Dilated pupils
Sensitivity to light
Loss of sensation

11. 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 coiling
After the release of the ISAT results, the percentage of aneurysm patients treated with coiling in England went from 40% to 90%

12. 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 aneurysm
A clip is placed at the neck of the aneurysm
1 week in the hospital
1 month recovery

13. ANEURYSM COILING
A minimally invasive procedure usually performed under general anesthesia by an interventional neuroradiologist
A 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
The catheter is then removed and the small groin incision covered with a Band-Aid
For an unruptured aneurysm, the patient is discharged home within 24 to 48 hours

19. Pros and Cons of Coiling
Minimally invasive
Short recovery
Safer than surgery
Cheaper than surgery
CONS
Shorter track record
Possibly less durable
Requirement for follow-up angiography

20. The Future
Increased percentage of patients treated with coiling, in large volume referral centers
Use of adjunctive maneuvers increases the percentage of aneurysms treatable with endovascular techniques
Increased efficacy of coiling therapy (new, bioactive materials, tissue healing strategies)
Development of non-invasive follow-up techniques with CT or MR scanning
Better educated population will actually demand availability and discussion of both endovascular coiling and surgical clipping options

21. Stent + Coil

22. Wide neck mid basilar aneurysm

23. Stent + coils

24. Hydrocoil

25. Matrix Bioactive Coil

26. 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

27. 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

28. 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 neuroradiologist
The death and complication rate for aneurysm therapy is dramatically reduced in high volume centers that offer both surgical clipping and endovascular coiling

29. Information and Links http://www.asitn.org/
American Society of Interventional and
Therapeutic Neuroradiology (ASITN)