How One Technique is Changing Neurosurgery

Dr. Pascal Jabbour, MD

Dr. Robert Rosenwasser, MD, MBA

The brain is a delicate organ. When things go wrong and surgery is necessary, there is always the worry of creating collateral damage. Brain surgery for life-threatening aneurysms – when a blood vessel balloons out of the vessel wall, risking rupture and internal bleeding – had always involved opening the skull and clamping, or clipping, the ballooned vessel. But over a decade ago, a new technique was proposed that offered an alternative to open-brain surgery. Endovascular surgery, or surgery from within the blood vessels, has become a major disruptor in the field of neurology, changing everything from the tools surgeons turn to first, to the very design of the surgical suite.

In 2002, a landmark study was published showing that endovascular surgery improved patient outcomes at least one year after surgery compared to the clipping technique. At Jefferson, the number of endovascular surgeries surpassed the microsurgeries as early as 2001, and today an overwhelming majority of treatment centers use coiling as a first-line treatment for certain cases.

Drs. Robert Rosenwasser, MD, MBA, president of the Vickie and Jack Farber Institute for Neuroscience at Jefferson and Pascal Jabbour, MD, neurosurgeon  and colleagues recently published an article describing the disruptive innovation that endovascular surgery has yielded on the field. Here they answer questions about the endovascular surgery, also called coiling, for the treatment of brain aneurysm and other conditions.

How does endovascular surgery work?

We typically go through a blood vessel in the arm or upper leg, and thread the tiny instruments all the way to the brain and the site of the aneurysm. We can see where we’re going in the vessels by using x-ray monitor called a fluoroscope and by releasing a stain into the blood vessels that shows up on x-ray.

What happens to the coil once it’s placed – how does it do its job?

Once we’re at the aneurysm, we let out a length of platinum wire or other material until it coils within the balloon, or outward bulge, of the aneurysm. Then we retract our tools. The coil stays in place, and promotes the body’s natural clotting process that closes off the balloon. The coil harmlessly becomes incorporated into the scar tissue at the site.

Does endovascular surgery make microsurgery, or open-brain surgery obsolete?

Not at all. There are still many cases where open-brain microsurgery is the right solution for the problem. But endovascular surgery gives us a new and very precise tool and offers an option for patients that might not be good candidates for open-brain surgery. For example, when the aneurysm is very deep within the brain, or otherwise difficult to access, endovascular offers surgeons a much safer option.

At Jefferson, we often pair the two procedures. Starting with a coil to quickly siphon off the flow to the ballooning blood vessel, and then go in later to perform a microsurgery to completely clamp off the aneurysm in a much less dangerous setting, after the clot has stabilize the vessel and decreased the risk of rupture.

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