Bigger is better – when it comes to stroke prevention

Brain aneurysm is a condition in which a blood vessel in the brain weakens and bulges.

While the sufferer is often unaware of their existence there is a risk that the vessel wall will rupture and result in a brain bleed or hemorrhagic stroke.

Approximately 5% of the US population will develop a brain aneurysm, most commonly women between the ages of 35 and 60.

And while the risk of rupture is only 1%, approximately 30% of such patients die within 24 hours and an additional 25-30% die within four weeks.

The traditional treatment for both ruptured and unruptured aneurysms involves clipping. During the procedure, surgeons open the skull, expose the brain and place a tiny metal clip on the abnormal blood vessel.

A less invasive technique known as endoscopic coiling, has been available since the mid-1990s. This involves inserting a catheter into the femoral artery and guiding it to the location of the aneurysm, where it is packed with platinum coils to prevent blood flow into the affected area.

Despite the introduction of coiling the outcomes of treatment of unruptured brain aneurysms, have remained stagnant over the last 10 years.

Now a new study published in the journal Stroke, suggests that this less than impressive result can be explained by the dramatic proliferation of procedures being performed at lower-volume community hospitals, where outcomes are inferior.

The research team of neurologists, neurosurgeons and neuro-anesthesiologists at NewYork-Presbyterian Hospital and Columbia University Medical Center compared hospital discharges for unruptured intracranial aneurysms (UIAs) in two time periods: 2005 to 2007 and 1995 to 2000.

They found that since 1995, there has been a six-fold increase in the treatment of UIAs by coiling at smaller community hospitals.

This isn’t a problem with technology but rather the way it has been delivered,” says study co-author Dr. Robert A. Solomon, neurosurgeon-in-chief at NewYork-Presbyterian Hospital. “Endoscopic coiling has been hugely helpful for the vast majority of patients, and it has actually been shown to have the potential for better outcomes relative to open surgery. It just hasn’t improved the overall picture, at least in New York state, where we focused our study.”

The authors say the increased popularity of coiling in smaller community hospitals may stem from the perceived ease of doing the procedure as well as cost concerns, with poor outcomes the result of technical shortcomings or errors in judgment.

Boosting overall outcomes, the authors say, will take a return to greater centralization of care at academic medical centers.  “Centers that offer comprehensive cerebrovascular care with both surgical and endovascular capabilities are best equipped to make treatment decisions based on what’s best for the patient,” says Dr. Solomon.

As a woman in the at-risk age group, should I ever need to clip or coil I’ll be sure to go comprehensive!

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