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.

IMAGE GUIDEDTHERAPIESMedia BriefingJune 19, 2003

S p o n s o r e d b y t h e

Radiological Society

of North America

Brain Aneurysms Successfully Treated Without Open Surgery

V A S C U L A R D I S E A S E

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

Brain Aneurysms Successfully Treated Without Open SurgeryJacques E. Dion, M.D., FRCP (C)Professor of Radiology & NeurosurgeryDirector, Interventional NeuroradiologyEmory University HospitalAtlanta, GA

History of Coiling

1987-1989: 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

1989-1990: Bench and animal research

March 6, 1990: First clinical use of Guglielmi Detachable Coil

FDA approval in 1995

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

ISAT A 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 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

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

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

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

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

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%

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

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

Pros and Cons of Coiling

PROS

Minimally invasive Short recovery Safer than surgery Cheaper than

surgery

CONS

Shorter track record

Possibly less durable

Requirement for follow-up angiography

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

Stent + Coil

Wide neck mid basilar aneurysm

Stent + coils

Hydrocoil

Matrix Bioactive Coil

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

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

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

Information and Links

American Society of Interventional andTherapeutic Neuroradiology (ASITN)

http://www.asitn.org/