Dr. Robert Solomon

Columbia University Medical Center has sent out a press release, For Stroke Prevention, Large 
Medical Centers May Have the Edge, where they announced the results of research done here at the Department of Neurosurgery. They interviewed Department Chairman Dr. Robert Solomon about the research and his comments appear in the article.

You can read the press release on multiple news sites.

The research, Technological Advances in the Management of Unruptured Intracranial Aneurysms Fail to Improve Outcome in New York State, was published in Stroke: a Journal of the American Heart Association.

Co-authors included Chairman Dr. Robert Solomon, Vice-Chairman Dr. E. Sander Connolly, Jr., along with department residents Brad E. Zacharia and Andrew F. Ducruet.

The authors looked back at statistics gathered for thousands of patients treated for unruptured intracranial aneurysms (UIA) during two distinct periods (1995-2000) and (2005-2007) in the State of New York.

We also asked Dr. Solomon a number of questions to help us understand the results of this research and the state of aneurysm treatment today which you can read about in our blog, Q & A With Chairman Solomon: Aneurysm Therapy Today.

Dr. Robert Solomon

Surgeons have been talking about how to treat brain aneurysms for over 250 years and though technology and medical knowledge have advanced them to a whole new level, they are still at it. The discussion today centers primarily around two specific treatments; endovascular coiling and surgical clipping (see definitions below).

This is what Department Chair, Dr. Robert Solomon and his colleagues were up to in their paper, Technological Advances in the Management of Unruptured Intracranial Aneurysms Fail to Improve Outcome in New York State, published earlier this year in Stroke: a Journal of the American Heart Association.

[Co-authors included department residents Brad E. Zacharia and Andrew F. Ducruet along with cerebrovascular specialist, Dr. E. Sander Connolly, Jr.]

The authors looked back at statistics gathered for thousands of patients treated for unruptured intracranial aneurysms (UIA) during two distinct periods (1995-2000) and (2005-2007) in the State of New York.

We asked Dr. Solomon a number of questions to help us understand the results of this research and the state of aneurysm treatment today.

Q: What does this research tell us?

A: There has been a doubling in the number of unruptured intracranial aneurysms treated in the two periods. This increase has been driven by a 5-fold increase in the use of endovascular coiling. However, there has been no data to suggest an expansion of indications for treatment.  While endovascular treatment as a whole had better outcomes than surgical treatment, the results were worse in low volume centers, and in centers that had a low percentage of patients treated with surgery.  The implication is that in low volume centers where endovascular treatment predominates, the overall results were significantly worse for the patients.  The likely explanation is that in high volume centers with expertise in both microsurgery and coiling, patients are selected for treatment based on the best approach for each patient.  Overall, this type of high volume collaborative team approach to unruptured aneurysms results in the best outcome for the patient.

Q: What would make a surgeon choose clipping over coiling at these large medical centers?

A: One reason that clipping is done more often at large centers is because patients have been specifically referred for clipping when coiling has failed.  Also, more clipping is done at large centers because inappropriate coiling is not done when there is a good surgical option.  Unfortunately, the surgical option is not always available at low volume centers, and without proper patient selection, the results are not satisfactory.

Q: Do you think that will change?

A: The large centers will change as the technology evolves and better endovascular options become available.  Surgery will be used only in appropriate cases.  If those indications for surgery change, the large centers will change accordingly.

Q: Why do you think coiling is being done more at these smaller facilities?

A: Coiling is done more at the smaller facilities because the surgeons at low volume facilities usually don’t have enough experience with aneurysm surgery to feel comfortable offering that alternative to their patients.

Q: Does your team at the Department of Neurosurgery perform more clipping or coiling for UIAs?

A: Here at Columbia we are about 50/50 with clipping and coiling.

Q: How is the decision made to do which procedure?

A: We review each case with experienced microvascular surgeons and expert neuro-interventionalists that perform coil embolization.  First we evaluate the risk of a complication with each procedure.  If there is a significant difference in the risk or a complication, we will generally choose the procedure with the lowest complication risk.  The other concern is the long-term outcome and chance for cure of the aneurysm.  We know that clipping usually offers a better chance of a complete cure, so when the risk analysis is favorable to clipping, we prefer clipping via microsurgery.  However, many factors such as patient health, age, and the exact anatomy of the aneurysm have to be considered for each case, and we choose the best option for each patient.

Q: Which do you think is better for UIAs (coiling vs clipping) from your own experience?

A: In my experience, clipping is a better option when all other issues are equal.  However, in the endovascular era, my surgical results have dramatically improved, because I will never attempt a surgical case that has high risk if there is a good coiling or endovascular option.  In a young patient with an aneurysm that has low surgical risk, clipping gives that patient the peace of mind that comes with a complete cure, and is worth undergoing the surgical procedure.

 

Definitions:
Intracranial Aneurysm: A medical condition where the wall of a blood vessel in the brain has weakend and creates a bulge or balloon like projection out the side. The aneurysm is dangerous because it can be at risk of bursting and causing a brain bleed or of pressing on vital structures in the brain.

Endovascular Coiling: A minimally invasive surgical technique where tiny metal coils are placed inside the aneurysm itself using X-Ray guidance. The coils fill up the aneurysm to prevent it from bursting.

Surgical Clipping: An open brain surgical procedure where a small clip is placed at the base of the aneurysm. This clip cuts off the blood supply to the aneurysm.

Related Blog: Solomon Heads Giant Aneurysms Off At The Pass

Approved by the Food and Drug Administration last April, the Pipeline Device had previously been used solely in clinical trials.

Dr. Meyers says, “We performed our first cases six to eight weeks ago and everybody is doing well. The treatment has been very effective for these patients and their aneurysms.”

An aneurysm occurs when a weakened area within a blood vessel wall balloons outward. They are dangerous, primarily because they can burst and cause a fatal brain bleed. Giant aneurysms, as in the images above, can also lead to an ischemic (non-hemorrhagic) stroke as it is prone to blood clot formation. A portion of that clot can then break free and lodge in a brain artery. In many cases, however, giant aneurysms become symptomatic by pressing on surrounding nerves and brain structures.

The key to treatment is to take pressure off of the aneurysm, this is usually done in one of two ways; clipping or coiling. Clipping is an open brain procedure where a small clip is placed at the base of the aneurysm to cut off its blood supply. Coiling is a minimally invasive technique within the blood vessel where tiny coils are used to fill the aneurysm to give it structure and keep it from bursting.

Philip Meyers, MD

The Pipeline Device is an all-together different approach. According to Meyers, “It is the first time that someone has applied a device that is specificlaly meant to remodel the blood vessel without actually treating the aneurysm seperately.”

A tiny mesh tube made of braided wire is placed within the blood vessel adjacent to the aneurysm.  There, it reinforces the vessel walls and takes pressure off of the aneurysm. Because of its mesh construction, circulation of blood within the aneurysm stops, then the aneurysm heals and disappears.

The images (red arrows in figure set above left) show a large aneurysm before and after treatment with the Pipeline Device. Notice in the bottom right image, blood flow to the aneurysm has completely stopped thus excluding it from the brain circulation so the vessel can heal.

Dr. Meyers says he is pleased with the results and is likely to continue to use the Pipeline device.

Watch this Pipline animation created by ev3, the maker of the device, to better understand how it works.

You can also learn more about the treatment of aneurysms in our previous blogs:
Get This Thing Out Of My Head!
Solomon Heads Giant Aneurysms Off At The Pass
Results From First IML: Aneurysm Coiling V. Clipping Still A Toss Up
Endovascular Neuroradiology; The New Frontier 

With nearly 80,000 attendees from around the globe, this meeting is one of the largest medical conference held in the United States each year.

Dr. Meyers tells us he spent the better part of a week in attendance and was able to present on Aneurysm Treatment in the Future.

Welcome back Dr. Meyers! 

Images from this publication

A team of our doctors has published an interesting case study in the journal, Surgical Neurology International.

The article is entitled, Medial lenticulostriate artery aneurysm presenting with isolated intraventricular hemorrhage and the authors from our department include, Dr. Philip Meyers, Dr. E. Sander Connolly and New Jersey affiliate Dr. Dorothea Altschul.

Dr. Altschul says, “We were able to identify a rare type of cerebral aneurysm that had caused a brain bleed in a 71 year old woman.”

You can read more about this case study here on Pubmed.

Lavine was one of three speakers during this session.  The other two were invited guests: Mika Niemela form Helsinki, Finland; and Christian Raftopoulous from Belgium.   They each presented a lecture and then participated in a panel discussion of selected cases.

Lavine’s talk was entitled, Endovascular Options for the Incompletely Treated Aneurysm and he says, “the case studies generated a lively discussion about treatment options for cerebral aneurysms.”

This continues to be a great topic for discussion in neurosurgery today.

Read more on the subject in our previous blogs: Results From First IML: Aneurysm Coiling V. Clipping Still A Toss Up, Galbraith Award Given To New York Aneurysm Study, Solomon Heads Giant Aneurysms Off At The Pass, Get This Thing Out Of My Head!.

Check out the video and see what all the fuss is about.



The program, entitled Current Management of Ischemic and Hemorrhagic Stroke, provided an “up-to-date appraisal of the evaluation and treatment of acute stroke, carotid disease, intracranial vascular disease, arteriovenous malformations (AVMs), and aneurysms.”

The one-day course was co-directed by Dr. E. Sander Connolly Jr. from the Cerebrovascular Center, and Dr. Joshua Z. Willey from the Department of Neurology.

According to Dr. Solomon, “The conference was a service for the medical community by the Neurological Institute to optimize patient care in the community; to update their knowledge base on the latest information about diagnosis and treatment of cerebrovascular diseases.”

The department of Neurological Surgery at Columbia puts on some form of continuing medical education at least once a year on various topics of interest to outside practitioners.

In addition to Dr. Solomon and Dr. Connolly from the Cerebrovascular Center, several other members of our department spoke at this event: from the Endovascular and Cerebrovascular Centers - Dr. Sean Lavine, Dr. Philip Meyers, and Dr. Dorothea Strozyk; and from the Gamma Knife Center - Dr. Steven Isaacson.  A list of our doctors and their presentation topics is below:

Robert Solomon, M.D.- Microsurgery for AVMs
E. Sander Connolly Jr., M.D. – Microsurgery for Aneurysms
Sean Lavine, M.D. – Endovascular Treatment of Aneurysms
Philip Meyers, M.D. – Endovascular Treatment of AVMs
Dorothea Strozyk, M.D. - Endovascular Treatment of Acute Ischemic Stroke
Steven Isaacson, M.D. - Radiosurgery for AVMs in eloquent areas

According to Dr. Solomon, “The conference was a great success.  About 150 local neurologists, nurses, and neurosurgeons got together to discuss management of ischemic and hemorrhagic stroke.  As well, all forms of surgical treatment of cerebrovascular diseases were covered.”

He also said, “There was a lively group discussion during the lunch hour with many members of the audience given a chance to voice their opinions and ask for advise from the faculty panel.”

Related: Docs Present at 2010 Congress of Neurological Surgeons Meeting, Solomon’s Brain Aneurysm Primer Video, Dr. Solomon’s Unruptured Aneurysms Article, Solomon Heads Giant Aneurysms Off at the Pass,