In this short video, vascular and endovascular surgeon Ethan Winkler, MD, PhD, explains the factors that go into determining the right treatment for different cases involving dangerously bulging blood vessels in the brain. Learn what the highly experienced neurosurgeons at UCSF can offer complex cases and why the ability to perform an angiogram in the OR matters.
My name is Ethan Winkler and I'm a vascular and endovascular neurosurgeon in the neurosurgery department at U CS F. I specialize in treating both adult and pediatric patients with brain aneurysms, brain arterial venous malformations, as well as carota disease and those in need of bypass. Our aneurysm practice here at U CS F is one of the busiest in the state of California. I treat in excess of 100 aneurysms per year. An aneurysm forms on a blood vessel in the brain. Typically, blood vessels are regular tubes where blood flows inside the brain, but sometimes on the side of those tubes, out pouches can form which are known as aneurysms. These out pouches are not supposed to be there and with time they can grow and just like a balloon that's inflated too much. They can burst when an aneurysm bursts. It's a life threatening condition because it releases a massive amount of blood into the brain. When I see a patient with an aneurysm. The first thing I want to know is if the aneurysm has blood or has not blood, an aneurysm that is blood is an emergency and has to be treated, an aneurysm that has not blood can be treated in one of three ways. The first way is observation where we do not treat the aneurysm, but follow it with imaging every 6 to 12 months. The latter two ways include open surgery to clip the aneurysm and endovascular neurosurgery to coil the aneurysm. When we do a clipping operation, it involves making an incision on the scalp behind the hairline, we then open a small window of bone just above the eye socket. And after we open the dura, which is the covering of the brain, we don't go through the brain, but we go under the brain. We find the blood vessels of the brain at the base of the skull and use those blood vessels to trace back to the base of the aneurysm. Once we find the base or the neck of the aneurysm, we place a clip across the neck so that it is no longer able to receive blood flow from the parent blood vessel. Once that happens, the aneurysm no longer fills. When we treat a patient with an endovascular approach, we start with a small needle stick in the wrist and this artery is called the radial artery. When we access the artery, we're able to place catheters inside the wrist, up the arm into the shoulder and using the blood vessels, we navigate the wires and catheters into the neck and then into the brain. Once we get into the blood vessels in the brain, we can get to the inside of the aneurysm using wires where we can place a very small catheter inside the larger catheter, that smaller catheter is what we use to place coils into the aneurysm. The coils are typically made out of platinum and they can be detached within the aneurysm. Once the coils are inside the aneurysm, they prevent blood from getting into the aneurysm. And then the coils also help the aneurysm clot. And once there's clotted blood in there, it can't fill any longer with new blood and it can no longer burst. Overall, when I decide how to best treat an aneurysm, it really depends on the individual aneurysm and the individual patient when we evaluate an aneurysm, one of the things we look at is how wide the neck is an aneurysm that has a wider neck is harder to treat with endovascular techniques because the wider the neck, the more likely the coils can fall out of the aneurysm. When the neck is more narrow, it's easier to place the coils inside the aneurysm and get them to stay within the aneurysm without falling out through the neck. Certain aneurysms that are closer to the brain's surface are better suited for open surgery. Such aneurysms are not as favorable for endovascular techniques. Given their anatomy and location, there are other aneurysms which are deeper like the Basler artery, which are often safer and more appropriate for an endovascular technique. Given some of the relative increase in risks on the open surgery side, for younger patients who have a longer life expectancy, the open surgery is well tolerated and will be more likely to have a durable cure in these patients who have many years of life ahead of them. For patients over 60 or 70 I tend to choose the endovascular option because it's safer for them and also less invasive in terms of efficacy. After an aneurysm is treated with open surgery, the chances or need for retreatment is somewhere on the order of 1% compared to an endovascular procedure where chances of retreatment are closer to the order of 10%. We are fortunate here at U CS F to have a hybrid operating room. The advantage to having a hybrid neurosurgery operating room is that for our most complex aneurysm patients, we can perform an angiogram which takes pictures of the blood vessels in the operating room and shows us that there is no longer blood flow into the aneurysm without a hybrid or an angiogram has to be performed the following day after surgery. If the results of the angiogram show that there is still blood flow into the aneurysm, then more treatments are necessary. I believe patients come to U CS F. Given our great experience in complex vascular neurosurgery cases in a typical week, at least half of our cases have been referred from elsewhere around the state or around the country. From neurosurgeons who have deemed these cases very complex or too challenging for treatment and have sent them to a high volume center that deals with these cases. Routinely. We also have a phenomenal team of IC U nurses, residents, fellows and staff who are very much used to dealing with the most challenging and most difficult cases in vascular neurosurgery.