Best Brain Aneurysm Care in NY
Columbia University Medical Center: Best Outcomes for cerebral aneurysms in New York according to NYS Database
By Dr. Philip Meyers
July 14, 2014
In the March 25, 2014 edition of Stroke, Journal of the American Heart Association, Zacharia et al. analyzed the outcome of patients who underwent treatment for cerebral aneurysms in the State of New York from 2005 – 2010 (Stroke. 2014; 45: DOI: 10.1161/STROKEAHA.113.004412). Columbia University Medical Center placed highest in all good outcome categories.
Cerebral aneurysms are an important cause of stroke, neurological injury, and death. It is believed that most people are not born with cerebral aneurysms, but rather, aneurysms are acquired at an increasing rate throughout life. Related primarily to smoking, high blood pressure, and certain genetic conditions, aneurysms are weakened places in the brain’s arteries that are subject to burst with disastrous results. When blood leaks from an aneurysm in the subarachnoid fluid space surrounding the brain, serious and potentially irreversible brain injury can occur. Approximately 20,000 persons suffer a subarachnoid hemorrhage each year in the United States. Although aneurysms are repaired as an emergency following a hemorrhage in an effort to save the patient’s life, many patients are permanently injury by the initial hemorrhage. Despite major improvements in neurological intensive care, up to 50% of patients with subarachnoid hemorrhage from ruptured aneurysms will die in the first month. Up to 80% of survivors have permanent neurological impairments.
Because of ongoing improvements in brain imaging using computed tomography (CT or “CAT” scan) and magnetic resonance imaging and angiography (MRI and MRA), an increasing number of people with incidental aneurysms, that is, aneurysms which have not ruptured, are identified. These patients have often undergone head and brain imaging for unrelated reasons, such as headache, hearing loss, paranasal sinus disease, seizure, and vision changes. In addition to the reason for which the scan was obtained, an aneurysm, or aneurysms, may be discovered. For these patients with incidental aneurysms, there are ongoing questions about best medical treatment. Some recent evidence points to a relatively high life-time risk of hemorrhage. For many of these people, the fear of rupture leaves them feeling that they have a “time- bomb” in their heads. Thus, they seek out treatment.
Treatment of brain aneurysms comes in two basic forms: surgical clipping and endovascular occlusion. Surgical clipping requires a craniotomy, or temporary opening in the skull, so that the surgeon can place a clip, sometimes multiple clips, on the aneurysm to pinch it closed. Once closed, the vessel walls pushed together seal the aneurysm off. The aneurysm is excluded from the blood supply to the brain so that blood cannot leak out. The aneurysm usually withers and disappears.
Surgical clipping of aneurysms was first performed in the 1930s, and the technique was ￼improved by adoption of the operating microscope. Surgical clipping continues to have a significant role in the treatment of cerebral aneurysms, but the skill set to clip complex cerebral aneurysms is not one mastered by many neurosurgeons. It remains a particular skill set, one mastered over many years.
Endovascular (through the blood vessel) aneurysm treatment was first described at the Neurological Institute of New York in 1941 by Werner and Blakemore. The Neurological Institute is now part of Columbia University and the New York Presbyterian Hospital. The endovascular technique to treat brain aneurysms remained experimental until the development of the Guglielmi detachable coil (GDC), which was introduced in 1991 and FDA approved in 1995.
Using delicate platinum coils to fill a cerebral aneurysm, the endovascular specialist can block the aneurysm and prevent bleeding. In many cases, the aneurysm will heal, creating a permanent repair. Approved initially for the treatment of surgically inaccessible aneurysms, the procedure now finds favor among patients and physicians alike, often for different reasons. Patients often prefer not to have a craniotomy if at all possible. Meanwhile, many surgeons do not have the training background or breadth of experience to be expert in open surgical procedures.
In many studies, endovascular treatment was shown to reduce treatment complications, reduce length of stay, and overall hospital cost. In the International Subarachnoid Aneurysm Trial (ISAT, 2002), patients with ruptured aneurysms randomized to surgical clipping or endovascular coil occlusion faired 25% better in the endovascular group with lower rates of neurological injury, seizure and later disability. The results of the trial have been generalized to all aneurysms even though there is no trial showing the specific benefit of endovascular treatment over surgical clipping for unruptured aneurysms. This has been largely dictated by the medical marketplace. Now, approximately 80% of all aneurysms (ruptured and unruptured) are treated using endovascular techniques. There are now many new tools to treat a broader variety of cerebral aneurysms using endovascular means. However, not all aneurysms are amenable to an endovascular procedure. Ironically, conventional surgery with craniotomy and clipping remain better options for some patients, creating better repairs with lower rates of injury in carefully selected patients. It is not possible to dispense with the traditional open surgical techniques and accomplish best outcomes for all patients.
Columbia University Medical Center has a unified team of cerebrovascular experts to treat patients with ruptured and unruptured cerebral aneurysms. Members of this team are highly subspecialized. Two surgeons only perform the open surgical treatment of cerebral aneurysms. These surgeons do not perform surgery on the spine or remove brain tumors. Brain blood vessel surgery is their full-time practice. Similarly, there are three endovascular surgeons who only treat cerebral aneurysms using through-the-blood-vessel methods. A highly specialized practice not shared by many, this approach is now vindicated by outcome data.
Using data from the New York Statewide Planning and Research Cooperative System (SPARCS), Zacharia and co-authors were able to evaluate the effects of aneurysm treatment at all medical centers in the State of New York. These data are collected by the State of New York using tax-payer dollars. The data are not subject to political whim but rather SPARCS data represents an accounting of actual experi- ence in New York. Focusing only on the high- volume medical centers, which have ￼repeatedly been shown to have the best outcomes, Zacharia and his team were able to determine the outcomes of patients with unruptured aneurysms recently undergoing treatment.
In general, patients with unruptured aneurysms are neurologically normal when they enter the hospital for aneurysm treatment. The majority (nearly 77%) of aneurysm patients were treated at high volume centers. Around 80% of patients with unruptured aneurysms had good outcomes across all high-volume centers but the rate of good outcomes varied widely: from 44.6% to 92.1%. Most of these differences, but not all, could be attributed to procedural volume. The more a doctor performs a procedure, the better that doctor becomes. However, some facilities perform better than others.
The difference between the facility that achieves 44.6% good outcome and the one that achieves 92.1% good outcome probably lies in the selection of technique to treat each patient. Aneurysm care is highly individualized. Not all aneurysms require surgery. Some patients just need careful observation. For those patients with aneurysms who should be treated, careful evaluation of each technique is required. Finally, a highly experienced operator using state-of-the-art technology must carry out the treatment.
Treatment of a brain artery aneurysm is a major life event, but it is one that can be addressed and surmounted. As the data show, patients treated at Columbia University Medical Center stand a better chance of a favorable outcome than patients at other centers.
Philip M. Meyers, M.D., F.A.H.A. is Professor of Radiology and Neurological Surgery at Columbia University and Co-Director of Neuroendovascular Services at New York Presbyterian Hospital. Dr. Meyers treats vascular disorders of the brain and spinal cord using minimally-invasive, image-guided techniques. Learn more about him on his bio page here.