Published November 2, 2003

'The coolest thing in medicine'

Tiny coils stuffed into an aneurysm help relieve pressure so it doesn't burst.

By Kathleen O'Dell
News-Leader

The headache came on suddenly and fiercely — a searing pain centered between her eyes and ears like she'd never felt before.
"Get me to the hospital quick," Vera Woolsey begged her husband as she staggered from church one morning last April. The Aurora woman lost consciousness in the car as they sped away for help.
Hospital tests revealed a brain aneurysm, something an estimated 18 million Americans will develop during their lifetimes. A weakened area on a blood vessel behind her right eye had bulged and burst, releasing blood into the space around her brain.
Woolsey survived the episode, but she returned home with limited options. Although there was a 50 percent chance of rerupture within the next six months, she was not a good candidate for surgery. Her deeply embedded aneurysm would be difficult for a surgeon to reach without great risk to her.
In the summer, a new option became available for her in the Ozarks called "coil therapy," which allows doctors to fix aneurysms without ever opening the skull.
On Aug. 5, Springfield's Dr. Michael Workman — the only interventional radiologist who does the procedure in the region — guided a microcatheter through blood vessels from the femoral artery of her leg up to her head. He then filled the aneurysm with hair-fine platinum coils to block it off from the blood vessel and prevent a rerupture.
The technique, which is gaining acceptance across the country, is safer and simpler than the standard treatment of removing a part of the skull and putting a metal clip across the aneurysm, Workman said.
"It's very exciting to be able to offer what I think is often a safer treatment for patients, and potentially allowing them to survive a very deadly disease," said Workman, who performs the procedure at Cox South hospital. "It's the coolest thing in medicine, is what it is."

Bringing it here

Developed in the early 1990s, the advance in interventional neuroradiology allows doctors to treat aneurysms — thin bubbles on the blood vessel walls — that lie deeper in the brain, inaccessible to surgeons' instruments. And because it's not necessary to open the skull, coil therapy can be repeated if new aneurysms occur, Workman said.
Workman brought the therapy to the Ozarks when he joined Litton & Giddings Radiological Associates in July after doing more than 125 coil therapies during fellowships in his subspecialty at Emory University Hospital in Atlanta. Emory is one of about 10 well-established training sites for the therapy, he said, and about 15 to 20 fellows are trained every year.
Workman brings to the Ozarks yet another medical innovation once offered only in larger cities, and raises the level of brain care in Springfield, said Norb Bagley, senior vice president of hospital services. Workman's arrival also completes a new coordinated system of comprehensive neurological care offered through the CoxHealth system, Bagley said.
Today, Vera Woolsey is still overcoming balance problems left from the aneurysm rupture in April, but her eye-hand coordination has improved so much she's started sewing again. She's already cut out a new quilt top, woven 20 potholders and has her sights set on making some pillows.
"I can't tell there's been anything the matter with my head or my eyes," said Woolsey, 63. "There are no more fierce headaches, I can sleep at night, and I'm so glad."

Cutting edge

Every year about 30,000 people suffer from a ruptured aneurysm. Only a small amount of blood escapes before clotting, but it creates enough pressure to cause severe pain or unconsciousness.
No one knows why they happen, but aneurysms can develop from continuous wear and tear on the artery walls as a person ages, usually after age 40, Workman said. Women who smoke and have high blood pressure have a slightly higher occurrence of brain aneurysms, he said. They also tend to occur in certain rare inherited diseases.
About one-third of people die within 24 hours of a rupture. Another third survive with severe neurological problems, while the remaining third have minimal neurological problems and go on to live fairly normal lives, he said.
Without some form of intervention shortly after the patient is stable, blood flow in the brain applies pulsing pressure inside the already-weakened aneurysm. It's only a matter of time before it bursts, Workman explained.
For the past 30 years, surgeons have intervened by removing a section of the skull, nudging brain tissue off the affected blood vessel and closing the aneurysm with a surgical metal clip.
Coil therapy, approved in 1996 for use in the United States, offered the first life-saving alternative for patients who aren't suitable for clipping surgery, or whose aneurysm is located where the surgeon can't safely get to it. Those at the back of the head pose the highest risk of triggering a stroke or death, said Workman, who has done coil therapy for half a dozen Ozarks patients since July.
Springfield resident Linda Meyers was thrilled when Workman brought the therapy to Springfield. Her 47-year-old daughter, who had an extreme case with 10 unruptured brain aneurysms in multiple vessels, has made repeated trips to St. Louis over the past two years for coil therapy. Doctors have corrected four so far, and Meyers is hoping her daughter can transfer care to Workman, closer to home.

Sophisticated technique

Brain aneurysm coiling is probably the latest and most sophisticated medical treatment yet using microcatheters, said Dr. Robert Vogelzang, chief of vascular and interventional radiology at Northwestern Memorial Hospital in Chicago.
"This is the culmination of a tremendous amount of work and vision of people who said, 'We think you can actually work inside the blood vessel.' It's a new world now," said Vogelzang, who is also a professor of radiology at Northwestern University and former president of the Society of Interventional Radiology.
In appropriate patients, the technique is preferable to surgery, he said.
"The benefits extend beyond that because it can be repeated, it can be followed up on and done again and again. ..." Vogelzang said. "To me, this is a better way to do things."
Doctors use three-dimensional diagnostic pictures of a person's brain blood vessels to decide which intervention is more appropriate, and whether the aneurysm shape and location can accommodate a catheter and coils.
If it will, the doctor determines the size and number of coils needed to fill the space, Workman said. He also measures the size of the opening to the aneurysm, known as the "neck," to make sure it will hold the coils.
If the neck is too wide, a coil can slip out and go into the blood vessel, causing a stroke. In many cases he can correct a wide neck by inserting a balloon or a stent-like device before inserting the coils, he said.
Workman and a team of radiology technician specialists perform coil therapy in a procedure room of the Cox South radiology department while the patient is under general anesthesia.
They watch the two- to six-hour procedure on a video monitor. It can be a relatively short, three-minute process under X-ray guidance to feed the catheter through blood vessels from the leg to the head, Workman said. But because of differences in each patient's anatomy, it can take several hours to nudge the catheter tip through the twists and turns of the final blood vessels and into the aneurysm.
After the catheter is in place, a coil is placed in the catheter and deployed into the aneurysm. Once Workman is certain the coil will stay in the aneurysm, he detaches it and continues filling the aneurysm with coils until they fill up the space.
The patient awakens from anesthesia with only a Band-Aid over the leg where the catheter was inserted.

Heading home

After several hours' recovery time, the patient with a previously unruptured aneurysm can go home the next day.
If Workman is correcting a recently ruptured aneurysm, the patient remains in the hospital up to two weeks so doctors can head off any complications such as stroke that can occur as a result of the rupture.
Workman deployed only two tiny coils in Vera Woolsey's 3-by-3-millimeter aneurysm because it was so small — half the size of a pea. The average aneurysm accommodates seven coils.
"Once you've coiled an aneurysm, it re-establishes blood flow through the vessel," Workman said. "Instead of the flow being turbulent and going inside the aneurysm, the blood comes up against the coils and bounces off of it and goes where it's supposed to go." Blood in the aneurysm soon forms a clot and the neck opening scars over.
Workman emphasizes that coil therapy carries risks, as any procedure does. About 5 percent of coil therapy patients have complications — about 2 percent to 4 percent of those suffer strokes during or immediately after the procedure, he said.
Like the clipping therapy that neurosurgeons perform, coil therapy only prevents a rerupture, he said, and it cannot reverse any neurological damage that occurred in the hours or days following the initial rupture.
Workman estimates that 85 percent of ruptured aneurysms can be repaired with coils, and at least one study shows it offers a better outcome than the clipping procedure neurosurgeons offer in Springfield.
A randomized study of more than 2,000 patients followed for nearly a year after intervention therapy showed that the risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than for those treated with clipping, Workman said. The International Subaracnoid Trial was conducted from 1997 to early 2002.
Woolsey had never heard of coil therapy, but was eager to try it after Workman explained everything, including the risks.
"I felt like God was with me and had been with me that far," she said. Besides, "I couldn't go on feeling like I was feeling then," Woolsey added. "I was walking on pins and needles."
After the procedure, she eased off the strong pain medicine she had been on since April, and now has no pain — only days of spoiling grandchildren and sewing quilts.