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Brain aneurysms

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Why do you put those things on my body? Why? Yeah We want to monitor the electrical activity of your heart. And that can tell us a lot of things about what is happening in the other parts of your body and how your heart is doing. Cora Anderson is no stranger to the operating room. She’s had several serious health problems, including a lung transplant and a knee replacement. This time she has an aneurysm in her brain. I know that it is time bomb, and I know that it has doubled in size and it’s very threatening. An aneurysm is a ballooning out of a blood vessel wall, the larger the aneurysm the higher the risk of rupture. And when a cerebral aneurysm bleeds the result can be catastrophic. If you have a large bleed, your outcomes are gonna be much worse, so if you treat these aneurysms before the rupture it’s always a better outcome. Patients may experience few warning signs before a brain aneurysm ruptures. Unfortunately there are no symptoms specific to aneurysms, temporary loss of vision, temporary loss of hearing, double vision, weakness or numbness on any side of the body. These are all general symptoms for all the strokes. Things that are very specific to aneurysms are if the person were to get what we call the worst headache of your life. Cora is one of the few million Americans walking around with aneurysms. As many as thirty thousand a year actually rupture. The patients who survive the bleeding and patients with unruptured aneurysms have similar options for treatment. There’re two treatments available to treat aneurysms these days, the one is the classical, might go inside, open the cranium and do microsurgery clipping and the other is the endovascular coiling, where you take a catheter up to groin, go into aneurysm and coil it. This is the vessel, this is the vessel. We gotta keep that, we gotta visualize it in 3D, so we just keep everything above, as long as we have everything above, then we are gonna be safe. Cora’s doctor, Gavin Britz is co-director of UW Medicine Brain Aneurysms Center at Harborview Medical Center. They treat as many as 300 aneurysms a year. That’s one of the highest volumes in the country, and the best part about this place, is we have specializations in each of different techniques we can use to treat the aneurysms, the endo-vascular approach, we have the best team, we have some of the greatest surgeons, who do direct clipping of these aneurysms. And also we have one of our team members who’s trained in both. So that gives him a unique perspective to decide which treatment may be suitable for a patient. And again there are a lot of studies which show that the more cases you treat the better you get at it. So I’m comfortable now, that is not in the vessel lumen, but is in the aneurysm itself. Many neurosurgeons probably see one or two aneurysms a year, you know, I treated that in the first two days of the week. Doctor Britz is a genius, I mean the guy’s a genius, who is very compassionate. I had the opportunity to have his shoulder, to actually cry on and he was there to hand me a tissue, and say to me ok, it’s gonna be alright. Cora’s multiple health problems as well as the size and shape of her aneurysm had to be considered when deciding on treatment. Doctor Britz is qualified to do either a surgical or an endovascular procedure. I’m a dual trained neurosurgeon, meaning that I’m certified to do both, to do micro surgical clipping as well as certified to do the endovascular coiling. There’re patient factors and aneurysms factors that are gonna make the decision. So patient factors that are important would be age of the patient, medical problems. And the aneurysm’s factors would be the specific factors of location of the aneurysm, the size of the aneurysm and then you make the decision based on those factors. Both procedures are effective for treatment of many aneurysms, but not all. By which I mean you cannot coil every single aneurysm. Coiling depends on two major factors. One is that the aneurysm, which is shaped like a ball, has to have a neck, which is the orifice, through which the blood enters. If the neck is narrow that the coil stays inside nicely and then we can coil it. If the neck is broad, then the coil gets washed out, you know. One way of preventing that and helping that is by placing a stent across the base of the neck, which can be done, but again not on all the patients. At Harborview treatment decisions are often made jointly by the team, Dr. Sekhar, Dr. Britz and Dr. Ghodke. We put our heads together and this is very critical, because each one brings a very, very special expertise to the table. Roch, for instance, is perhaps the most experienced and expert neurointerventional radiologist that I know. Gavin Britz is dual trained. I’m in training for endovascular, but I bring with it, you know, very special skills in terms of surgery. So we all, you know, put our heads together and decide what’s best for the patient. Cora’s case was complicated as radiologist Brian Cott showed us in this 3 dimensional image of her aneurysm. You can see here this aneurysm is extremely large, extremely complex and it’s involving large portion of this internal carotid artery to where there really isn’t any definable or discernible neck of the aneurysm that we think in the traditional sense. Endovascular coiling was chosen to treat Cora Anderson, but because of her aneurysm’s shape, a Neuroform stent, like this one, was needed to make the procedure work. Ideally this would be treated surgically. The problem with the surgical approach for her would be that all the other medical issues, which make it very complicated and properly, not worth the risk. The new treatment is now available for this broad base aneurysms called Neuroform stent what will go inside then form a threads around the vessel and then we can treat it. Cora was involved in discussing treatment choices. But for her it was a very simple decision. I would like to to, to live some more. So let’s go and get it taken care of. This is what the coiling procedure looks like. Doctor Raj Ghodke is director of interventional neuroradiology for the UW Medicine Brain Aneurysm Center at Harborview. We put a small needle into the groin, put a small catheter up, about 6 inches inside and through that we put this tube, which is about 3 millimeters wide and this goes all the way through the urethra and so it goes down, you go up into the carotid arteries. So this catheter right now is gonna be in carotid and through that we are gonna put a small micro catheter up into the aneurysm and then through that catheter we are gonna deploy what is called platinum coils and these are small wires made of platinum are very soft, and we end up filling this area, which looks like bleed on the vessel coil of the aneurysm and plug it from the inside, so the risk of bleeding goes away. And everything is flushed. There is saline infusions going between all the catheters to reduce friction and then the catheters are advanced under fluoroscopy so we have a screen where we can actually see the catheters and wires traveling. We have what is called a road map, this whole angiogram is super imposed on our fluoroscopy, so we can see exactly where we are going and we can navigate through all the twists and turns of these vessels. Cora Anderson had a Neuroform stent, putting place during an earlier procedure. This stent usually goes across the neck of an aneurysm, to help us keep the coils inside and prevent them from coming out. See you can’t hold that without a stent. There is no way. And I think this is the perfect treatment for her. Some people go inside and put the stent and the coil at the same time and it can be done. But with my experience, when you do that I think the complication is slightly higher cause the Neuroform stent hasn’t settled in the wall yet and this is more moveable. So what I did with Cora is I got the aneurysm first and then went inside one week and placed the Neuroform stent and then brought her back the following week and then just coil through the stent. I’m happy, it’s very good. Five years ago we were coiling less than 10 percent of the aneurysms and now we’re coiling about 2/3 of the aneurysms here at Harborview. I think the technology is got better and micro catheters are better, the materials we use to coil the aneurysms are better and I think it’s gonna evolve, it’s gonna shift the curve even further towards coiling. The endovascular is still new, there’s still new advancements that can be made that gonna make it safer and more effective and durable in the long term. It’s looking very good. Yeah, I think it’s looking very good. Raj I think is good! I think I’m extremely happy with all this. I couldn’t wish for a better result . It was great. I like that, that’s really… that’s the finest I’ve ever made. And next to my favorite Santa Claus. Next to your Santa Claus, yeah. John and Roxie Phillips moved from San Diego to Washington state to be closer to their children and grandchildren. That Santa Claus is old, you know, you know how many years old? One of their first connections here was Doctor Laligam Sekhar, because Roxie has had a brain aneurysm for several years. The first sign was a violent headache as it ruptured. She nearly died after the hemorrhage. That was not here, she was in San Diego at that time, but she recovered to the point that she could be treated and she was treated by using endovascular coiling method, which is the right thing for her age and location. At the time she had a complete right turn of paralysis, which indicates that, you know, she has no movement of her right eye, she had a couple of strokes, as a result of the hemorrhage. which follow after this type of hemorrhage, but she recovered from all that. The problem however was that she would get an angiogram every year, and the coils were compacted and pushing into the aneurysm, so the aneurysm had to be opened. So each year she had to have more coils put into the aneurysm. I had a total of five, I had one every year, except 2001, I had 99, 2000, 2002, 2003, 2004, you know, I was getting pretty tired of having procedures. The coiling procedures weren’t working as a long term solution. But clipping an aneurysm is very difficult after coils have been placed inside. Roxie’s age and the location of the aneurysm were also concerns. The location of the aneurysm is the most difficult area for neurosurgeons to deal with. So, because of that, I have to do a very, very special operation. The idea was to take the radial artery from the forearm and connect it as a graft from the right middle cerebral artery to the posterior cerebral artery, which is one of the vessels that comes off in the aneurysms and with that as protection, then clip the aneurysm or close off the artery, banding the aneurysm. Doctor Sekhar pioneered this technique and was the first to perform it in Seattle. Before offering the procedure to Roxie, he discussed it with the team. So surgically what we can do here is to either consider or do clipping of the aneurysm in itself if the neck is favorable or do distal vascular occlusion. But in order to do that safely we need to put a bypass into the right posterior cerebellar artery, so that she has good collateral flow through that. So what do you think about that option? I think is a great option especially because the major limitations are the vessels, her vessels are so loopy. It prevents us from doing the right optimal treatment with catheters. She seems to be a very big individual, in good health and she really wants to, wants to live and wants to continue to have a quality of life. She is aware that this is a very dangerous situation for her, where the aneurysm is reopening like this. She wants to have something done. He has two different options that he offers. I don’t remember how they work exactly. But I like the one, the bypass makes better sense and also it looks like might be a long term solution. This way she gotta a good chance of a perfect life for years and years, after she does this, and you know, there’s always a lot worries about and I am certainly worried about it. But I’m also very upbeat about it, and I think she is, too. Now what criticism, if there is any? About the cookies? Oh, come on Roxie, you know those are better than anybody else could make. John and Roxie have been married for almost 50 years. They laugh at the same things and the success of her surgery is equally important to both. How many pies you made on your life? Two. I thought so, I thought exactly so, oh well. One of these days, you know, something may slip, maybe as a result of the surgery you’re going to do… you’re going to wake up afterwards and you’ll have great desire to make pies all the time. Then I’m not going to have this surgery You’re not going to do it? Not if I’m gonna wake up and bake pies. Hi, good morning! Good morning! How’re you doing? I’m doing fine. Ok, all the tests came out well. So we are all set to go. Oh, good Do you have any question? No I don’t think so. We’re all set and ready to go? Patients are naturally nervous when they come in to have surgery and they are particularly nervous when they are coming for something as major as intracranial surgery, and it’s totally understandable. I think the best part that we can do to allay inside is to explain to the patients what is gonna happen, what we are gonna do to the patient. What time is it? It’s now just 7:25 7:25, ok As with Cora Anderson there is an entire team involved in Roxie Phillips’ care during her stay at Haborview. Particularly myself, Dr. Raj Ghodke and Dr. Gavin Britz, we have a very good relationship on understanding each other and each others goals and aspirations. To this team that we bring in anesthesia, for instance, Dr. Lam, neurophysiology monitoring, or nursing and then intensive care nursing and critical care specialists, we have radiology technicians and so forth. All of these people, you know, become a critical mass. I worked in many places in the country and I would say that at Harborview we have probably one of the best team that I ever seen, you know, in all my life. And it’s a 24/7 can do hospital, that means patients come in and you say: I need an MRI, I need an angiogram, yes doctor, it’s done. So this is particularly suited for treatment of aneurysms and strokes because aneurysms and strokes happen 24/7. I mean they are not things that can wait. This team process is extremely important, you know, there is an ongoing process of discussion among neurosurgeons, stroke neurologists, anesthetists, a critical care and so on, which facilitates everything. Ok, Roxie. Are you ready? We are gonna put you to sleep now, ok. You are gonna slowly try to sleep. Think about something nice. Think about a nice place to go. What differentiates a neuroanesthesiologist from a regular anesthesiologist is the interest in a better understanding of the pathophysiology of the brain and what are the special requirements for intracranial surgical procedure, like the one we’re discussing today, and there are specific surgical demands that require special knowledge to have optimal conditions for the care of the patient. Certain periods of the surgical procedure, the patient is particularly placed at risk of cerebral ischemia or lack of blood flow to the brain. That occurs when the surgeon has to put a temporary clip on the major fitting vessel to decrease the amount of blood flow to the aneurysm or allowing to do the bypass. What we do is that, we do two things, one, we monitor what is going on the brain, by way of doing evoked responses or electroencephalography, that is the brain wave that is normally generated by the brain. The only thing that we can do is to calm the brain down and actually decrease the amount of oxygen that the brain requires, during this particular vulnerable times. Right there on the MRI you can see the aneurysm. On the CT scan right here you can see the coils, giving an artifact, a scattered artifact is what you see here, that’s the coils. And on this 3D imaging, this is the 3D angio reconstruction, you can see that the coils are right there, and on just a regular angiogram you can see the coils right here, you see ball of sort of silver colored ball that is compacted, that’s inside of the dome of the aneurysm. Part of Roxie’s skull is removed to expose her brain for the surgery. Doctor Sekhar takes part of an artery form her arm for the bypass. Both Roxie and Cora were slightly higher risk for aneurysm because they are women. Age also contribute to developing an aneurysm as well as some conditions such as polycystic disease of the kidneys. No todos los aneurismas requieren de un tratamiento, en especial aquellos pequeños. We just follow it up if there any dramatic increase in size or if there some symptoms which you think are caused by the aneurysms, then of course, you think about the treatment. But there are a significant number of aneurysms, which may be riskier to treat than to leave them alone. Brain aneurysms are very distinct and different from aneurysms in the body elsewhere. So when we’re talking about brain aneurysms, these are usually what we call saccular aneurysms, and these are weak areas, weak points, and very thin walled structures. Large brain aneurysms are more difficult to treat because, you know, they are inside the head. It’s a challenging field to choose for a specialty. A lot of intensity. I mean that there is, its the one thing about vascular and skull base is that it’s always pressured, it’s not, you know, there’s some points of surgery, you know, regardless of the specialty, the routine cases you know nothing’s going to go wrong, people are always going to wake up fine. The problem with vascular is even if the operation goes perfectly people can have complications. So, why did these doctors choose this specialty? Personally you wanna make the difference and these are some of the most high skill operations you could do and you do make the difference, you are saving a lot of people’s lives by preventing this from rupturing or preventing them from bleeding again. So it is kind of exciting to be in this field. I’ve always wanted to do neurosurgery from I think from the age of seven possibly related to my father’s spinal cord injury…when we were very young I was exposed to neurosurgeons and I was exposed there. It just set the tone and that’s what I wanted to do from being a youngster. Vascular, I chose because I think it’s still the most, that and skull base, still the most technically demanding part of neurosurgery, and most of us go into into neurosurgery are complicated and ambitious people and we like to what’s the most challenging to do. That’s why I like to do it too. That’s certainly true in Roxie’s case, specially the technique of bypassing the brain’s blood vessels. It is a technically difficult operation in terms of microsurgical skills, you do have to have extremely sturdy hands and very good hand, you know, hand-eye coordination and you’re looking into the microscope in a deep space and so forth. And there are so many little details, not only of the operating technique, but also anesthesia, nursing, angiography, all those things, the whole team is important. The radial artery from Roxie’s arm is sutured to the arteries in her brain completing the Bypass graft. Once that’s done her surgeon closes off the aneurysm with the titanium clip. It’s a very delicate operation, made more difficult by the coils placed in the aneurysm during earlier procedures. When surgery is complete, Dr. Sekhar calls for radiology to step in. So what I’ve done is connect the graft from the MCA to the right PCA. And then eventually, I was able to actually clip the aneurysm. Initially I put a clip on the distal basilar artery, but I was able to dissect and clip the neck, it was not very easy, because the coil mass was really hard and I could not see, I couldn’t… the space was not enough to look behind, so I could only see it after the clip was set up closing down. And I think the left PCA is slightly kinked but I could see all the perforators. They’re okay. So I think you just need to… I think you probably need I think you probably need to do a top angiogram. Ok, yeah well we’ll just go ahead and shoot the right carotid and look at the graft... the MCA to the p2 and then we’ll come back and shoot the left for the vertebral artery. The angiogram shows that the bypass and clipping procedures have been successful. Ok, here is injection of the left for two arteries, the basilar artery, this area up here is where the aneurysm was and you can see here it’s gonna roll back, you can see on this injection that there is not filling of contrast inside where the aneurysm was, so it’s been completely excluded by the clip. And the vessels that go on beyond the aneurysm are filling normally, that are on the left side and on the right side, they are being filled a little bit from this side, but also primarily from the graft that was placed. Great, all done. Thank you very much. After surgery Roxie appears to have some complications. Three days after the surgery she developed symptoms of a stroke involving the right side of the brain and she had left sided weakness and not complete paralysis but some speech difficulties. We did all tests and nothing major was found and she was treated with fluids and she got better. Roxie’ s been working with the rehabilitation team at Harborview. John’s been able to stay there with her, sharing the room and participating in her recovery. How are you? Fine, I’m reading my food book. It was about time! I appreciate having him here. I put him to work. Yeah she did, yeah I’ve had plenty of instruction. Yeah and the therapist put me to work, she puts me to work, the nurses put me to work. Hello, how are you doing today? Pretty well, thanks. Meanwhile Roxie’s doctor is happy with the results of her surgery. Lift your hand for me, all the way, good, move your fingers, excellent, touch my finger. Good! She’s recovered almost back to where she was previously and she is still improving, so I do expect that, you know, she will be completely recovered from this procedure. The angiograms since that time have demonstrated that the aneurysm is not completely closed (the aneurysm is not longer seen) and the bypass has done its job. For Roxie and John Phillips it’s a job very well done. You like it? Yeah! Well I’ll say the same thing I said to Dr. Sekhar and that is that, due to his skill and his abilities, this whole misery that’s been hanging over Roxie’s head for six years now is taken away. She is essentially cured of the problem and doesn’t have to worry, is that going to get worse? Is that going to get into an incurable state? What’s going to happen for the next time I go back for a test? All of that is taken away and she can just, you know look on a future with confidence. And that is worth an awful lot, just an awful lot.

Video Details

Duration: 27 minutes and 48 seconds
Country: United States
Language: English
Producer: ResearchChannel
Director: ResearchChannel
Views: 653
Posted by: ambler on Jul 8, 2010

Laligam Sekhar , Gavin Britz, Raj Ghodke

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