For stroke prevention, large medical centers may have the edge
Despite advances in the diagnosis and treatment of unruptured brain aneurysms, outcomes have remained stagnant over the last 10 years. This can be explained by the dramatic proliferation of minimally invasive endoscopic coiling procedures at lower-volume community hospitals, where outcomes are inferior.
These findings are reported in a study by neurologists, neurosurgeons and neuro-anesthesiologists at NewYork-Presbyterian Hospital/Columbia University Medical Center and published in the journal Stroke.
“This isn’t a problem with technology but rather the way it has been delivered,” says study co-author Dr. Robert A. Solomon, neurosurgeon-in-chief at NewYork-Presbyterian Hospital/Columbia University Medical and the Byron Stookey Professor of Neurological Surgery and chairman of the Department of Neurological Surgery at Columbia University College of Physicians and Surgeons. “Endoscopic coiling has been hugely helpful for the vast majority of patients, and it has actually been shown to have the potential for better outcomes relative to open surgery. It just hasn’t improved the overall picture, at least in New York state, where we focused our study.”
The authors say the increased popularity of coiling in smaller community hospitals may stem from the perceived ease of doing the procedure as well as cost concerns, with poor outcomes the result of technical shortcomings or errors in judgment. For instance, community hospitals may choose to perform the procedure on smaller aneurysms despite attendant risks, in part because they lack access to neurosurgeons trained in microsurgical clipping (see below for an explanation of the two treatment options).
Boosting overall outcomes, the authors say, will take a return to greater centralization of care at academic medical centers such as NewYork-Presbyterian Hospital/Columbia University Medical Center. “Centers that offer comprehensive cerebrovascular care with both surgical and endovascular capabilities are best equipped to make treatment decisions based on what’s best for the patient,” says Dr. Solomon.
A stroke occurs when blood flow to the brain is blocked, either by blood clots or narrowed blood vessels, or when there is bleeding in the brain. Deprived of nutrients, brain nerve cells begin to die within a few minutes. As a result, a stroke can cause sensory and vision loss, problems with talking and walking, or difficulty in thinking clearly. In many cases, the effects of stroke are irreversible.
There are 2 broad categories of stroke:
Ischemic strokes are caused by a blood clot or blockages in the arteries, and Hemorrhagic strokes occur when blood vessels rupture. Ischemic strokes are most commonly caused by blockages in the carotid arteries and are responsible for up to 80% of strokes. As people age, arteries become narrowed with rough deposits of plaque called “stenosis”.
Diseased arteries can clog up completely as the plaque accumulates or can be shut down by clotting conditions called “embolism” and “thrombosis”. When the arteries become plugged, the blood is no longer able to reach the brain and stroke results.
The research team compared hospital discharges for unruptured intracranial aneurysms (UIAs) identified via the New York Statewide Database (SPARCS) in two time periods: 2005 to 2007 and 1995 to 2000. They found that since 1995, there has been a six-fold increase in the treatment of UIAs driven almost completely by coiling at smaller community hospitals, while outcomes have remained flat.
So what steps can you take to help prevent a stroke?
Control your blood pressure. Have your blood pressure checked often, and, if needed, take measures to lower it. Lowering high blood pressure reduces the risk for both stroke and heart disease.
Stop smoking. Cigarette smoking is linked to increased risk for a stroke. Research indicates that the risk of stroke for people who have quit smoking for 2-5 years is lower than people who still smoke.
Exercise regularly. Common sense dictates that moderate exercise makes the heart stronger and improves circulation. It also helps control weight. Being overweight increases the chance of high blood pressure, atherosclerosis, heart disease, and adult-onset (type 2) diabetes. Moderate physical activities like walking, jumping on a mini-trampoline, cycling, yoga, swimming, and yard work lower the risk of both stroke and heart disease.
Eat a healing diet. Eat a variety of fruits and vegetables. Juicing is an excellent and delicious way to include raw foods in your diet.
If you are diabetic, control your diabetes. If left untreated, diabetes can damage the blood vessels throughout the body and lead to atherosclerosis.
Surprisingly, they also found that overall outcomes for traditional surgical clipping worsened. This too can be explained by the proliferation of the minimally invasive approach, say the authors. With most cases being treated with coiling, the cases referred to surgery are increasingly complex. At the same time, there has been less training and practice for cerebrovascular surgeons.
The study’s lead author was Dr. Brad E. Zacharia, postdoctoral residency fellow in neurological surgery at NewYork-Presbyterian/Columbia. Additional co-authors are Drs. Neeraj Badjatia, Mitchell F. Berman, Sander Connolly Jr., Andrew F. Ducruet, Bartosz T. Grobelny, Zachary L. Hickman and Stephan A. Mayer.
Aspirin for stroke prevention?
Some recommend aspirin on a daily basis to prevent a heart attack or stroke. In one study, UK researchers reviewed 287 trials of treating high-risk individuals with anti-platelets such as aspirin. The 135,000 patients involved either had cardiovascular disease or conditions which predisposed them to heart attacks and strokes, such as peripheral artery disease, which is characterized by blockages in arteries supplying the legs and feet, and diabetes.
The investigators, all part of a team known as the Anti-thrombotic Trialists’ Collaboration (ATC), looked at whether or not the anti-platelets cut patients’ risk of heart attack, stroke and death from a cardiovascular cause.
They found that, overall, any anti-platelet therapy led to a 1/3 drop in heart attack risk, while the risk of non-fatal stroke fell by 25% and cardiovascular death risk declined by 16%.
Aspirin was the most widely studied anti-platelet. Based on this review, the evidence “supports daily doses of aspirin in the range of 75-150 mg for the long-term prevention of serious vascular events in high risk patients.
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British Medical Journal January 12, 2002;324:71-86, 59-60
Brain Aneurisms and Their Treatments
When a blood vessel in the brain weakens and bulges, a condition known as an intracranial aneurysm, there is a risk of the vessel wall breaking and bleeding occurring within the brain – a Hemorrhagic stroke. Approximately 5 percent of the population may have or develop an aneurysm, most often patients between the ages of 35 and 60 and more commonly women. Diagnosis usually occurs during a scan for some other medical problem. The risk of aneurysm rupture is only 1 percent, depending on the location of the aneurysm as well as risk factors including smoking, high blood pressure and family history of aneurysms. Approximately 30 percent of those with ruptured intracranial aneurysms die within 24 hours and an additional 25 to 30 percent die within four weeks.
The traditional treatment for both ruptured and unruptured aneurysms involves surgery to expose the brain and place a tiny metal clip on the abnormal blood vessel. Endoscopic coiling, which has been available since the mid-1990s, involves inserting a catheter into the femoral artery and guiding it to the location of the aneurysm, where it is packed with material, either platinum coils or balloons, to prevent blood flow into the affected area.
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Provided by New York- Presbyterian Hospital