Brain Aneurysms | Treatment and Case Reports

– Hi everyone, this is Dr. Omar Choudhri. Today, I’ll be talking to
you about brain aneurysms. I am a neurosurgeon with training in open
vascular neurosurgery as well as endovascular neurosurgery with interventional neuroradiology and I’m part of the Penn Center for Cerebral Revascularization as well as the Cerebrovascular Center for Treatment of Aneurysms. Today, I will be talking
about brain aneurysms and updates regarding
management of patients who are diagnosed with brain
aneurysms on a routine basis. So let’s talk a little bit about what treatments are
available for aneurysms and some aneurysms they
really don’t need treatment because the risk of them
bursting is much lower than the risk of the aneurysm treatment. Similarly, there is open
surgical treatment of aneurysms which is open brain surgery
which involves us going in, removing the part of the skull, working using a microscope
between the brain spaces, finding an aneurysm and putting
a titanium metallic clip across the aneurysm that
essentially strangulates the neck of the aneurysm,
I’ll show you some pictures, and the aneurysm can then be deflated. And the endovascular treatment is something that’s more recent. It’s been there since mid ’90s and it involves minimally
invasive treatment that is done from inside
the blood vessels, similar to an angiogram, and involves treating the
aneurysm from the inside with filling it up with
very soft platinum coils and often involves the use of many devices which have been a lot
popular in the past decade which we will discuss shortly. Microsurgical clipping is time tested. It’s been there for more than 50 years. I usually prefer it for people
who are less than 65 years. It’s a very durable treatment. The chances of any aneurysm coming back after it’s been clipped is
very, very close to zero. And it’s best suited for aneurysms in the surface of the brain like the middle cerebral artery aneurysms and primarily the anterior
circulation aneurysms which are very easily
accessible with low morbidity. The patients usually stay in the hospital for around two or three days
after their aneurysm is clipped and they’re able to
get back to their life. And again, we manage
these treatments risks by looking at the patient’s age, what are their medical comorbidities, if they have a healthy heart and they’re able to
undergo general anesthesia, and then the aneurysm
location and those things. The endovascular treatment, which is done from
inside the blood vessels, this is a schematic that
shows what that looks like. So traditionally, we’ve
been treating aneurysms from the femoral artery in the groin. The patients are asleep for this. And we thread a catheter under x-ray all the way up into the brain and put a very tiny catheter
called a microcatheter inside the aneurysm and fill the aneurysm
with small platinum coils that essentially blocks the
aneurysm from the inside. The patients on endovascular procedures make a very quick recovery, are able to go home later
the same day or the next day. And in aneurysms that have a wider neck that looks like this that
don’t look like a light bulb, the coils once you put them there they can fall out of the aneurysm. So often we need to put a stent, very similar to heart stents, but they’re made for brain blood vessels to help keep the coils inside and that’s called stent assisted coiling and the patients have
to be on blood thinners for at least three months
for a treatment like this. But again, patients do very well, works great for patients who are older and cannot undergo open surgery and a lot of the aneurysms
are very well treated with endovascular treatment. In fact, in most of the
practices around the country, I would say around 60-70% of the aneurysms are treated endovascularly very safely and patients do extremely well. Over the years, a number of
new devices have come out that alow treatment of
aneurysms and this just lists all of those treatment
options for aneurysms. These are all the different
tools that are available to the endovascular neurosurgeon
for treatment of aneurysms. One of the treatments is
something that’s called as a pipeline flow diversion. This is a technology that
was FDA approved in 2011 for large carotid aneurysms and now it’s been approved
for smaller aneurysms too and it’s a very interesting technology. I’m gonna illustrate that
by giving you an example. This is a patient with a
carotid artery aneurysm which is pointing at with an arrow and this is a 3D angiogram that demonstrates the huge
bulge on a blood vessel. And a pipeline device you can think of it as a
very soft tightly knit mesh similar to a stent and
that essentially goes and sits in the normal blood vessel. So we normally don’t put
anything inside the aneurysm. It essentially lays in
the normal blood vessel from where the aneurysm is arising from. These people have to be on blood thinners. And because of diverting
flow away from the aneurysm, these people can have a beautiful result with up to greater than 90%
occlusion rates at one year and greater than 85%
occlusion rates at six months and this is a patient
before pipeline placement and this after pipeline placement. And as you can see, the aneurysm
is completely obliterated and they essentially
have a new blood vessel. Patients have to be on blood thinners, usually aspirin and Plavix
for around six months after the pipeline device is placed and usually a week before it’s placed. And once the aneurysm goes away, they’re usually on a
baby aspirin for life. The other interesting thing
about pipeline devices is that once an aneurysm is obliterated with flow diversion technology, there hasn’t been a report of
an aneurysm that has returned so it’s a very durable
and definitive treatment if the patient is a good candidate for it. And here you can see how the blood vessel is
every nicely remodeled. I would take a few minutes to
talk about a newer technology that just got FDA approved this year for very wide-based aneurysms where a ball of mesh is
placed inside the aneurysm and this is a new technology
which is available at Penn and we can treat aneurysms
which are more wide based and we can place this
device inside the aneurysm and this aneurysm can
very nicely be obliterated within a period of around
three to six months. So the fact is that traditionally, we have been treating patients
in an open operating room where we do open surgical clipping and patients have been treated in the biplane angiography
suite for coiling, but now we really are in a situation where we can do both those
functions in the same room which is called a hybrid operating room which is something that we
offer at our institution. I’m gonna give examples
of two or three cases of brain aneurysms just to illustrate all of the things we’ve talked about and how decisions are made
regarding brain aneurysms and what treatments are available. The first one is a 40-year-old patient that I saw in clinic last
month with headaches. She’s otherwise healthy, but
has a history of smoking, had a sister who died of
a ruptured brain aneurysm and she was found to have a six millimeter middle cerebral artery aneurysm right here which is considered an
anterior circulation aneurysm. She also had high blood pressure. And by putting her risk
factors into the PHASES score, she had a 0.7% risk of
bursting at five years and around a 6% lifetime risk of rupture during her lifetime. A risk of aneurysm treatment
for an aneurysm like this for major complications is
around 5% or less and hence, it made reasonable sense to
offer treatment to this patient. So we had a detailed discussion
about treatment options which included the WEB device which is the intra-saccular mesh ball that’s placed inside the aneurysm versus open surgery for clipping. The obliteration rate for a WEB device are up to around 85% at six months and surgical clipping it’s
100% obliteration rate after surgery which is
what the patient chose. These are a few pictures from surgery where you can see this aneurysm dome which is really dilated
and thinned in this area. And you can see the clip which
is going across the aneurysm to strangulate the aneurysm. And in the next picture, you can see these two
clips have been placed across the aneurysm and the
aneurysm dome has been punctured and completely deflated. And this is an intraoperative angiogram that shows the clips in place and the aneurysm completely gone and the normal blood vessels
are filling very nicely. This patient is young, healthy,
can tolerate surgery well, and as a very good durable treatment, she would not have to
worry about this aneurysm for the rest of her life and
she was discharged in 48 hours. This next case is of a 60-year-old female who had a very large aneurysm
at the back part of her head in this artery called the
superior cerebellar artery and she had double vision, that’s how her aneurysm was diagnosed because it was pushing
on a very important nerve at the back of the head. If you put her numbers into the chart, into the PHASES score, she had
a 20% lifetime rupture risk which is there’s a one in five chance that her aneurysm would bleed and hence, she was recommended treatment. Open surgery is really not a great option for treatment of this aneurysm because of the risks of surgery. So therefore, we had very good solution by treating it from
inside the blood vessel. This is a 3D angiogram that was completed that shows what this aneurysm looks like. And as you can see, we can get a lot of detail
in terms of the aneurysm dome and all these blood vessels
that come out of it. This patient underwent treatment and these are coils that are
placed inside the aneurysm and we put a stent in this blood vessel and her aneurysm is completely gone. She was able to go home the next day and has been doing very well. The next patient is a
patient who was found to have some mild memory issues and was found to have an 11
millimeter basilar aneurysm and she was considered for this new device that is good for aneurysms that are very bulging
and wide at their neck. So this is her aneurysm and this is what her
3D angiogram looks like and you can see these irregular bulges. They all indicate a very
high risk of rupture in these aneurysms. And this is after treatment where you can see the
coils have been placed and there’s a device
which is like an umbrella called a PulseRider which
sits at the aneurysm neck and prevents the coils from falling out. And this is that device which sits at the neck of the aneurysm and helps the aneurysm
treating effectively. Now, the next case is a short video that I’d like to illustrate because some aneurysms
are very complicated and a part of my practice
is taking care of aneurysms which have been managed at other hospitals and the patients come to
me for second opinions and they often require very
different surgical solutions and often endovascular solutions which tells you the beauty of really being able to study these pathologies and looking at solutions
which work for these patients. So this is a 68-year-old
gentleman with high blood pressure who was found to have a
12 millimeter aneurysm in the left side of the head almost five years before seeing me and the patient was treated
at an outside hospital where the doctors placed some coils and treated the aneurysm. Before seeing me, the
patient had started to notice some worsening headaches, was having severe pain behind the eye, and we got an MRI that
demonstrated that the aneurysm that was treated had started
filling back up again and the patient had started to have a lot of swelling around the brain, and you can see this aneurysm on the left, from the aneurysm. These are all the MRI
scans from this patient where you can see this large aneurysm which has clot forming in it. And because the aneurysm was so large, we offered an angiogram and
you can see how this is filling and all of these branches are coming out at the base of the aneurysm which demonstrates like how dangerous and quickly the aneurysm is
coming back in this patient. This is a rotational 3D angiogram where we get all those nice 3D pictures that we have shown before. And this is the picture that
we see from the aneurysm. And because these blood
vessels were so small and were at a certain angle, we really did not find a good solution with putting more coils ’cause
they had clearly failed. The blood vessels were too
small and were at an angle where we couldn’t put a stent. The pipeline device had very high risks in such a small blood vessel. And so this patient was
considered for open surgery with possibility of rerouting
the blood flow if needed by a process called bypass. Again, this is something that was done in our hybrid operating room. And this is a blood vessel
that we harvested out. This is something called
the Sylvian fissure which allows us to go
between the brain spaces to find where the aneurysm is
and to ultimately treat it. And all these membranes of the arachnoid, which are the spider-like trabeculations we talked about before, are cut under the microscope
with very fine movements. And these are the nerves
that go to the eye called the optic nerve. This is the carotid artery. And we’re releasing all
these trabeculations to get to the aneurysm. And as you will see in a moment that this is the blood vessel
that feeds the aneurysm and in a moment you will
see how this large aneurysm can be seen in the operative field and this is that aneurysm right here. We often use fluorescent dyes to help us see the blood
vessels coming out of it. And this whole aneurysm is full of clot and full of the previous
coils that were used and it’s filling at the base. And our attempts to just put
a clip across it wouldn’t work because there was so much clot and the aneurysm was so dysplastic. So at that point, a decision was made to
open up the aneurysm and this is one of those few scenarios we actually see what an
aneurysm looks on the inside and you can see the oil
coils that were there. And even after removing part of the blood clot and the coils, clipping was not possible
and at that point, we decided to use a
complex clip reconstruction by using a combination of clips to give the aneurysm a new wall. And here you can see that
the whole aneurysm dome has been cut off and this
is a very impressive picture where you can see the oil coils, the clot, and part of this giant aneurysm, and we cleaned off the
inside of the aneurysm. And again, we see how this
aneurysm was filling before and this is something that was published in a neurosurgical journal as well as a good illustrative teaching case, but it kinda gives you an idea on how a combination
of clips has been used to form a new aneurysm neck and to really reconstruct the aneurysm. So again, this shows you how a complex aneurysm
treatment can be completed. And sometimes there are no good
minimally invasive solutions for treatment of an aneurysm in someone who has failed
endovascular treatment and also sheds light
on how these treatments are very complimentary. So now all these clips have been placed and any bleeding from the aneurysm from this reconstruction
has been controlled and you will see all the space that’s left from the large aneurysm dome right here which has been removed and
these clips reconstructing it. We used fluorescent dyes to check everything is filling nicely and the patient essentially
has a new blood vessel now and not having to worry
about the aneurysm at all. We always do an intraoperative angiogram to confirm that the aneurysm
is essentially completely gone and you can see that the previous aneurysm you were seeing filling is completely gone and these clips have
reconstructed the aneurysm and the patient was in the hospital for approximately four days
before being discharged and made a very good recovery. So this brings me towards
the tail end of this webinar and I hope this gave a
sense to all the viewers about the fact that aneurysms
are really complex lesions and they really need to be managed on an individualized basis and they have a very
high mortality or death once they bleed. Once they are diagnosed,
they can be treated safely and all the things we talked about between minimally invasive treatment more than 70% of the aneurysms can be treated that way endovascularly. Some aneurysms need open
surgery and clipping. And the fact is that aneurysm treatment has to be individualized for every patient depending on multiple aneurysm
factors and patient factors and that’s what I call this
personalized aneurysm care. Not every aneurysm needs treatment. It’s only warranted if the
rupture risk of the aneurysm during a patient’s lifetime is higher than the treatment risk. And the aneurysm management
should really be sought at specialized cerebrovascular centers with aneurysm experts. We here at Penn Medicine in
the Cerebrovascular Center are neurosurgeons and
interventional neuroradiologists who work as a multidisciplinary group for treatment of brain aneurysms. My neurosurgical service manages patients in this multidisciplinary fashion with both open surgery and endovascularly depending on what is the best
treatment route for patients. There is a neuroscience blog that we published earlier this year which talks about basic questions
regarding brain aneurysms which comes in very handy when
talking about brain aneurysms for someone who’s just been diagnosed. Penn Cerebrovascular Center
is equipped with offering all the latest treatment options and really having
discussions with patients regarding what having
a brain aneurysm means and what’s the risk of its rupture. We also have a brain
aneurysm support group which is including patients who have had prior
brain aneurysms treated, both ruptured and nonruptured. You can share experiences with patients. Feel free to reach out
to me and my department regarding management
of your brain aneurysm and cerebrovascular conditions and we would be glad to have you in and answer your questions
and manage your care. I would also encourage if
someone needs a second opinion regarding their brain aneurysms, it’s highly recommended. Thank you.

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