Latest Advances in the Treatment of Brain Aneurysms

Podcast Transcript

Dr. Alex Rae-Grant: Neuro Pathways, a Cleveland Clinic Podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host, Alex Rae-Grant, neurologist in Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological practice, today we're talking about the latest advances in the surgical treatment of brain aneurysms. We're very pleased to have Dr. Mark Bain join us for today's conversation. Dr. Bain is a neurosurgeon and Head of Cerebrovascular and Endovascular Neurosurgery in Cleveland Clinic's Neurological Institute. Mark, welcome to Neuro Pathways.

Dr. Mark Bain: Thank you. Pleasure to be here.

Dr. Alex Rae-Grant: Mark, let's start with the easy questions so our listeners can get to know you a bit. Where are you from? Where did you train? When did you begin your career at Cleveland Clinic

Dr. Mark Bain: Well, I think I can handle this one. I'm from Buffalo, New York, originally and I did my training here at the Cleveland Clinic, so I've been here since 2004 and I came on staff here in 2010.

Dr. Alex Rae-Grant: Today, we're talking about treatment of brain aneurysms. Can you set the stage a bit? What's been the historical practice in treating a brain aneurysm surgically?

Dr. Mark Bain: Brain aneurysms are a worrying lesion that we deal with, and the reason that they're so worrisome is they can cause such problems when they bleed. When these aneurysms rupture, they tend to really damage the brain and the outcomes of patients are really poor. We know that about 25% of people that have a brain aneurysm rupture will do well. Most of our treatment is to get rid of these aneurysms before they rupture. Historically, these aneurysms were treated with surgery, and the surgical treatment of these aneurysms had to do with getting a pretty bad looking haircut, so we'd shave a lot of hair which patients did not like. We'd have a big incision on the head. We'd take a fair amount of bone off to access the brain and using skull-based techniques, we would actually get down with a microscope. We would actually be able to see the aneurysm from the outside and then we would place a small aneurysm clip across the aneurysm, basically pinching it off from the circulation so that the blood couldn't touch the aneurysm and the aneurysm couldn't rupture. It was a very, very effective treatment. We could pretty much treat all aneurysms in the brain with this treatment, but it carried with it a lot of recovery time, a fair amount of morbidity, so a lot of patients that we did this operation to simply didn't get back to their normal lifestyles afterwards.

Dr. Alex Rae-Grant: Where did brain aneurysm surgery head after that? Can you talk a bit more about the devices that we're using?

Dr. Mark Bain: Yeah.

Dr. Alex Rae-Grant: That are entering the market?

Dr. Mark Bain: Yeah, so obviously there was a need to improve on these technologies. People just didn't want to have these treatments, these open surgical procedures done. As most fields of medicine have done, things have gone more in a minimally invasive fashion, and I think neurosurgeons, neurologists, in fact, really a lot of neurointerventional radiologists sort of picked up from the cardiologists and how they're placing stents in the heart through endovascular inside the blood vessel techniques. We saw these approaches and said, "Hey, listen, can we do this?" This happened well before my time. There's some great pioneers in the field that started doing some pretty amazing procedures with not very good equipment, but they were noticing that they could actually get up to the aneurysm, get into the brain through inside of the blood vessel, through a little needle stick in the groin, and be able to take care of the aneurysm by placing certain things into the aneurysm through the blood vessel. People would go out of the hospital in a day or so, and as you can imagine, that really caught on and companies started making better and better devices. Now, we're to a point to where I would say probably about 90% of aneurysms are treated from inside the blood vessel and patients are going home with a little Band-Aid on their groin or a Band-Aid on their wrist and they're getting back to work in two days.

Dr. Alex Rae-Grant: Wow. Is your team part of any new device trials? Can you talk about any devices currently in trials?

Dr. Mark Bain: Yeah, so it's a great time to be an aneurysm surgeon. The reason for that is we used to have a couple of options, and now every day we're hearing about a new device that's on the horizon. Here at the Cleveland Clinic, we're part of almost all of these trials that are looking at these new devices. One of the biggest changes I would say probably over the past five years has been these flow-diverting stents that we're placing into the carotid artery or other arteries of the brain, whereas before, we had to go into the aneurysm with a catheter and place these little coils. As you can imagine, trying to take a 2mm catheter from the groin and putting it into a 3mm aneurysm all the way in the brain, a lot can go wrong in that whole pathway up there, so it would be nice if you didn't have to go into the aneurysm. These flow-diverting stents are like little mesh tubes and we can place them just across the aneurysm. We don't even have to go into the aneurysm, and then over the course of months to a year, the aneurysm just clots off and the blood vessel just heals over the stent and the aneurysm goes away. We were involved in multiple trials that brought that device to market. Now, it's an FDA-approved device. It's really the standard of care for aneurysms. 

Dr. Alex Rae-Grant: Let's shift gears and talk about surgical planning in your practice. With so many different devices, I assume the candidate pool for patients with non-emergent brain aneurysms is a bit larger. Can you tell me when it's most appropriate for a practicing neurologist to refer a patient for surgical treatment of an aneurysm?

Dr. Mark Bain: Most of the time, especially smaller aneurysms, we actually will do something we call kind of conservative management or medical management, meaning that we'll make sure that the patient's blood pressure is low and sort of do serial imaging over a year just to watch the aneurysm and make sure it doesn't change or grow. We're always happy to follow those aneurysms, but I think when neurologists in the community are seeing certain aneurysms, we definitely want to know about those, and I think some of those things are the patient has a strong family history of aneurysms. If you're seeing a patient, they have a 2 or 3mm aneurysm, most of the time you probably watch those because they're small, but if the patient starts talking about or you ask them, they say, "Yeah, I have a direct family member that had a ruptured aneurysm. I have a family member that has a brain aneurysm. Everyone in my family had an aneurysm." That's something that we probably should see because we tend to treat patients with smaller aneurysms with strong family history. Simply their risk of rupture is much higher. Tobacco smoking is a big thing that our research has shown increases the risk of aneurysm rupturing. We're more inclined to treat aneurysms that are smaller, so a 4 or 5mm aneurysm that we would usually watch if someone has been smoking 50 packs a year smoking or something of that nature, then we would probably look towards treating that.

Some of the other more subtle things that we look at or that we like to see patients for, certainly if patients are having increasing headaches that are unusual to them and they have an aneurysm. Sometimes we worry that that aneurysm is changing, maybe causing those. Now, I know headaches is tough because people get headaches for a lot of reasons, but if they're sort of saying, "This is different to me, I'm concerned about it", maybe that's somebody you want to see. I think the last thing is if a radiologist calls and says, "This aneurysm is irregular", or if you're looking at the images yourself and the aneurysm has little bumps on it or there's multi-lobes on the aneurysm, even though it's small, those tend to be higher risk aneurysms, so we may treat a smaller aneurysm because it's just an ugly looking aneurysm, to be honest.

Aneurysms are probably best treated in larger centers and I think there are very good practitioners throughout the country at smaller hospitals that do a great job, but I think at some point the treatment of these aneurysms becomes very complex and I think as the treatments gets more and more complicated, meaning more devices to choose from, surgical planning like you kind of mentioned, we have to really do a lot of planning now on the anatomy of the aneurysm. What device is going to be good? It's not just yes or no for this device, it's, "Can we use this device? This device? This device?" I think patients should be transferred to some of these tertiary or larger centers like the Cleveland Clinic because we have all of those options and we can educate patients on what the best treatment is. I think that's probably the best way to lower the morbidity of treatment and to get patients back to their lifestyle, which is the main thing.

Dr. Alex Rae-Grant: What sort of new techniques do you have for surgical planning? Are there new approaches to radiology or simulation or anything that you bring to bear before you go in and do the procedure itself?

Dr. Mark Bain: Yeah, so historically it's really just been looking at scans, so we'd look at a CAT scan or an MRI scan, and that's great, but it takes many, many years and I think that's one of the things surgeons try to learn as they get better and better is how to realize and how to understand the 3D anatomy they're going to see when they're doing surgery or they're going to see when they're doing an angio procedure. How does that correlate to sort of the two-dimensional imaging you're sort of seeing when you're looking at a CAT scan or looking at an MRI? What we've sort of thought about here is, "Can we take some newer technologies and enhance our ability to look at these aneurysms and the anatomy?"

One of the things we came up with is using 3D printer technology. Based on some of our 3D angiograms we do, we get some pictures and we can send them off to some of our colleagues and radiologists and they can actually 3D print an aneurysm. I knew nothing about 3D printing before this happened and I was absolutely amazed. The radiologist came up to us and handed us a life-size model of the patient's carotid artery and their brain aneurysm and I was astounded. I couldn't believe, first of all, the size because when we use a microscope it looks much bigger and when we're looking at our screens it looks huge because we're magnifying so much. I was holding it in my hand. It just sort of struck you as, "This is what we're dealing with, these small little aneurysms." You could see blood vessels that were coursing near the aneurysm and it really allowed us to plan the procedure.

The first case this was involved with, there was an aneurysm that I was a little bit worried about doing surgery. It was going to be a little bit of a complicated case and I had the model in my hand. One of the great things was I was able to give the patient his aneurysm. He could hold it and look at it, and it really was great because he could kind of really understand what we were going to do, but the best part was I was able to plan what clip to use, what the approach was before. Typically, a surgery like this would take about three hours, we actually finished the procedure, skin to skin, from start to close, at about an hour and a half. Really, it was amazing. I was astounded at how much it actually helped. You could kind of go right to the point of the aneurysm, use that clip, and that planning was everything. It really made a big difference.

Dr. Alex Rae-Grant: Do you generally give the 3D models to the patients?

Dr. Mark Bain: Yeah, I have. I have a lot of them sitting in my desk in my office as well. I'm sort of collecting these, yeah.

Dr. Alex Rae-Grant: Very cool.

Dr. Mark Bain: It is.

Dr. Alex Rae-Grant: Well, when approaching surgical cases, how do you think about incorporating the new devices in your practice? I know your team does a bunch of hybrid/open endovascular surgeries. How do you determine which way you're going to go and what you're going to do?

Dr. Mark Bain:  I think in the end it's having a discussion with a patient and really understanding what their goals are of the treatment and realizing that. In the end, we want to get rid of the aneurysm because we want to get rid of that risk for hemorrhage in the brain, but you're not going to do anybody a favor if you put them through a horrible procedure and they have a long recovery time. A lot of patients will look back retrospectively and say, "Why did I do that procedure? I didn't get any benefit from that." The biggest thing we look at is, how are we going to get the patient back to their life but not have this aneurysm or reduce the risk or eliminate the risk of rupture? A lot of it is imaging, like we've discussed. Sometimes we have to think outside of the box, and that's where a lot of these combined approaches have come.

There's been multiple cases where endovascular therapies such as these stents and coils and things like that have failed and the aneurysm continues to grow despite our best efforts. In some of those instances, we've had to deploy surgery in order to take care of those aneurysms. There's been some really difficult cases where we didn't have an option either way, and we found that by combining the two options, so by doing surgery and by doing the endovascular technique, we could actually eliminate the aneurysm.

In one instance, a patient had a large aneurysm that we were putting coils in over and over and it kept growing back. It was a very, very difficult to operate location. That's why we were doing this so many times. We were trying to avoid that surgery. One thing we did is we decided, "Hey, listen. This aneurysm is coming back." We replaced the patient's circulation with a big brain bypass to fill the blood vessels. We put some more coils in the aneurysm for the last time, and we actually sacrificed the blood vessel surgically, and you think, "Well, if you sacrifice the blood vessel isn’t the patient going to have a stroke?" Well, the bypass filled in those vessels, so by combining... replacing the circulation with the bypass and then putting some more coils in, we actually got that aneurysm taken care of. Those are some of these things why you would probably refer a patient to a tertiary center because we have all of these options available.

Dr. Alex Rae-Grant: How does the structure of the team at the Cerebrovascular Center contribute to surgical planning, decision-making? How does that help you out?

Dr. Mark Bain: Well, first of all, it's always good to have good partners you trust so that you can talk to them about cases and we always discuss cases. In fact, we have almost like an aneurysm board where we actually will review a lot of cases and sort of, "Hey, listen, did you think about that procedure?" Or, "Hey, what about this from a surgical approach?" I think bouncing those ideas off each other, we actually have a very multidisciplinary team, so we have neurologists, neurointerventional radiologists, and neurosurgeons all doing sort of the similar procedure, so we can all kind of offer something from each of the different disciplines, which is very good and it helps patients. I think in that realm, being in a place like the Cleveland Clinic really helps because we have this multidisciplinary approach to how to treat aneurysms.

Dr. Alex Rae-Grant: Mark, any other closing remarks or major takeaways for our audience?

Dr. Mark Bain: Yeah, one of the other devices that we haven't talked about, in fact, I just got done doing two of them is this WEB device that we're using now. We talked a little bit about using flow-diverting stents, these mesh stents that will take down aneurysms, but one of the problems has been dealing with aneurysms that are at these branching points of blood vessels. We used to do a lot of surgery in this realm. A device called WEB came out, and it's actually a very fascinating device. Instead of it being a mesh tube like that stent we were talking about, this is actually a mesh ball and we're able to deploy it into the aneurysm. The mesh has sort of a lot of friction on the wall, so we're able to put this device into these sort of circular aneurysms and the mesh ball just sort of sticks in there and it stays in there very nicely.

These procedures are taking about 15 minutes to do and patients are leaving the hospital the next morning afterwards. In fact, probably we're going to get to a point where people could leave the same day after the surgery and it's really taken aneurysms that were once only surgical aneurysms and now we're able to treat endovascularly. This device just hit the market probably about six months ago and we really... they're deepening our experience in that realm and it's going very, very well. It's another very, very exciting breakthrough in aneurysm procedures right now.

Dr. Alex Rae-Grant: Pretty cool. Well, having spent three months doing neurosurgery in my training in Canada and observing the patients and the outcomes and the haircuts they had, I'm really appreciative of what you guys are up to.

Dr. Mark Bain: Funny that the haircuts... it's a big deal.

Dr. Alex Rae-Grant: It's a big deal.

Dr. Mark Bain: It's all about the patient's experience and no one wants to go home and after they're fully recovered, they have to let their hair grow back in, right? That's very rare we have to do that and now most patients leave the hospital with simply a little Band-Aid on their wrist with a little needle stick around their groin, and it's actually great to see. It really makes your day to be a part of the surgical treatment, and the past now, we're bringing the field out of that sort of maybe even the Dark Ages and into this newer realm.

Dr. Alex Rae-Grant: Very cool. Well, Mark, thanks so much for joining us. I really appreciate your time and insights.

Dr. Mark Bain: Thanks for having me.

Dr. Alex Rae-Grant: This concludes this episode of our Neuro Pathways podcast. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast. Subscribe to the Neuro Pathways podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinics Neurological Institute on our Consult QD website, consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word. That's @C-L-E Clinic M-D on Twitter. Thank you for listening. Please join us again soon.