If Aneurysms Come in Multiples, Surgery Need Not

A couple of years ago, Gilbert Porter, a builder from Silver Spring, Md., was bothered by what he could only describe as “a pulsation” in his left ear. The 58-year-old had an MRI, and a local neurologist spotted a large, ripe aneurysm ballooning in a cerebral artery.

Rafael Tamargo, the aneurysm expert.

But two days later, when Porter saw Hopkins neurosurgeon Rafael J. Tamargo, M.D., for a second opinion, an angiogram of Porter’s brain showed not one but four aneurysms, each in separate vessels. Multiple brain aneurysms aren’t rare, Tamargo says; some studies show the situation occurs in as many as a third of intracranial aneurysms. This can be hard on patients, though, because they usually face multiple surgeries.

Two of Porter’s aneurysms were deep in the brain, in places too risky for traditional surgery, so Hopkins neuroradiologists worked with Tamargo and sealed them off with a platinum coil fed through a blood vessel. But the remaining two aneurysms warranted surgical clipping before they ruptured. Normally, that would mean separate brain surgeries, each with a month’s recovery time. Tamargo, however, handled the repairs in a single surgery.

After opening the right side of Porter’s skull, gently retracting the frontal lobe and clipping the aneurysm in the right middle cerebral artery, he cleared a pathway to the left posterior communicating artery, where he sealed off the other aneurysm. In a recent article in the Journal of Neurosurgery, Tamargo explains that the technique avoids the risk of neurologic deficit or a rebleed between two operations.

“These operations are far from simple,” the neurosurgeon says, And the reason they’re not done more often is because no one had mapped out safe routes between one prime aneurysm site and another. Tamargo did a study of 16 cadavers to locate these approaches and evaluate risk. Over the past few years, he’s done 15 of the contralateral approaches for aneurysms—including Porter’s— all successfully.

When the aneurysms are very large, Tamargo, cardiothoracic surgeon Duke Cameron, M.D., and a Hopkins team buy time through circulatory arrest, placing patients on a heart-lung machine and cooling the body to 15 degrees Celsius. Hopkins is one of a handful of major centers in the country to offer this. For aneurysm surgery in general, its track record is among the top four in the nation.