To Clip Or To Coil?

Think of it as a blood vessel in the brain that weakens like an old inner tube, develops a blister and eventually pops, spilling large quantities of blood into the skull. That, in a nutshell, is what doctors call a ruptured cerebral aneurysm. What it feels like is the worst headache of your life. My patients have described it as a “thunderclap” in the head followed by blinding pain, nausea and vomiting. They can’t look at bright lights. Their necks get stiff. Confusion sets in. Half the people who suffer through one don’t live to describe it.

Until quite recently, not much had changed in the treatment of aneurysms, as Ardith Eastlund learned after her twin sister Arlene Erickson died of a ruptured one last fall in Reed City, Mich., at 64. The sisters were identical in so many ways that Eastlund naturally wondered whether she too might be carrying a time bomb in her brain. “I just want to put my mind–and my family–at ease,” she told Dr. B. Gregory Thompson, chief of cerebrovascular surgery at the University of Michigan.

Unfortunately, Thompson couldn’t do that for her. Although Eastlund wasn’t prone to headaches or the other symptoms, tests revealed that she had an aneurysm in her brain, just as her sister had.

Suddenly, Eastlund and her husband Dale faced a terrible choice. They could do nothing and hope that the aneurysm would never start to leak. Or she could get the standard treatment, first performed in 1937, in which a neurosurgeon drills a hole in the skull and puts a clip (usually titanium) around the blister-like pouch. Or she could try something new: a procedure called coiling, approved by the FDA in 1995.

It works like this: a surgeon feeds a catheter from the groin into the affected blood vessel and then seeds the aneurysm with tiny platinum coils that promote clotting (see diagram). This seemed safer to Eastlund and would spare her a major operation. But, she wanted to know, are coils as effective as clips?

A study in the current issue of Neurosurgery helps answer that question. Researchers at the University of Illinois followed 141 aneurysm cases for an average of 16 months. They report that none of the patients suffered any subsequent bleeding, and in 85% of the cases the coils largely or completely filled in and blocked the aneurysm. The scientists did not provide a direct comparison, but Thompson reports that of the more than 500 aneurysms he has clipped, all but four closed up completely.

While he sees the value of coiling for hard-to-reach aneurysms, Thompson, like a lot of neurosurgeons, is still a little skeptical. “Sixteen months isn’t long enough,” he says. “We won’t know for sure how effective the coils are until we follow patients for 10 years or more.” Eastlund, unfortunately, doesn’t have that long. She has to make a decision in the next few weeks.

Dr. Gupta is a neurosurgeon and CNN medical correspondent