 |
 |
|
UW Medicine Brain (Cerebral) Aneurysm Center
at Harborview Medical Center
| Emergency phone number: 1-888-731-4791 | |||
| Ruptured Aneurysms | Unruptured Aneurysms | Our
medical team |
Case Studies |
The University of Washington Brain Aneurysm Center at Harborview Hospital provides state-of-the- art evaluation and treatment of patients with intracranial aneurysms. It is one of the few centers in the world offering advanced endovascular treatments and advanced microsurgery including Brain Bypasses.
More than 250 patients were treated at our center in 2004. The number of patients is steadily increasing because of our innovative treatments and the coordinated efforts of our multidisciplinary team which includes neurosurgery, neuro-interventional radiology, anesthesia, and critical care nursing.
Ruptured Aneurysms:
Patients with aneurysmal rupture present with intracranial hemorrhage and are usually admitted to the hospital emergently. After initial clinical evaluation and treatment in the Emergency Trauma Center, patients undergo CT Angiography which enables planning of further treatment. This is usually followed by Intra – Arterial Digital Subtraction Angiography with 3-Dimentional imaging. After discussion among our specialists, a joint decision is made to proceed with Endovascular Treatment or Microsurgical Treatment.
Endovascular treatment involves placement of intravascular coils into the aneurysm to create thrombosis and excludes the aneurysm from circulation. Microsurgical treatment consists of craniotomy, skull base bone removal to enable aneurysm exposure, and clipping of the aneurysm using non-magnetic titanium clips. Another approach is to perform brain artery bypass and exclusion of the aneurysm. Microsurgery is performed under high magnification operating microscope, and neuro-endoscopy, assisted by a team of sophisticated neuro-anesthesiologists and brain monitoring by neurophysiologists. Patients frequently undergo intraoperative Doppler and Angiographic evaluation to ensure adequacy of aneurysm clipping, and to confirm continued patency of branch arteries.
Link to quote of Dr. Gavin Britz in the BBC News about Aneurysm Clipping
Postoperative management:
The initial treatment of the aneurysm by endovascular coiling or clipping
is only a part of the management needed (to optimize recovery) for patients
with Subarachnoid Hemorrahge (SAH). The patient’s problems often
include brain injury from the initial hemorrhage, vasospasm of the brain
arteries, hydrocephalus, hyponatremia (low sodium concentration in the
blood) and other medical complications. The patients are monitored and
treated for several days in the Harborview Medical Center Neuro Intensive
Care Unit by an experienced, capable, and compassionate team of nurses,
physicians, and other health care professionals. In addition to the monitoring
of cardiac, cerebrovascular, and neurological parameters, patients are
evaluated by transcranial Doppler evaluation and Single Photon Emission
Computed Tomography (SPECT) scanning, for the occurrence of vasospasm.
When present and clinically relevant, patients are treated medically with
hypertensive, hypervolemic, hemodilutional (HHH) therapy, and frequently
by Endovascular Angioplasty.
Patients with SAH caused by aneurysms often require neurological and psychological rehabilitation to enable them to become independent, and return to their former activities. The Aneurysm Management Team at HMC assist the patients in achieving their maximal recovery potential. Sometimes, the recognition of persisting hydrocephalus and treatment by a ventriculo-peritoneal shunt may improve the patients functional recovery dramatically. In other instances, adjustment of the patients’ medication, or finding the right rehabilitation facilities may make a great difference to the patients.
Unruptured Aneurysms:
Unruptured anurysms are discovered in many patients because of aneurysm specific symptoms, or other non specific symptoms. Such patients are referred by other physicians, and are evaluated expeditiously by MR-Angiography or CT-Angiography, and intra-arterial DSA. After discussion amongst the team members, a decision is made to offer either no treatment but continued follow up, endovascular treatment, or microsurgical treatment. In many cases, the patients are presented with endovascular and microsurgical options, with a discussion about the pros and cons of the modalities.
The treatment of patients with unruptured aneurysms is much easier than those with ruptured aneurysms, due to the absence of intracranial hemorrhage. Because of the experience, expertise, team co-operation, and the range of sophisticated treatment modalities available, our center is able to achieve outstanding results for the majority of patients.
UW Brain Aneurysm Center at Harborview Medical Center Team:
| Director: |  Laligam
N. Sekhar, MD, FACSProfessor and Vice-Chairman, Department of Neurosurgery, Harborview Medical Center, Seattle, WA |
| Co-Director: |
|
| Senior Advisory Board: | Norman Beauchamp, MD Richard
Ellenbogen, MD Scott Barnhart, MD |
| Emergency Admissions and Referrals: | Transfer Center at Harborview Medical Center Tel: 206-744-3597 or 1-888-731-4791 |
| Elective Patient Referrals: | Tel: 206-744-9300 |
Basavaraj
Ghodke, MDCase Studies:
Following are a sample of patient cases treated by our team of Harborview Medical Center physicians; click on each case to learn more:
Case #1
Basilar Artery Aneurysm Clipping:
This 57 year old woman presented with a one week history of headache. Three Dimensional CTA and intra-arterial DSA revealed a 0.8 cm basilar artery bifurcation aneurysm with a broad neck.
|
|
 |
| Vertebral Angiogram shows aneurysm of the top of the Basilar Artery | |
Because of the unfavorable dome/neck ratio, surgical clipping was elected. The aneurysm was exposed by a frontotemporal craniotomy and orbito-zygomatic osteotomy.
 |
 |
 |
Dissection was performed after temporary basilar artery occlusion (3 minutes), and the aneurysm was clipped and excluded from the circulation. Neuro endoscopy confirmed the complete clipping of the aneurysm and the preservation of important arteries, including perforators (small arteries). The drawings show the key steps of the operation. (See video for details)
| Intraoperative and postoperative angiography confirmed excellent clipping and vascular preservation. |  |
The patient had no deficits postoperatively and is doing well after 2 months.
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Case #2
Radial Artery Bypass and Trapping of Large Internal Carotid Artery Aneurysm:
This 45 year old man presented with left upper quadrantanopsia(visual field deficit). He had an MRI scan which lead to the diagnosis of Carotid aneurysm. He also had severe headaches, suggesting impending rupture of the aneurysm.
The imaging studies revealed a 2.2 x 2.1 x 2.3 cm Internal Carotid Artery aneurysm. The middle cerebral artery, and the anterior cerebral artery were arising from the aneurysm, making it unsuitable for clipping, or endovascular coil occlusion.
|
|
 |
 Operative steps of the Bypass and Aneurysm Trapping. |
 |
 |
 Postoperative Angiography showing the clips in place and the bypass with critical arteries fed by the bypass. |
His operation involved a fronto-temporal craniotomy and orbital osteotomy. He underwent a Radial Artery Bypass Graft from the extracranial carotid artery to the M2 segment of the middle cerebral artery, followed by microsurgical aneurysm trapping with preservation of the anterior choroidal artery. Bypass patency and the aneurysm occlusion were verified by intraoperative Doppler sonography followed by cerebral angiography. The aneurysm was excluded from the cerebrovascular circulation.
The patient recovered well, and was able to return to his occupation as a physician.
Case #3
Occipital –Posterior Inferior Cerebellar Artery (PICA) Bypass &
Clipping of PICA Aneurysm:
A 54 year old woman presented with severe subarachnoid hemorrhage Cerebral angiography revealed a fusiform aneurysm involving the left posterior inferior cerebellar artery(PICA), just after its origin from the vertebral artery. The PICA was feeding an arteriovenous malformation in the cerebellar vermis. The aneurysm appeared to be the source of the subarachnoid hemorrhage. She recovered slightly after the insertion of a ventriculostomy.
 The Arteriovenous Malformation of the Cerebellar Vermis is seen. |
 The Fusiform Aneurysm of the origin of PICA is seen. |
 |
 |
 |
| These drawings show the operative exposure of the vertebral artery and the aneurysm at the origin of PICA with small critical arteries arising from the PICA. | |
Postoperative Angiogram demonstrates the connection
of the Occipital Artery to PICA. |
 The aneurysm is now excluded from the circulation. |
 |
 |
 |
A microsurgical approach was elected. By left-sided extreme lateral partial transcondylar approach the previously ruptured PICA aneurysm was clipped, also occluding the PICA. Revascularization of the PICA was performed by using an occipital artery to PICA extra-to-intracranial bypass. Postoperative angiography revealed bypass patency and the exclusion of the aneurysm from the circulation. The patient recovered well, after standard postoperative and postbleed management. Future treatment of the AV malformation was planned.
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Case #4
Complex Middle Cerebral Artery Aneurysm:
This 46-year-old man presented with subarachnoid hemorrhage.
| CT scan revealed hydrocephalus and a large, complex aneurysm arising from the left middle cerebral artery. |  |
| Angiography confirmed that it was a complex 2-cm sized aneurysm, which encompassed the entire middle cerebral artery trifurcation. It appeared that at least two branches of the MCA arose from the neck of the aneurysm. Because of this, preparations were made for possible radial artery graft bypass reconstrucion of the vessels. |  |
However, during surgery, the surgeon was able to reconstruct the aneurysm neck and the middle cerebral artery trifurcation in such a way that the graft was not necessary.
 |
 Postoperative Angiography demonstrates the clipping of the aneurysm but with a bulbous middle cerebral artery trifurcation. |
|
The patient recovered well, and was discharged home 12 days later. He was independant for daily activities, but under the supervision of family members, and is continuing outpatient rehabilitation.
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Case #5
Complex Carotid Artery Aneurysm - Balloon Assisted Coil Embolization
“This is a 64 year old female who presented with acute onset of severe headache and diffuse intracranial hemorrhage. Conventional angiography and 3D Rotational Angiography (3DRA) revealed a complex aneurysm arising from the internal carotid artery. The aneurysm was successfully repaired with endovascular treatment with Balloon Remodeling.
Balloon Remodeling is a special endovascular technique that utilized a separate balloon catheter to protect the main artery while coils are being placed within the aneurysm lumen. During the procedure, the balloon prevents coils from being dislodged into other vessels, and also allows for tighter packing of the aneurysm sac for appropriate long term treatment.”
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Case #6
Mid Basilar Aneruysm - 3D Rotational Angiography, Endovascular Coil Embolization
“3D Rotational Angiography (3DRA) is a special angiographic technique that allows fine detailed three dimensional evaluation of a aneurysm and adjacent branch vessels. Images acquired using 3DRA allow for the most accurate visualization and assessment of the aneurysm configuration, and are critical for planning the appropriate operative or endovascular repair. At Harborview Medical Center, all aneurysms are evaluated using this state-of-the art technique in conjunction with conventional angiography and CT angiography.
This 68 year old woman presented with acute headache and intracranial hemorrhage. 3DRA revealed a mid-basilar artery aneurysm with a configuration ideal for endovascular repair, which was successfully treated without complications.”
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Case #7
Endovascular Balloon Angioplasty for vasospasm of the Basilar Artery
Click
here to view the video of this procedure.
*View video with Windows Media Player, which is a free download for both PC and Mac (best viewed in Safari or Firefox on a Mac)
Patient Care Introduction
| Aneurysms
| Brain Mapping | Case Studies | Chiari Malformation
Congenital Abnormalities
| Epilepsy | Movement Disorders | Moyamoya Disease | Pain
and Spasticity
Pediatrics | Peripheral
Nerves | Radiosurgery and Radiotherapy | Spine
Stroke and Vascular Lesions | Trauma | Tumors