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

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

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

History of Coiling FDA approval in 1995 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 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 http://www.asitn.org/ American Society of Interventional and Therapeutic Neuroradiology (ASITN) http://www.asitn.org/