A woman comes to the Massachusetts General Hospital (MGH) Emergency Department (ER) with a large blood clot causing great pressure in her brain. She is rushed to the operating room where she undergoes a hemicraniectomy (a surgical procedure that temporarily removes part of the skull) to allow the brain room for swelling. The next morning, a small aneurysm is discovered. It is closed using a platinum coil that fills the inside of the aneurysm and blocks blood flow.
Treating a patient in such an acute state involves close collaboration between neurosurgery and neuroendovascular care. “Our multidisciplinary approach makes us unique at MGH. Each of us brings a different perspective, which enables us to provide more comprehensive care and give patients all the options,” says Aman B. Patel, MD, Director of Cerebrovascular and Endovascular Neurosurgery and co-director of Neuroendovascular Care at MGH, who performed the hemicraniectomy. Thabele Leslie-Mazwi, MD, neuroendovascular specialist at MGH, treated the aneurysm.
Open surgery and the ever-growing number of neuroendovascular treatments offer a wider range of options than ever before. Deciding the best treatment for individual patients requires the expertise of a multidisciplinary group of neurosurgeons, neuroradiologists and neuroendovascular specialists. “One treatment doesn’t work for every patient. I am committed to strengthening our multidisciplinary team and working together to carefully assess each case so we can provide the highest quality care and increase patient volume,” says Dr. Patel, who came to MGH in August 2014 from Mount Sinai Medical Center.
With training in both endovascular and open surgical procedures, Dr. Patel can evaluate patients and make an unbiased assessment based on the disease and the patient’s anatomy and risk profile. He is also able to provide back-up support to both neurosurgeons and neuroendovascular specialists and advise them on treatment options.
When Open Surgery is the Optimum Treatment
Open surgery, recommends Dr. Patel, is indicated for the following conditions:
- Aneurysms – some aneurysms can’t be treated using devices, such as flow diverters or coils, and need to be clipped. One patient with a complex aneurysm with the vessel coming out of the base was first treated with a coil embolization then returned a week later for open surgery to clip the aneurysm.
- Carotid artery blockage – surgery is the preferred option for patients who aren’t high risk. “Stents are effective but there’s a higher risk of recurrent stenosis and of a stroke occurring during stenting,” says Dr. Patel.
- Acute stroke – while most patients respond to IVTPA, 10 percent can have side effects. In those cases, the clot is aspirated.
- Asymptomatic aneurysms – “If you perform an endovascular procedure, the likelihood of the aneurysm coming back is higher even though open surgery is a riskier procedure. Patients with aneurysms that are difficult to treat using an endovascular approach should have surgery to take care of the lesion definitively. All procedures should have perfect results; even a small complication rate is unacceptable,” says Dr. Patel.
Intraoperative visualization using fluorescence is making operating on aneurysms easier by enabling neurosurgeons to see blood flow going into the vessel and confirming that the aneurysm is completely closed and the vessel is open.
Evidence-Based and Research Driven
Mass General neuroendovascular care is guided by the latest research evidence. With new neuroendovascular devices becoming available every few months, physicians are continually reassessing treatment options and combining outcomes from devices. Mass General collects data on an ongoing basis to improve patient outcomes. “Lee Schwamm, MD believes we should enroll every patient with a stroke in our in-house study to learn the long-term results of treatments,” says Dr. Patel.
Having MGH participate in a greater number of clinical trials of endovascular devices, such as flow diverters and intra-aneurysmal diverters, is another of Dr. Patel's goals. MGH may join a trial evaluating the safety and effectiveness of the SURPASS flow diverter, which treats large or giant wide-necked intracranial aneurysms in the internal carotid artery up to the terminus.
Dr. Patel is awaiting the results of the MISTIE III trial evaluating a new treatment for intracranial hemorrhage, which is fatal in 30 to 50 percent of patients. The treatment uses a catheter to directly deliver one milligram of TPA to the clot every eight hours, dissolving the clot in three to four days; one month after treatment, 80 percent of patients were alive. If the Phase III trial proves successful, it would provide yet another alternative to open surgery in treating a serious form of stroke.
For patient referrals or any clinical questions, please contact the Mass General Neuroendovascular Program.
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