Aneurysms & Neurovascular Disorders

What is a cerebral aneurysm?

A cerebral aneurysm can best be described as a balloon-like sac that arises from the wall of an arterial blood vessel supplying the brain. There are four types of aneurysms, and they can all vary in severity. They include:

• Saccular: This is the most common type of aneurysm. They occur at sites where the vessel wall is weakened by stress, typically at a point where the artery forms branches to supply the brain. This type of aneurysm affects about 3% of the adult population and becomes more frequent with age.
• Dissecting: This is the second most common type of aneurysm, and can occur at any age. Artery walls are composed of multiple overlapping layers — a dissecting aneurysm occurs when the inner layers are damaged allowing blood to enter into outer layers.
• Mycotic: These aneurysms are a result of localized infection in the arterial wall. The infection leads to damage of the wall, which we often associate with infections of the heart valves, such as bacterial endocarditis.
• Pseudoaneurysm: This type of aneurysm is caused by trauma to the head that results in direct damage, and weakening of the arterial wall.

How experienced is the Barrow team in treating aneurysms?
Barrow is one of the largest referral centers in the United States for patients with cerebrovascular disorders, treating more than 200 aneurysms per year and more than 200 arteriovenous malformations (AVMs) and cavernous malformations per year. We are frequently looked to as the worldwide center of choice when it comes to complex aneurysm treatment.

What are the most common types of treatments for aneurysms?
There are multiple approaches to consider for the treatment of aneurysms. Depending on the size and location of the aneurysm, procedures may include microsurgery for clipping of the aneurysm neck, endovascular coiling, or stenting for obliteration of the aneurysm dome, or a combination of microsurgical and endovascular procedures.

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What is a cavernous malformation?
Cavernous malformations are abnormal clusters of blood vessels that form in the tissue of the brain. These clusters have a tendency to leak blood into the surrounding healthy brain. These hemorrhages in the brain can cause a range of serious complications, including stroke and seizure.

How experienced is the Barrow team with treating cavernous malformations?
Barrow is one of the largest referral centers in the United States for patients with cavernous malformations, treating more than 200 patients with this procedure per year. We are frequently looked to as the worldwide center of choice when it comes to complex cavernous malformation treatment.

What are the most common types of treatments for cavernous malformations?
We select from several microsurgical treatment options to access the portion of the brain where the cavernous malformation has formed, and remove the blood vessels that are at increased risk of hemorrhaging.

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What is carotid artery disease?
Carotid artery disease is the narrowing of the arteries in the neck, which is a leading cause of stroke.  Stroke is literally the death of brain tissue because of a lack of blood supply to a particular part of the brain. Carotid artery disease can produce stroke when the atherosclerotic plaque or blood clots at the site of narrowing break off and migrate into the arteries of the brain. 

How experienced is the Barrow team in treating carotid artery disease?
Our team possesses the mastery it takes to open these blockages through catheter-based (endovascular) techniques. We’re available to critically ill patients for this service 24 hours a day, 7 days a week, 365 days a year. The efficacy of endovascular techniques for the treatment of carotid artery disease was proven in 2015, through the demonstrated success of four major national and international trials, solidifying our belief in the value of this approach.

What are the two most common types of treatments for carotid artery disease?
We rely on several effective approaches to treating this disease: carotid endarterectomy, and carotid angioplasty and stenting.  Carotid endarterectomy entails surgically opening the neck, and then the artery, in order to remove the plaque within the vessel.

The second treatment, carotid angioplasty and stenting, involves threading a small balloon and metallic stent from the artery in the leg up to the carotid artery.  The balloon is inflated to open the narrowed artery and then the stent (a small mesh-like metal tube) is deployed in order to keep the artery open. We will determine the best approach for you based on your overall health and prior history of neck or carotid artery surgery.

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What is Moyamoya Disease?
Moyamoya Disease is a rare disorder that affects the blood vessels of the brain. It causes the walls of the main arteries of the brain (carotid arteries) to become thickened and narrowed, which can lead to stroke.

How experienced is the Barrow team in treating Moyamoya Disease?
Our team of Barrow physicians have been pioneering treatments for Moyamoya disease since the early 1980s.  We’re highly skilled at evaluating Moyamoya patients and guiding them to the optimal treatment.  It’s critical that Moyamoya patients are monitored closely, which is a standard protocol for our team. Our long-term experience with Moyamoya disease is evidenced through many peer-reviewed articles and chapters on the subject, as well as a recent textbook. 

What are the most common types of treatments for Moyamoya Disease?
The majority of Moyamoya patients are treated with anti-platelet medications such as Aspirin.  Most patients ultimately require a type of bypass surgery  to improve the compromised blood flow to the brain. Various procedures can be performed, including those that form direct connections between arteries such as the STA-MCA bypass, and indirect procedures where brain revascularization occurs from donor tissues placed on the surface of the brain. These bypass procedures can help stop common stroke symptoms for Moyamoya patients.

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What is an arteriovenous malformation (AVM)?
An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels inside the brain or spinal cord, which can compromise blood flow to the surrounding tissue and eventually result in hemorrhage and injury or damage. An AVM can occur in any part of the brain or spine.

How experienced is the Barrow team in treating AVMs?
We’re one of the premiere institutions treating AVMs and have pioneered a number of treatments and diagnostic methods. We have elite imaging capabilities that help us better diagnose and treat the problem. The most commonly used grading system (Spetzler Martin grading scale) was developed right here at Barrow.

What are the most common types of treatments for AVMs?
AVM treatment will vary depending on symptoms, the location of the blood vessels, and the size of the cluster. Craniotomy (which involves removing a small piece of the skull) is the most common approach, often performed in conjunction with endovascular embolization, which involves treating the AVM through a small catheter designed to block individual arteries of the AVM.

Finally, if the AVM is small, your neurosurgeon may recommend stereotactic radiosurgery, which precisely targets the affected blood vessels with radiation.

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What is a dural arteriovenous fistula (DAVF)?
The dura is a thin, leathery layer of tissue that covers the brain and spinal cord. It has a rich arterial supply and the main venous drainage from the brain is through channels in the dura known as sinuses. Occasionally a direct connection (a fistula) can develop between the dural arteries and the draining veins or sinuses creating a kind of “short circuit” in the circulation. When untreated, DAVFs can cause bleeding in the brain or spinal cord, or cause neurological injury by impairing the normal blood flow in the central nervous system.

How experienced is the Barrow team in treating dural arteriovenous fistulas?
Most often, these lesions are treated endovascularly (through the vessels). When an endovascular cure is not possible, surgical or radiotherapeutic options may be used. We’ve pioneered a number of catheter-based techniques for these disorders.

What are the most common types of treatments for dural arteriovenous fistulas?
The most common treatments are catheter-based techniques, in which the abnormal artery to vein connection is closed.

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What is endovascular coiling?
Endovascular coiling is a technique for treating intracranial aneurysms that is done through a very small tube (a catheter). The catheter is introduced through a needle puncture most often through an artery in the leg. The catheter can then be painlessly navigated through the arterial system until the tip of the catheter is placed within the sac of the aneurysm.

“Coils” are very soft threads of wire, usually platinum, that have a pre-specified shape when they are unsheathed from the catheter. A series of coils are carefully placed into the aneurysm, filling the sac with the soft coils and preventing blood from flowing into the aneurysm. Plugging the aneurysm in this way greatly reduces the chances of the aneurysm rupturing in the future. Although aneurysm coiling is not a painful procedure, it can take several hours during which time the patient must remain very still, and for that reason these procedures are most often done under general anesthesia.

How experienced is the team with endovascular coiling?
Coiling was approved as a treatment for aneurysms in the United States by the FDA in 1995, and we’ve been treating aneurysms this way since that time. The endovascular team at Barrow is one of the most experienced teams in the country.

What is the estimated recovery time?
Recovery time depends upon the presenting symptoms of the patient. For patients with unruptured, asymptomatic aneurysms, it is typical to be discharged home the day after the procedure. Most patients will experience minimal symptoms after the procedure, such as tenderness at the puncture site or some post-anesthetic fatigue, but usually regular activities can be resumed in just a few days. Patients presenting with a ruptured aneurysm or AVM hemorrhage, however, require a longer recovery, which often includes physical and occupational therapy.

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What is microsurgical clipping?
Microsurgical clipping is a procedure that requires making a small opening in the skull to allow direct access to the blood vessels supplying the brain. The procedure is performed under general anesthesia. An operating microscope is positioned over the opening in the skull, and using the microsurgical technique, the aneurysm is identified and a very small titanium clip is placed across the neck of the aneurysms, permanently closing the defect in the arterial wall.

How experienced is the team with surgical clipping?
The old adage that “Practice makes perfect,” is particularly true when it comes to the complex procedures used to treat cerebral aneurysms. Barrow is one of the largest referral centers in the world for the treatment of cerebral aneurysms. On average, we perform more than 200 microsurgical procedures per year for the clipping of aneurysms. We believe that this level of experience translates to the best possible care.

What is the estimated recovery time?
For patients with an unruptured aneurysm who undergo microsurgical clipping, expect to be hospitalized for 3 to 4 days before being discharged. Normal activities can be resumed within 2 to 3 weeks.  For patients who present with ruptured aneurysms, the minimal period of hospitalization is 2 to 3 weeks regardless of treatment (surgical or endovascular). Rupture of an aneurysm is a type of stroke, and many of the patients who present with rupture require additional treatment for a complete recovery, including additional inpatient and outpatient rehabilitation.

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What is skull base surgery?

When an aneurysm forms in the skull base, it requires extremely precise, skilled care. We use advanced imaging technology to help determine the exact location of the aneurysm or malformation, and then select one of several minimally invasive techniques to safely address the condition. Some of those options include:

• Endoscopic Endonasal Surgery, which relies on a camera inserted through the nasal passage and up to the skull base.
• Radiosurgery uses highly precise radiation waves to eliminate malformations with little impact to the surrounding tissues. The Gamma Knife®, CyberKnife®, and other advanced tools are extremely safe, accurate, and non-invasive.
• Laser thermal ablation involves creating a tiny opening in the skull, through which we insert a laser probe to address the malformation.
• Keyhole surgery requires removal of a small amount of bone from the skull, granting access to the brain to find and address the problem.
• Craniotomy involves removing a larger portion of bone to access the malformation or AVM.

How experienced is the team with skull base surgery?

Barrow Brain and Spine is one of the top referral centers in the country for a variety of complex brain conditions, because of our expertise with endoscopic techniques (entry through the nose or mouth). Our team is well-versed in the complexities of this procedure, equating to better outcomes and increased confidence for our patients.

What is the estimated recovery time?

Depending on the specific type of skull base procedure you have, recovery can vary. In some cases, you can expect to be released from the hospital within one day, and in other cases, the recovery may be more involved. Every patient is different, which is why we work together to decide on the right treatment plan for you.

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