Approach to Aneurysm Treatment Is Saving Lives
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
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
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
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.
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.
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.
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.
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."