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Winter 2012

Choosing an Approach for Cerebrovascular Patients

As vascular surgical techniques evolve, experience with the toughest surgical challenges and corresponding outcomes research help clarify the best techniques for each particular condition and patient, says Michael Lawton, M.D., director of the cerebrovascular disorders and skull base surgery programs at UCSF Medical Center. "Making the right choices can make all the difference," he says.

Treating Aneurysms

At UCSF, the first step is almost always a meeting of an experienced team of neurosurgeons, interventional neuroradiologists and neurologists to discuss possible approaches.

In the case of aneurysms, the team chooses from among:

  • Careful monitoring for smaller aneurysms
  • Endovascular approaches, such as coiling
  • Surgical approaches, including microvascular clipping and bypass procedures

The bypass procedures are for complex aneurysms that may have recurred after previous coiling or that have broad necks or unusual anatomy. In the bypass, surgeons clamp off both sides of the artery leading to the aneurysm and then graft another artery to reroute the flow of blood.

"We do nearly 300 aneurysm procedures a year and around 25 bypass procedures a year, where we graft either nearby intracranial arteries or extracranial arteries," Lawton says.

Follow-up care includes monitoring for vasospasm with transcranial Doppler velocity measurements, and endovascular therapies like intra-arterial vasodilators and angioplasty. At UCSF, the complete team and range of services, including a subarachnoid hemorrhage bed, are available 24 hours, seven days a week.

AVMs and Cavernous Malformations

Patients with less common neurological conditions, such as arteriovenous malformations (AVMs) and cavernous malformations, also benefit from the experience gained in centers of excellence like UCSF.

vascular defect

For AVMs, physicians choose from among embolization, surgery, stereotactic radiation or a combination. "The optimal combination and sequence depend on the anatomy of the AVM and the patient's clinical presentation," Lawton says.

"In the last decade, after measuring and analyzing the results of over 500 AVM surgeries, we've developed a grading scale that helps us properly select patients and procedures."

With cavernous malformations, surgery is the only option, but there are more than 25 potential procedures, some of which have been developed at UCSF. "Our experience and clinical research have contributed to an especially precise system for choosing among those procedures," Lawton says. "This contributes to our ability to remove lesions without violating brain tissue."

Through the team's use of such techniques as intraoperative navigation, neurophysiological mapping and sophisticated microsurgical techniques, 73 percent of UCSF patients are completely seizure-free after surgery, and 16 percent see improvement in their seizures.

For more information, contact Dr. Michael Lawton at (415) 353-2529.

When to Refer Patients for Aneurysms

  • A sudden, extremely severe headache
  • A focal neurological deficit, such as double vision
  • A previously coiled aneurysm that grows back

UCSF Medical Center has a referral hotline available 24 hours daily at (877) 272-4611 or 877) BRAIN-1-1, and a bed that’s always available for patients with aneurysms.

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