Amazing Aneurysm Progress

By Dr. Scott Shay
Interviewed by Guest Writer
Wednesday - May 13, 2009
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Dr. Scott Shay
Medical Director of Neuro-Interventional Surgery at The Queen’s Medical Center

Interviewed By Melissa Moniz

What is Neuro-Interventional Surgery?

Neuro-Interventional Surgery is a minimally invasive technique that can treat vascular problems of the brain and spinal cord. The most common abnormalities treated are brain aneurysms and strokes or pre-stroke conditions.

What are brain aneurysms?

Brain aneurysms are blister-like outpouchings that occur in brain arteries. These “blisters” can rupture, leading to a life-threatening brain bleed. Since I’ve been here at The Queen’s Medical Center, we’ve been averaging about one ruptured brain aneurysm per week. When a brain aneurysm ruptures, the person will develop a sudden thunder-clap headache, which is described as the worst headache of one’s life. It happens suddenly, and once that happens many people will lose consciousness. A certain percentage will not make it to the hospital alive, but for the ones who do, it’s important to secure the aneurysm so it doesn’t rebleed. Rebleed rate within the first two weeks is at least 20-25 percent, with the greatest risk of rebleed within 48 hours. We try to secure the ruptured aneurysms within 24 hours of admission since a rebleed markedly increases mortality rates.

Are there ways to know that you have a brain aneurysm?

Brain aneurysms are usually less than 10 mm (25.4 mm = 1 inch) and do not cause any symptoms. They are usually discovered when a CAT scan or MRI is performed looking for something else. Although smaller aneurysms have a lower probability of rupturing, most ruptured aneurysms are small and measure in 2-10 mm of dimension. Since I’ve been operating here at The Queen’s Medical Center, the largest aneurysm I’ve seen and treated has been 7 mm in dimension. The question of when and whether to operate on a detected aneurysm depends on the size, shape, location and a multitude of other factors. It’s definitely a case-by-case determination.

Francis Hasegawa, Steve Freeland, Yukari Nakatsuji, Dr. Scott Shay and Alden Uyeda

How do you prevent an aneurysm from rupturing?

If blood flows into an aneurysm, there is a risk for rupture. To “secure” an aneurysm, blood must be prevented from flowing into the aneurysm. A neurosurgeon can open the skull, displace brain tissue and place a metal clip across the neck of the aneurysm.

I use a minimally invasive technique to pack the aneurysm with platinum coils that excludes the aneurysm from the blood circulation. I make a small incision (3 mm) at the top of the leg and enter the femoral artery (2 mm hole in the artery). Catheters (long, hollow tubes) can be guided from the leg into the brain. The brain aneurysm can then be packed with platinum coils. These coils come in all sizes and shapes, and once the aneurysm is filled with coils, no bleed or re-bleed can occur. This procedure requires general anesthesia and takes several hours to perform.

What causes aneurysms?

We are not exactly sure, but most people have aneurysms because of a congenital weakness in the wall of the blood vessel, usually at a branch point where one vessel splits into two vessels. There are a few medical conditions that can pre-dispose one to aneurysms - certain types of vascular disease and certain rare kidney diseases. In addition, infection, trauma and drug abuse (cocaine/crystal meth) can cause an aneurysm. Finally, there appears to be genetic factors, so if one or two first-degree relatives have a brain aneurysm, other first-degree relatives should be screened with a CAT scan.

Can you talk about the minimally invasive procedure you mentioned earlier?

The technique is called coiling an aneurysm, which is placing platinum coils into the sac of the aneurysm. They come in different sizes and shapes, and you basically fill up the sac with these coils so that no blood flows into the aneurysm and in turn it can’t bleed. They’ve been doing that here for a few years, but it was basically done to treat ruptured aneurysms, and they’ve never used balloons and stents. Now, with new technology, we’re able to treat 85 to 90 percent of aneurysms. And the new coil technology has really grown. Up until a few years ago, there was only one manufacturer for coils, and now there’s five. Competition brings about innovation, and now we have much better coil technology.

And before we were only limited to treating narrow-neck aneurysms. The conventional neurosurgical option is where you have to actually have a craniotomy, where the skull has to be opened up like a walnut and you go in a put a surgical clip at the neck of the aneurysm. It’s a lot more invasive and the risks are much higher, which is why neurosurgeons are reluctant to treat aneurysms that haven’t ruptured unless they are bigger than 7 millimeters. But with this new technique it’s less risky, and a majority of patients do very well.

So where exactly is the incision made?

The incision is made at the top of the leg. It’s not really even an incision, it’s really a nick in the skin. I don’t even use a suture at the end of the procedure. Then we put a little tube into the artery, and through that tube we are able to advance catheters (long tubes) that reach from the top of the leg all the way up to the brain.

How many operations have you performed using this technique?

I have been performing this technique for four years and have performed more than 750 surgeries.

Referrals are accepted from all local neurologists, neurosurgeons and primary care physicians. Patients with known aneurysms are welcome to call for a consultation. For more information or to make an appointment, please contact The Queen’s Outpatient Center at 585-5494.

Self-referred patients should be prepared to bring in previous brain scans.

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