Surgery or minimally-invasive endovascular coiling techniques can be used in the treatment of brain aneurysms. It is important to note, however, that not all aneurysms are treated at the time of diagnosis or are amenable to both forms of treatment. Patients need to consult a neurovascular specialist to determine if they are candidates for either treatment.
Endovascular therapy is a minimally invasive procedure that accesses the treatment area from within the blood vessel. In the case of aneurysms, this treatment is called coil embolization, or "coiling". In contrast to surgery, endovascular coiling does not require open surgery. Instead, physicians use real-time X-ray technology, called fluoroscopic imaging, to visualize the patient's vascular system and treat the disease from inside the blood vessel. Endovascular treatment of brain aneurysms involves insertion of a catheter (small plastic tube) into the femoral artery in the patient's leg and navigating it through the vascular system, into the head and into the aneurysm. Tiny platinum coils are threaded through the catheter and deployed into the aneurysm, blocking blood flow into the aneurysm and preventing rupture. The coils are made of platinum so that they can be visible via X-ray and be flexible enough to conform to the aneurysm shape. This endovascular coiling, or filling, of the aneurysm is called embolization and can be performed under general anesthesia or light sedation. More than 125,000 patients worldwide have been treated with detachable platinum coils.
Treatment of Ruptured Aneurysms:
Until recently, most studies on the surgical clipping and endovascular treatment of brain aneurysms were either small-scale studies or were retrospective studies that relied on analyzing historical case records. The only multi-center prospective randomized clinical trial - considered the gold-standard in study design - comparing surgical clipping and endovascular coiling of ruptured aneurysm is the International Subarachnoid Aneurysm Trial (ISAT). The study found that, in patients equally suited for both treatment options, endovascular coiling treatment produces substantially better patient outcomes than surgery in terms of survival free of disability at one year. The relative risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than in surgically-treated patients.
The study results were so compelling that the trial was halted early after enrolling 2,143 of the planned 2,500 patients because the trial steering committee determined it was no longer ethical to randomize patients to neurosurgical clipping. Long-term follow-up will be essential to assess the durability of the substantial early advantage of endovascular coiling over conventional neurosurgical clipping for the treatment of brain aneurysms. It is important to note that patients enrolled in the ISAT were evaluated by both a neurosurgeon and an endovascular coiling specialist, and both physicians had to agree that the aneurysm was treatable by either technique. This study provides compelling evidence that, if medically possible, all patients with ruptured brain aneurysms should receive an endovascular consultation as part of the protocol for the treatment of brain aneurysms.
Treatment of Unruptured Aneurysms: <
Although no multi-center randomized clinical trial comparing endovascular coiling and surgical treatment of unruptured aneurysms has yet been conducted, retrospective analyses have found that endovascular coiling is associated with less risk of bad outcomes, shorter hospital stays and shorter recovery times compared with surgery. Studies have shown that:
Average hospital stays are more than twice as long with surgery as compared to endovascular coiling treatment Four times as many surgical patients report new symptoms or disability after treatment as compared to coiled patients There can be a dramatic difference in recovery times. One study showed that surgically-treated patients had an average recovery time of one year compared to coiled patients who recovered in 27 days.
To get to the aneurysm, surgeons must first remove a section of the skull, a procedure called a craniotomy. The surgeon then spreads the brain tissue apart and places a tiny metal clip across the neck to stop blood flow into the aneurysm. After clipping the aneurysm, the bone is secured in its original place, and the wound is closed.
Embolization treatment of AVM is also known as Embolotherapy or Endovascular therapy. Embolization has been used to treat AVM since the early 1980's. This procedure involves the injection of glue or other non-reactive liquid adhesive material into the AVM in order to block it off. For this purpose, a small catheter is passed through a groin vessel all the way up into the blood vessels supplying the AVM.
Your arteries carry oxygen-rich blood away from the heart to the head and body. There are two carotid arteries (one on each side of the neck) that supply blood to the brain. The carotid arteries can be felt on each side of the neck, immediately below the angle of the jaw. There are two smaller arteries called the vertebral arteries that supply blood to the back part of the brain (the brainstem and cerebellum). The carotid arteries supply blood to the large, front part of the brain, where thinking, speech, personality and sensory and motor functions reside.
What Is Carotid Artery Disease?
Carotid artery disease, also called carotid artery stenosis, is the narrowing of the carotid arteries, usually caused by the buildup of fat and cholesterol deposits, called plaque. Like the arteries that supply blood to the heart (the coronary arteries), the carotid arteries can also develop atherosclerosis on the inside of the vessels.
Over time, the buildup of fat and cholesterol narrows the carotid arteries, decreasing blood flow to the brain and increasing the risk of a stroke. A stroke is similar to a heart attack. It occurs when brain cells (neurons) are deprived of the oxygen and glucose (a sugar) carried to them by blood. Oxygen and glucose are essential for neurons to function and survive. If the lack of blood flow lasts for more than 3 to 6 hours, the damage is usually permanent. A stroke can occur if:
A stroke can occur as a result of other conditions, such as sudden bleeding in the brain (intracerebral hemorrhage), sudden bleeding in the spinal fluid space (subarachnoid hemorrhage), atrial fibrillation, cardiomyopathy or blockage of tiny arteries inside the brain.
What Are the Risk Factors For Carotid Artery Disease?
The risk factors for carotid artery disease are similar to those for coronary artery disease:
Typically, the carotid arteries become diseased a few years later than the coronary arteries. People who have coronary artery disease have an increased risk of developing carotid artery disease.
What Are the Symptoms of Carotid Artery Disease?
There may not be any symptoms of carotid artery disease. However, there are warning signs of an impending stroke. A transient ischemic attack (TIA) is one of the most important warning signs of a stroke. A TIA occurs when a blood clot briefly blocks an artery that supplies blood to the brain. The symptoms of a TIA, which are temporary and may last a few minutes or a few hours, can occur alone or in combination:
All people with carotid disease should take aspirin as prescribed to decrease the risk of stroke due to blood clots. Talk to your doctor about other options if you are unable to take aspirin due to an allergy or other medical condition. In some cases, Coumadin (warfarin) may be prescribed. If so, blood work will need to be checked regularly to ensure you are prescribed the proper dose. Antiplatelet medications such as Plavix (clopidogrel) may also be prescribed.
If there is severe narrowing or blockage in the carotid artery, a procedure must be done to open the artery and increase blood flow to the brain, to prevent future stroke:
Carotid stenting is a treatment option for certain patients with carotid artery disease. Performed in a catheterization laboratory, a small puncture is made in the groin. A specially designed catheter, with an umbrella tip, is placed over a guide wire and directed to the area of narrowing in the carotid artery. Once in place, a small balloon tip is inflated for a few seconds to dilate the artery. Then, a stent (a small stainless steel mesh tube that acts as a scaffold to provide support inside your artery) is placed in the artery and opens to fit the size of the artery. Tiny filters are used to capture any particles that are released and prevent them from going to the brain and causing a stroke. The stent stays in place permanently. After several weeks, your artery heals around the stent.
This is the traditional surgical treatment for carotid artery disease and has proven to benefit patients who have a 50 percent or greater blockage in the carotid artery. While the patient is under general anesthesia, an incision is made in the neck, at the location of the blockage. The surgeon isolates the artery and surgically removes the plaque and diseased portions of the artery. Then, the artery is sewn back together to allow improved blood flow to the brain.
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