Sealing Leaks in The Brain Without Opening The Skull

This is a story of a 33year old gentleman, working as a driver in Gulf, who had come to Kerala to get married. 16th Sunday was his marriage. Three days after marriage, while having bath, he had sudden severe occipital headache, fell down and became unconscious.

Relatives found him in an unconscious state and having a seizure. He had severe neck pain and occipital headache 2 days prior to this episode. CT scan of the brain showed diffuse subarachnoid hemorrhage. Cerebral angiography showed left vertebral artery dissecting aneurysm.

Obliteration of the aneurysm was done by a novel procedure called aneurysm coiling. This is a treatment by which the blood vessels of the brain are reached through the femoral artery in the groin. A small pinhole puncture is made in the femoral artery and a small catheter is passed into the affected part of the brain under fluoroscopic guidance in a cath lab. Once the small tube is taken into the point where the blood vessel has ruptured, small platinum coils are carefully deployed into the affected area , to occlude the bleeding area and seal the bulging spot or aneurysm. In this particular patient, two catheters were used, one to monitor the blood flow in the opposite vertebral artery also. So two punctures were taken, one in each femoral artery. Four coils were used for complete obliteration of the aneurysm. This procedure was done under general anesthesia and took one hour and 30 minutes for completion. Patient had no fresh neurologic deficits. Patient had normal food and started walking and could go to the toilet after 6 hours.

There are many advantages of coiling over open surgery. This is a relatively painless procedure. There is no need to open the skull and surgery can be avoided. The only scar in the body is two small pinhole sized puncture marks in the blood vessel in the thigh. Since there is no opening of the brain, the chance of infection and bleeding is extremely reduced, also recovery time is significantly reduced. Usually patients can be discharged in 2-3 days after coiling.Dissecting vertebral artery aneurysm is a very rare cause of subarachnoid hemorrhage. Bursting of aneurysm can occur at times of sexual excitement, physical exertion etc.

What is a brain aneurysm?

Aneurysm is a small bubble that forms on the walls of the blood vessel that carries blood to the brain. The aneurysm has a thin wall compared to the thicker wall of a normal brain artery. This thin wall bubble is prone to rupturing.

What are the causes of aneurysm?

An aneurysm is the result of a weakness in the wall of a blood vessels. Most aneurysm occurs without any known cause. High blood pressure and smoking are some of the factors that may cause weakness in the wall of an artery leading to aneurysm. Some of the brain aneurysms seem to occur in families suggesting there may be genetic cause.

How is a brain aneurysm treated with coils?

When we treat an aneurysm with coils, we generally have the patient completely asleep while an anesthesiologist monitors the patient. Patients are placed under general anesthesia because it makes the procedure safer and more comfortable for the patient. After the patient is asleep, a thin, hallow, soft tube called a catheter is placed in the artery in the leg. This catheter is approximately 1/8 of an inch wide, but long enough to reach from the leg to the neck. Depending on where the aneurysm is located, the catheter is then guided into the carotid artery in front of the neck, or the vertebral artery in the back of your neck. Placement of the tube is done by continuously watching the tube move through the body on an x-ray monitor. Once this catheter is placed, a much smaller catheter , called a micro catheter is navigated through the arteries in the neck, and into the artery in the brain where the aneurysm is located. The microcatheter is then gently guided into the aneurysm itself. After the microcatheter is in the aneurysm, soft metal coils made of platinum are gently pushed into the aneurysm. These coils wind and bend because they are very soft, and fill up the aneurysm. Several coils may be placed in the aneurysm to completely fill it. Once filled the aneurysm with coils, the microcatheter is removed from the aneurysm and pulled out of the body.

How does the coil treat the aneurysm, and how quickly is it effective?

The coils are a foreign body, once they are placed in the aneurysm, blood begins to clot on the coils. Clotting happens very quickly, within hours, and provides protection against bleeding. Over the next six weeks, the clot changes into scar tissue, this provides further protection from bleeding.

What are coils made from?

The coils we use for aneurysms are made from platinum. Platinum never breaks down in the body and will remain forever. It is safe to have MRIs if the coils are used, as they do not affect that test. You can also have CT scans, but the coils will cause artifacts on a brain scan. There have been no negative reactions to platinum coils. They do not cause allergic reactions

What are the symptoms of subarachnoid hemorrhage?

When an aneurysm bleeds, it usually causes sudden onset of an extreme severe headache. Typically the head ache is described as worst headache of a lifetime. Often there is nausea and vomiting. If the bleeding is severe, the patient often loses consciousness. Patients can have seizures also at the time of bleeding. In about a third of the cases successful treatment can lead to complete recovery. In other third of cases the patient will survive but may go on to suffer a stroke. In the remaining third the bleed is ultimately fatal.

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Dr. Sai Sudarsan

Pulse Hospital, Ranchi. India

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