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ATLANTA --Brain aneurysms -- bulging blood vessels in the brain that can rupture without warning, oftentimes killing large numbers of brain cells before they can be diagnosed and treated -- claim the lives of 22,000 Americans every year and result in temporary or permanent disability for approximately 8,000 more.
Although these events are relatively common, they are often undiagnosed or misdiagnosed. But experts say prompt treatment in a facility that offers attention from a team of multi-disciplinary specialists, who see a large volume of aneurysm cases each year, represents a patient's best hope. This approach allows doctors from various specialties to review each case as a group, and then decide as a whole which treatment option is best for the individual. Decisions for treatment are based on the size and location of the aneurysm, the type of aneurysm, the condition of the patient and the patientís medical history.
The Emory-MBNA Stroke Center is able to offer this multi-disciplinary method to patients and their families. "We feel a team approach offers the most comprehensive care for patients with aneurysms," says Daniel Barrow, MD, professor and chairman in the Department of Neurosurgery, Emory University School of Medicine, and director of the center. "Each patient that comes into our center is evaluated by specialists in neurology, neurosurgery, neurocritical care and interventional neuroradiology to tailor a treatment plan for that individual, using our wide range of resources. Following evaluation, we all then decide the best manner to treat that patient."
Many people may have aneurysms that never cause problems, unless they rupture. When an aneurysm in the brain ruptures or hemorrhages, blood flows into the space surrounding the brain, causing "the worst headache in a personís life." A ruptured aneurysm can cause a stroke or even death. Aneurysms can occur in any artery of the body, but only those affecting the arteries supplying the brain can cause a stroke.
"We donít know what causes aneurysms," says Jacques Dion, MD, professor of radiology and neurosurgery, Emory University School of Medicine, and director of interventional neuroradiology for Emory Healthcare. "Aneurysms present in about two percent of the population, but they donít target a specific make-up of people. They are not the result of any disease and they are only occasionally hereditary. They are very uncommon in patients under 20 years of age, but are increasingly common in older patients," Dr. Dion explains.
Drs. Dion and Barrow often find themselves poring over the same charts and consulting with the same patients who come to Emory for care. When these patients are in need of treatment for their aneurysm, neurosurgeons, like Dr. Barrow, and interventional neuroradiologists, like Dr. Dion, team up to determine if a patient is best suited for surgery or a less invasive procedure to prevent or stop a brain bleed.
Surgical clipping is currently the most commonly used treatment for brain aneurysms. It involves creating a small opening in the skull and placing a surgical clip at the neck of the aneurysm to prevent bleeding. As a result, "clipping" prevents future bleeding and nearby brain tissue is protected from further damage. A less invasive procedure is called "coiling." Coiling involves inserting a catheter through an artery in the leg and, with the help of X-ray guidance, moving it up through the head into the aneurysm.. Once in place, specialists thread tiny platinum coils, best described as looking similar to miniature slinkies, through the catheter and into the aneurysm. The coils create a ball of yarn effect to seal off the aneurysm and stop further bleeding in the brain.
Emory treats approximately 250 aneurysm cases a year, both ruptured and unruptured, with the numbers on a steady increase. Of those cases, 70 percent are clipped, while the other 30 percent are coiled. Clipping is the standard procedure for aneurysms, but following the 1995 U.S. Food and Drug Administrationís approval, more and more patients are being coiled, according to Dr. Dion.
Both procedures have their advantages and risks. While coiling is less invasive and has a shorter recovery time, a potential concern exists about the durability of the treatment and the necessity for follow-up studies; coiling may not be suitable for all types of aneurysms. In a recent publication, coiling was shown to be less costly than clipping in unruptured aneurysms ($37,000 vs. $64,000). Surgical clipping, however, has a longer recovery time, is suitable for most types of aneurysms and is associated with less chance for reoccurrence. The issue of permanency of results and protection from bleeding could very well be addressed by the long-term follow-up of patients in the International Subarachnoid Aneurysm Trial (ISAT). It compared coiling to clipping in 2143 participants and found coiling to be associated with a significantly better outcome, in terms of decreased mortality and survival free of disability at one year.
"No matter what procedure they undergo, our patients and the individual care they receive are our top priorities," says Dr. Dion. "By coming to a center where patients are evaluated by a team of experts across a number of disciplines, and where multiple aneurysm cases are treated each year, we see better clinical outcomes."
The Emory-MBNA Stroke Center has the only neurocritical care unit staffed by trained neurointensivists in the state of Georgia, equipped to handle these delicate cases before and after treatment. Two neurointensivists, or specialists in neurocritical care, run the unit with the help of nurses and other staff dedicated specifically to this population of patients.
"This multi-disciplinary approach goes beyond patient care," says Dr. Barrow. "All of the departments in the center work together on research projects and educational aspects involving neurovascular disorders. Because all of the funding goes to the center as a whole, both clinically and academically, it makes for less competition and more harmony among specialties, a win-win situation for all, and particularly for the patient."