June-August 1993

New Approach to Aneurysm Treatment Is Saving Lives

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Dianne Honeycutt of Medford was looking forward to several days at New Hampshire's Lake Winnepesaukee as she drove north with her 5-year-old daughter last summer. But her drive was interrupted by the worst headache she had ever had, so painful that she could hardly see.

Somehow she made it to her friends' lakeside cabin and after a brief walk felt better. But several hours later, as she was getting ready for bed, she lost consciousness and tumbled to the floor. Her friends rushed to her side and found she had no pulse.

What happened to Dianne Honeycutt happens to about 28,000 people in this country yearly. Inside her brain an aneurysm -- a weak spot that forms a bubble in a blood vessel -- had burst, releasing blood into the space between the outer coverings of the brain (a subarachnoid hemorrhage).

The outcome could have been tragic, but Mrs. Honeycutt, 36, was fortunate in several ways. One of those present when she collapsed, Betsy McCarthy, was a nurse who applied the life-support measures that restored Mrs. Honeycutt's pulse.

Less than 10 hours after her collapse, Mrs. Honeycutt was at the MGH under the care of neurosurgeon Christopher S. Ogilvy, MD , and other members of the hospital's Brain Aneurysm/AVM Center.

Dr. Christopher Ogilvy examines an angiogram--a blood vessel X-ray--showing a brain aneurysm.

After a thorough evaluation of her condition, she was taken to an operating room where Dr. Ogilvy and his team would attempt to close off the aneurysm with a surgical clip.

Mrs. Honeycutt's husband, Steve, arrived at the hospital soon after his wife. He recalled, Dr. Ogilvy and the others were very honest. "They told me how serious Dianne's condition was and that they were going to operate right away. We had to hope for the best."

At another time or in another institution, Mrs. Honeycutt's treatment would have been quite different. In the past, standard practice for patients with a ruptured aneurysm was to wait for as long as several weeks to attempt a surgical repair. It was thought that by giving the brain a chance to recover, there would be fewer problems during surgery.

"But if you wait," Dr. Ogilvy said, "a quarter of those patients will have a second hemorrhage within three weeks, which can cause further damage or death. So whenever possible, we do surgery early. And it turns out there aren't as many problems with the operations as everyone expected."

Even more significant was the fact that Mrs. Honeycutt was operated on at all. Patients with a subarachnoid hemmorhage (SAH) can show a range of symptoms -- from a slight headache to deep coma and signs of brain damage.

Traditionally those with the most severe symptoms -- like Mrs. Honeycutt, who was in a coma -- either were put in an intensive care unit until they improved or given comfort measures only. It was thought that operating on them would be fruitless as long as they were in such poor neurological shape.

At the MGH, however, neurosurgeons are talking a more aggressive approach. Following the lead of a group in Arizona, they are closely evaluating patients to find exactly how the SAH caused their neurological condition.

Blood from the aneurysm can form a subdural hematoma, a large clot that exerts pressure on the brain, or a clot within the brain tissue. The clot may or may not be removeable, depending on its location. Excess cerebrospinal fluid (which bathes the brain and spinal cord) also can cause increased pressure. If pressure is not too high, draining the fluid can produce an improvement.

MGH neurologist Daryl Gress, MD, explained, "Traditionally, all patients with major neurological deficits had been lumped together in a uniformly hopeless condition. Now we know we can sort out patients whose prognosis is much better than it originally appears."

Unfortunately, sometimes the examination shows an irreparable problem: the blood clot or aneurysm is located where it cannot be operated on without further damage; loss of bloodflow has damaged an area critical to thinking; pressure inside the brain is too high to safely open the skull.

In Mrs. Honeycutt's case, the surgeons found that simply inserting an instrument to measure pressure and release fluid relieved some of the pressure on her brain. Because her condition improved, and because her aneurysm was in an accessible location, the decision was made to operate.

In an operation that took about six hours, Dr. Ogilvy successfully closed off the aneurysm. Mrs. Honeycutt was taken to the Neuro-ICU. She was still in a coma, her outcome uncertain.

Several days after the operation, Mr. Honeycutt was reading to his wife at her bedside. "All of a sudden one of Dianne's eyes opened, and she looked straight ahead," he recalled. "I called her name, and she looked at me. I asked, 'Can you hear me?' and she nodded. Then I knew she would get better."

Nevertheless, she was just starting on the road to recovery. Over the following days she experienced intense vasospasm, a contraction of blood vessels in the brain, typically occuring four to seven days after a hemorrhage. In the most serious cases, vasospasm can completly shut down an important vessel, causing a stroke.

Dr. Ogilvy, who is also an assistant professor of neurology at Harvard Medical School, explained that the risk of vasospasm is another reason why early surgical correction of an aneurysm is so important. "Standard treatment for vasospasm uses drugs to raise blood pressure and push more blood through the contracted vessel into the rest of the brain. With an unrepaired aneurysm, if you push the pressure up, it'll rehemorrhage. But if you've taken care of the aneurysm, it shouldn't bleed again."

Because of the risk of vasospasm, patients like Mrs. Honeycutt are closely monitored using what is called a transcranial Doppler. An external ultrasound probe measures the speed of blood flowing through the brain's vessels. An increase in the blood's velocity indicates narrowing of the blood vessels.

Rapid identification and treatment brought Mrs. Honeycutt safely through the episode of vasospasm. Soon she began rehabilitation, involving the services of speech-language pathologists, physical and occupational therapists, and other health care professionals.

Mr. Honeycutt also recalls the personal support he received from MGH staff members -- nurses, social workers and many others. "One woman really helped me in terms of our daughters, who are 8 and 5," he said. "She discussed questions they were going to ask and what they might worry about. And she was right about everything."

He added that the support and prayers of family members, friends, and countless members of their community were invaluable.

Mrs. Honeycutt began recovering rapidly. After four weeks she transferred from the MGH to its major affiliate, the Spaulding Rehabilitation Hospital. She continued with physical, occupational, and speech therapy, with special attention to her biggest problem -- her memory.

"I really didn't want to be in the hospital," she said recently, "I wanted to go home. But when I look back, those therapists made a big difference for me. I was weak on one side, and they gave me exercises; they taught me tricks to use for my memory problems."

Less than two months after her aneurysm ruptured, Dianne Honeycutt was at home. In fact, just two days after she left the Spaulding she was able to attend the wedding of Betsy McCarthy, the nurse who helped save her life when she collapsed.

"Today I'm just the way I was before it happened," she said. Her memory problems are gone; she is able to drive and take care of her daughters, one of whom has special needs.

"The children and I are extremely fortunate to have Dianne back," her husband said. "We have nothing but praise and thankfulness for Dr. Ogilvy and everyone at the MGH."

Not everyone whose aneurysm is corrected will recover as completely as Mrs. Honeycutt did. Many factors were in her favor: she was young and generally healthy, and there was no permanent brain damage. But Dr. Ogilvy stresses that her story shows how positive the results can be for a patient who, until recently, might have been given up on.

"A lot is still unknown about why some people recover so much better than others," he said. "Through future research we hope to define which patients will benefit most. If we succeed, we'll be able to tell families, as soon as they come in, whether their loved one has a good chance of getting better."

Coil is Important Advance in Aneurysm Treatment

The MGH is one of fewer than 20 hospitals in the world and the first in New England to offer an important advance in treating brain aneurysms. By using the device -- known as the Guglielmi coil -- physicians can correct aneurysms that are not approachable surgically, either because of their position in the brain or other factors that present a high risk.

The coil is an extremely fine wire made from platinum -- one of the softest metals -- at the end of a longer stainless steel wire. Several coils, depending on the size of the aneurysm, are inserted inside the bubble-like aneurysm through a catheter (a long, narrow tube) threaded through the patient's blood vessels.

When the coil is in the correct position -- verified by a blood vessel X-ray called an angiogram -- it is given a positive electric charge. The charge causes the steel wire to dissolve at the point of junction with the platinum coil, and the positively charged coil attracts blood cells to form a clot within the aneurysm.

The coils and resulting blood clot fill up the aneurysm, essentially sealing it off. Eventually the lining of the blood vessel grows over the aneurysm's neck.

In Sup Choi, MD, MGH Director of Interventional Neuroradiology, explained that coil has several advantages over the alternative treatment using tiny balloons.

Balloons have a specific size and shape that may not exactly match the shape of the aneurysm. The soft coil, in contrast, conforms to almost any shape without placing stress on the aneurysm's fragile walls.

Also, the balloons are detached from their guide wires by pulling -- another source of stress avoided by the electric-charge detachment of the coil.

The coil is named for its inventor Guido Guglielmi, a neuroradiologist at the University of California at Los Angeles (UCLA) and the University of Rome Medical School. It was first used in patients at UCLA in 1990.

Dr. Choi -- one of about 25 specialists in the treatment worldwide -- noted that the coil does have limitations. It may not be possible to completely fill an aneurysm with a wide neck. In those instances, the aneurysm is filled as much as possible and the patient followed closely for any future increase in the bubble's size.

Since last September, when he arrived at the MGH, Dr. Choi has successfully completed 18 coil procedures.

"The interventional neuroradiologists in our service work very closely with the neurosurgeons and neurologists to select patients who can be treated most effectively," Dr. Choi said. "It is excellent teamwork that is achieving good results."