TODAY news - February 19, 2004 - Loma Linda University Medical Center news

Thursday, February 19, 2004 TODAY

Loma Linda University Medical Center news

Endovascular coiling offers choice for aneurysm patients

The Rycraft family, from left: Stephany, 14; John; Irving, 12; Patricia (patient who received coiling); Alexandra, 6 weeks; and Karla, 14.

Sometimes having a choice makes all the difference in the world. At Loma Linda University Medical Center, a new procedure is being offered that gives aneurysm patients just that, a choice.

For the past 30 years surgery has been the only option for treating bleeding brain aneurysms. A brain aneurysm is a small bubble that forms on the wall of an artery that carries blood to the brain. The aneurysm has a thin wall, which can easily break and cause bleeding into the brain. Another name for brain aneurysm is cerebral aneurysm.

In surgery, these aneurysms in the brain are corrected by a tiny metal clip placed across the neck of the aneurysm to stop blood flow into the aneurysm. This requires removing part of the skull because the clip is placed from outside the blood vessel.

The newcomer to the scene is endovascular coiling. This method treats the aneurysm from inside the blood vessel. Offered since September at LLUMC, this technique is a minimally invasive procedure that uses a microcatheter and very thin platinum coils. The microcatheter is a tiny, flexible tube that is navigated through the blood vessels of the body starting from the groin all the way up to the brain where the aneurysm is located. Once the microcatheter is inside the aneurysm, soft thin platinum coils are placed through the microcatheter into the aneurysm. The aneurysm is then filled with these coils until it is plugged up, thereby preventing any further bleeding. The microcatheter is guided by real-time X-ray technology called fluoroscopic imaging that allows the physician to visualize the patient’s vascular system and treat the disease from inside the blood vessel. Everything is done through a small incision, about four to five millimeters, in the groin.

Both surgery and coiling are methods used to prevent the aneurysm from breaking or rupturing. A rupture is the worst-case scenario that leads to bleeding in the brain, called subarachnoid hemorrhage, the deadliest form of stroke. But even before they rupture a cerebral aneurysm can be fatal—15 percent of all victims die within minutes. The number rises to 50 percent within a month if left untreated.

"This represents a great advance in treating cerebral aneurysms," says George Luh, MD, director of interventional neuroradiology at Loma Linda University Medical Center. "What it really means is that prior to this you didn’t have a choice of how to treat aneurysms. Now there is a choice."

The coiling procedure usually takes about two hours and requires overnight observation. Patients can usually go home, the next day, which is a shorter recovery time when compared to surgery. It is important to treat aneurysms that have bled as soon as possible. And as Patricia Rycraft of Ontario, California, found out, acting in time is essential.

Image of Ms. Rycraft’s vascular system where the aneurysm formed. George Luh, MD, an interventional radiologist at LLUMC, coiled her aneurysm four days after it was discovered.

Ms. Rycraft was already in her last term of pregnancy with her daughter, Alexandra, when she went with her husband, John, to his company’s annual picnic on September 6, 2003. Later that night she and her husband attended a party at one of their neighbors in their apartment complex. Upon arriving home Ms. Rycraft complained of a lot of pain. She couldn’t get comfortable lying down, sitting, or standing up. She described it as "the mother of all migraines." It was so severe Mr. Rycraft decided to take her to the local hospital in Chino.

An MRI didn’t turn anything up but a spinal tap found blood where it shouldn’t have been, and Ms. Rycraft was transferred to Loma Linda University Medical Center immediately, the closest medical center equipped to properly treat the suspected aneurysm. After more tests and a CAT scan a small aneurysm sac was discovered in Ms. Rycrafts brain.

"The pain was very hard," remembers Ms. Rycraft. She and her husband met with Walter Johnson, MD, a neurosurgeon at LLUMC, and Dr. Luh.

"They gave us the run down on what could happen if they did surgery and what could happen with the coiling," says Mr. Rycraft. "We decided the coiling technique was a better option all around that wouldn’t affect the baby.

"But it was a scary thing."

On September 10, Dr. Luh performed the endovascular coiling technique, filling Ms. Rycraft’s aneurysms with the tiny platinum coils. She recovered from the general anesthesia and went on pain medication for two days. The week before Christmas she delivered her healthy baby daughter, Alexandra.

"We’re starting to get back into the swing of things," says Mr. Rycraft. "Our view of life has a lot more depth now. We don’t take things for granted anymore."

Ms. Rycraft will get check ups every six months for the next two years. She was one of the first nine patients able to take advantage of the new technique at LLUMC.

"This is not like a magic bullet," warns Dr. Luh. "Not all aneurysms are amenable to coiling." He urges that to get the best treatment patients should go to a hospital that offers both coiling and surgery and be advised about both. The neurosurgeon and interventional neuroradiologist compliment each other and together can provide the best course of action for the patient.

"Some aneurysms are better off being clipped," says Dr. Luh.

Endovascular coiling was brought to the forefront of aneurysm treatment in 2002 after the completion of a multi-center randomized clinical trial comparing surgical clipping to endovascular coiling. This trial, called the International Subarachnoid Aneurysm Trial (ISAT), found that in patients equally suited for both options, coiling produced a substantially better patient outcome than surgery in terms of survival free of disability at one year (the relative risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than in surgically–treated patients). The study was ended early after its steering committee determined it was no longer ethical to randomly assign patients to surgery and not give them the choice of coiling. In the study 1,073 patients were dedicated to coiling and 1,070 to clipping.

Long-term follow-up will be essential to assessing the durability of this new coiling technique. However, at least now patients have the choice.

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LLUMC orthopaedic specialists visit three Japan conferences

Loma Linda University Medical Center orthopaedic specialists Ian Clarke, PhD, director of the orthopaedic research center on East Campus, and Tom Donaldson, MD, director of the joint replacement center, spent four days in Japan on a whirlwind tour of three conferences in December, 2003.

They first visited Tokyo Medical University. As Dr. Clarke explained, the first tribology research fellow who came to LLUMC in 1998 was Kengo Yamamoto, MD, an orthopaedic surgeon from Tokyo Medical University. Dr. Yamamoto has now been promoted to full professorship in Tokyo. Part of his success was a result of the good research he performed at LLUMC and the publications that resulted.

"We are both very proud of his successful promotion this year," says Dr. Donaldson. "This is a big moment for both our teams and certainly adds a new dimension to our orthopaedic mission in 2004."

Drs. Donaldson and Clarke then went by high-speed train (Shinkansen) to Kyoto University of Technology to present their LLUMC research ideas at a nano-technology conference run by another collaborator, Professor Giuseppe Pezzotti. This 2-day symposium was jointly sponsored by the Italian Ministry for Foreign Affairs, the National Research Council of Japan, and the Kyoto Institute of Technology. Nano-technology is the science of materials at the sub-microscopic level. For example, a fine human hair is only about 0.7 millimeters in diameter. However, a nano-fiber would have a diameter of about 7 nanometers, which is 1,000 times finer than the human hair.

"This is relevant to our orthopaedic practice," notes Dr. Donaldson, "because the wear debris released inside artificial joint replacements has the same scale." The relative size of plastic particulate as recovered by Paul Williams, MS, in our wear debris lab on East Campus is equivalent to a printed period.

"Such wear debris is 10 times smaller than even a red blood cell," remarks Dr. Donaldson. LLUMC’s orthopaedic group invited Professor Pezzotti to LLUMC to present on this nano-size ceramic implant wear at the 16th Annual Residents’ Science Day on May 13.

To end this trip, Drs. Donaldson and Clarke took the train to Osaka to attend a design conference with a team of Japanese surgeons developing a new total-knee replacement. The pair flew back to the USA on the fourth day of the trip.

"This was really living in the fast-lane ending 2003. This bodes very well for our international collaborative missions in 2004," says Dr. Donaldson.

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Thursday, February 19, 2004 TODAY