Neuroendovascular surgeons at Brigham and Women’s Hospital (BWH) are delivering newer catheter-based options and advanced hybrid approaches for patients with aneurysm and stroke.
“These procedures can typically be completed in a shorter period of time with less risk of complications and improved outcomes,” said Ali Aziz-Sultan, MD, Section Chief of the BWH Center for Cerebrovascular Diseases and Section Chief of the Endovascular/Interventional Neuroradiology Service at BWH. “Using the hybrid operating suite, we also are able to combine minimally invasive endovascular and traditional neurosurgical approaches in one location to improve efficiency and reduce morbidity.”
Flow-diverting stent – Flow-diverting stents are placed across the aneurysm neck into the parent vessel, rather than the aneurysm sac. The stent impedes flow to the aneurysm, causing the aneurysm to shrink. This procedure can be completed much more rapidly than aneurysm clipping or coiling with less risk of complications in select cases. It also can be performed for select patients who are not eligible for clipping or coiling. Dr. Aziz-Sultan has performed more than 60 of these procedures throughout his career and has taught this approach across the country (see Case Study One);
Stent retrievers – Mechanical embolectomy using the newest mesh stent retrievers in patients with acute ischemic stroke has seen recanalization rates as high as 90 percent, significantly greater than the rates seen with older devices. This is one of many options available to patients as part of comprehensive multimodality stroke care at BWH, which brings together neurosurgeons, stroke neurologists, and interventional neuroradiologists to evaluate and treat patients;
Hybrid approaches – Dual-trained neurosurgeons with expertise in interventional neuroradiology and open vascular surgery at BWH use a hybrid operating suite to provide simultaneous multimodality treatment for stroke or aneurysm, including patients with intracranial hemorrhage and acute ischemic stroke (see Case Study Two).
A 53-year-old presented with ocular dryness and increased eye pressure. Magnetic resonance imaging revealed an incidental left-sided para clinoid aneurysm. Cerebral angiogram showed the aneurysm to be 7.2 mm.
The patient was taken to the neuro-angiographic suite at BWH. Frontal and lateral digital angiography was performed on the left carotid artery prior to deployment of the embolization device. The device was unsheathed and expanded to span from the distal ophthalmic segment of the internal carotid artery to the lacerum segment of the internal carotid artery, covering the aneurysm neck. Repeat lateral digital angiography of the left internal carotid artery was performed during the embolization device deployment to confirm parent vessel patency and appropriate device sizing and placement. Flow within the aneurysm was notable for delayed, stagnant filling of the aneurysm. The patient tolerated the procedure and removal of the aneurysm without complications.
The patient remained neurologically intact at baseline and was discharged on the second post-procedure day. She continues to be symptom free.
A 27-year-old patient presented to a community hospital emergency room with a sudden severe headache and left-sided paralysis. Imaging showed a very large right-sided hemorrhage and a surgically difficult to access distal cerebral aneurysm.
The patient was transferred to BWH, where he was rushed into the hybrid operating suite for emergent, life-saving treatment. Here, the patient underwent both coiling of the aneurysm and evacuation of the hematoma. This treatment paradigm, which was specifically tailored to the patient, is traditionally completed in two separate environments – embolization in a radiology suite and hematoma evacuation in a traditional OR. Both procedures were completed in the hybrid operating suite in less than two hours. The reduced time to treatment prevented brain herniation and significant morbidity.
The patient’s bleeding was controlled following obliteration of the aneurysm. Hematoma evacuation prevented a cerebral herniation. The patient has made a great recovery. He is able to move both sides of his body and ambulate. In addition, he is back to his communication baseline including following commands and home address recall.