The ballooning and weakening of an artery wall known as an aneurysm is an anatomical defect, but it has at least one thing in common with everything else in the human body. It’s fed by blood. In serious cases, it’s the job of the neurosurgeon to deprive the aneurysm of that precious commodity.
But aneurysms near the heart or brain frequently hide from view. Some people go years without knowing they have one and suffering few, if any, effects. Others aren’t so lucky and need help from neurosurgical techniques used at innovative medical centers, such as University of Colorado Hospital.
A decade ago, Sara Brustkern (now Cash) was 26 and studying to be a teacher at Jackson State University in Mississippi when she began having severe headaches. A series of tests initially diagnosed her with a brain tumor. Shortly thereafter, she passed out and was rushed to the hospital, where providers determined that the source of her headaches wasn’t a brain tumor, but rather an aneurysm that had ruptured.
The crucial task now was to stem the blood from seeping into the space around Sara’s brain. Her surgeons found the aneurysm with an angiogram and worked to block any more blood from reaching it. They guided a catheter to the bulge in the artery wall and packed it with platinum coils resembling tiny strands of dental floss to protect the aneurysm from further siege.
Cash says she spent five or six weeks in the intensive care unit in the hospital in Mississippi and underwent other surgeries. These included surgeons placing a shunt to drain cerebrospinal fluid that put pressure on her brain after the aneurysm ruptured. Her right side was paralyzed for a time and she was still badly weakened when she flew back to Fort Collins to try to restart her life.
Her aneurysm came with her.
In July 2014, the severe headaches that had plagued Cash in Mississippi returned. On one especially bad day, she went to the emergency room at Poudre Valley Hospital, where providers took a CT scan, looked at the images and quickly transferred her to University of Colorado Hospital. An angiogram there revealed that the coils were steadily losing the battle of the bulge. Blood was again exerting strong pressure on the weakened spot in the artery wall.
“The aneurysm was laughing at the coils,” as UCH neurosurgeon Joshua Seinfeld, MD, put it.
In the pipeline
There was an alternative – a supplement, really – to coils: a silky smooth patch of braided strands of cobalt-nickel chromium and platinum known as a pipeline embolization device (PED). Instead of packing the aneurysm for protection, the PED is designed to lie across the neck of the aneurysm, seal it, and divert the blood flow from it. After the procedure, blood that remains inside the bulge clots, further reducing pressure on the fragile wall.
“It’s a way of reconstructing the normal blood vessel so there is no blood entering the aneurysm, instead of blocking it with coils and leaving the sac,” Seinfeld said. The hope is that with time, the blood-deprived arterial balloon will wither and die.
The PED had received approval from the Food and Drug Administration in 2011, but for patients like Cash there was a catch. The FDA gave the device the okay to treat aneurysms greater than 1 centimeter in the internal carotid artery, which supplies blood to the front of the brain. Cash’s aneurysm was on the basilar artery, which delivers oxygen to the cerebellum, brain stem and occipital lobes. It is a much less common site for aneurysms than the internal carotid artery.
With the danger of a rupture high, Seinfeld decided to use the PED off-label to treat Cash’s aneurysm. He had done so many times with consistent success. In addition, at least one study of patients who received PEDs following treatment with coils showed the devices were safe and effective in stopping blood flow to the aneurysms.
Graphic illustrates the PED (gray area) after it has been deployed within the artery to seal off the aneurysm (as depicted by the large bulge). (Graphic credit: Brain Aneurysm Foundation.)
“The majority of cases done with this device are technically off label and it is a novel way to treat some large aneurysms that previously were very difficult or impossible to cure,” Seinfeld said.
Seal the deal
Three days after her July 2014 angiogram, Cash underwent the PED procedure. Seinfeld guided a catheter through her femoral artery to the aorta, then on to the verterbral arteries and finally to the basilar artery at the back of her head. He repacked the aneurysm with coils to protect the weakened dome, then delivered the PED to the aneurysm and placed it over the neck.
Seinfeld said that in a majority of cases, one PED procedure is enough. But when Cash returned to UCH in February 2015 for a six-month follow-up visit, another angiogram revealed some blood flow to the aneurysm remained. She had a second procedure in March, during which Seinfeld delivered and deployed additional coils and a second PED to gird the arterial wall. In September 2015, tests showed Cash’s aneurysm, its blood supply choked off, was gone.
In that sense, Cash’s story has a happy ending. But the aneurysm exacted a steep price. She said she still has memory problems and headaches and can’t do heavy physical work. Seinfeld said she will probably continue to have these problems, at least to some extent, although he said he is hopeful they will improve over time.
But Cash is alive and grateful for the help Seinfeld and neurosurgery physician assistant Jason Rich, PA, did to give her a second chance.
“I know my limits,” she said. “But I’m confident now that the aneurysm isn’t coming back.”