Surviving a Brain Aneurysm Hinges on the Right Treatment

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Renowned brain surgeon Dr. Dongwoo John Chang discusses why surviving an neurysm depends on getting the right treatment.

SACRAMENTO, Calif. ( people have family members who have died from a ruptured brain aneurysm. In fact, about 30,000 Americans experience an aneurysm every year. Of these, more than 50 percent die after the rupture. Of the survivors who are able to undergo brain surgery, a minority return to their prior quality of life.

Through advances in brain imaging, we're able to obtain pictures of the insides of people's brains without much difficulty. With them, doctors are able to diagnose the un-ruptured brain aneurysm, or weak point along a blood vessel.

The telltale sign of a ruptured brain aneurysm is the proverbial "worst headache of your life." Some people pass out, become comatose, vomit, have a stiff neck, or become bothered by bright lights. You might be saying to yourself, 'Hey, I've experienced those symptoms." But if you've lived to talk about this experience, it was not an aneurysm.

A diagnosis, which usually includes a CAT scan, will show fresh blood from a ruptured brain aneurysm in most cases. If the CAT scan is negative, then a lumbar puncture is possible. If this is also negative, then you are in the clear. If it's positive, you need to see a neurosurgeon who specializes in treating brain aneurysms.

Ideally a cerebrovascular neurosurgery specialist is the best doctor to see, since it means that this person has received further training beyond the standard residency in neurosurgery. He or she will discuss the various options with you, from doing nothing, to surgery, or something called "coiling" the aneurysm.

Surgery is straightforward. The surgeon opens your skull, works between the brain crevices, finds the aneurysm and secures it with a titanium clip. Then the surgeon confirms that all other normal vessels are open and closes the head. Done properly, the aneurysm problem is erased for good.

"Coiling" is a little more involved. An artery in the groin is punctured and a catheter is fed up to the brain arteries. It's a long stretch, but this is done fairly often. At this point, a platinum "coil" is placed into the sac of the aneurysm. It is supposed to cause the aneurysm sac to clot and remove the threat of a rupture.

So why don't we coil all aneurysms? It seems easier, less risky, and doesn't require opening up the head. The answer is that coiling can result in recurrent aneurysms and can lead to complications similar to open-brain surgery. However, in the game of intuitive appeal, a catheter in the groin seems better than opening up your head. But we are still within the initial maturation phase of the brain aneurysm coiling procedure. It has been around for only 15 years compared with 70-plus years for "craniotomy," the procedure for opening the skull to treat brain aneurysms.

In the heavy industry push for implanting "coil" devices to treat cerebrovascular disease, one element is forgotten - the patient. As surgeons, once we cut someone, we generally have them as patients for life. Chances are your aneurysm will be coiled by an interventional neuroradiologist, who is quite qualified, but not trained to take care of you post-procedure.

You need to think about your brain and your brain aneurysm, and make sure you understand all of the implications for the remainder of your life, prior to agreeing to a particular treatment. When someone does a procedure, you should be able to follow up with that particular physician for all aspects of care relevant to your brain aneurysm.

How would you feel if your neurosurgeon just turned you over to your family doctor for aftercare? Well, that is what happens in many cases of brain aneurysm management. It's sad but true, but that's the influence of industry on the continuity of patient care.

Dongwoo John Chang, MD, FRCS (C) is the Chief of Cerebrovascular Neurosurgery, Chief of Epilepsy Surgery, and Co-Director of the Comprehensive Epilepsy Program of the UC Davis School of Medicine and Medical Center in Sacramento, California. A Stanford University graduate, Chang served his neurosurgery residency at McGill University Faculty of Medicine/Montreal Neurological Institute.


Submitted by Anonymous (not verified) on
ooh, he's cute!

Submitted by Michael J. Alex... (not verified) on
Unfortunately, Dr. Chang's article has a lot of misinformation, and to me it appears that he is trying to scare patients into having surgery instead of the coiling procedure. What he failed to mention was that there was a highly respected prospective randomized trial published a few years ago (the ISAT trial) that demonstrated conclusively that there were less complications, and less permanent disability with coiling, compared to surgery. I do both procedures, surgery and coiling, and I can tell you that most patients and their families prefer coiling to open surgery. So that IS putting the patient first. It seems that Dr. Chang is trying to politicize this medical problem to suit his own interest. Michael J. Alexander, MD FACS Director, Cedars-Sinai Medical Center Los Angeles, California

Submitted by Donna (not verified) on
I would as a patient have to agree somewhat with Dr. Chang. I was treated last month for an aneurysm at the basiler tip. 7mm with a 4+mm neck. I understand why the coiling was pushed in my case(location) However Dr.Chang is correct with reguards to after care. I barley remember seeing my interventional neuroradiologist at all after the procedure. Only a quick, "Everything went perfect" As far as I am concerned it did not and I am having a hard time getting him to admit or do anything. I have neck pain, dizzy, headaches, numbness of my fingertips and toes, sick to my stomach, my pulse rate is now at rest 100-110 bpm, my bp is 90/70, constant fatigue and a pain in my head like an ice pick is stabbing the back of my head. I was given one follow up appointment with him. He refuses to admit that any of my problems have anything to do with the coiling and told me to call my primary doctor. He left 2mm of one of the coils protruding out and all he would say was " No big deal, the aneursym is coiled, take asprine everyday, it's good for you anyway. When I tried to ask him why he did not remove it or use a balloon or stint he just got very defensive. As far as he is concerned, he is done, see you in 6 months to have another angiogram. I am actually worried that there is or was a small leak or clot or something. I am only 42 my mother died at 45 as well as my brother at 45 from a rupture. I will go to my primary doc and see if she will run an MRA and check for me. I do agree with Dr. Chang there is no after care after a coiling. If he or anyone has any advise on what to do about the 2mm protruding please let me know. Thanks much and "Good luck and the best to any and all that have had or or currently dealing with an aneursym". Also,Michael J. Alexander is partly correct about that study, he should though not just use the part that supports his opinion. That study also shows that coiling does in fact run a higher risk post prcedure than does cliping. Coiling runs a high risk of aneursyms returning, growing, bleeding and needing more coiling procedures or in some cases needing to be clipped.

Submitted by Anonymous (not verified) on
I would also agree with DR. Chang, about after care..... I experienced a 2cm widenecked aneurysm rupture, not expected to survive... but I did.. Thankful of that, but....this aneurysm was treated with 19 coils..followed up by an angiogram 6 months later... 5 months after that angiogram, I asked my family doctor to refer me to see the neuroradiologist again to discuss the problems I was experiencing with balance, vision, headaches, matalic taste in mouth, and tongue numbness along with memory problems. He had not heard from him on the results of the angiogram and like me felt no news is good news.... Well to my surprise/shock... when I went to see him, he informed me the aneurysm was back... something he had known since the angiogram 5 months earlier, and I would require re-coiling... all of a sudden this is important to get done ASAP. If I hadn't requested the appointment... what would have happened??????? I had the re-coiling done, and am now waiting for a follow-up angiogram. I call the Nero's office and said I would like to speak with him when I go for the angiogram. They will get back to me. He doesn't normally see the patients when they go for angiograms errrrrrr. I'm still experiencing fatigue, headaches, tongue numbness and dizzy spells. My initial aneurysm rupture was June 23, 2006.

Submitted by Anonymous (not verified) on
As a patient, I can tell you lack of follow up or patient/doctor relationship happens before surgery. I have just been recently diagnosed with an aneurysm. I only recently saw the same neurologist twice at the same clinic. I've been told a surgeon will call as I need surgery and that was three weeks ago. I have no doubt I will rarely have the same surgeon for follow up care as it is the same facility. I'm not terribly hopeful for receiving the best care as I don't feel I do now. It is actually comforting a physician is aware of this problem, a problem I consider a bit unnerving.

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