Jon White, M.D. Answers Questions On: Brain Health and Neurosurgery

The endovascular treatment is called the coiling of aneurysms. It’s a way of going up through the artery in the leg and then filling up these aneurysms with metal coils and sealing them off. At UT Southwestern, we do about half of our aneurysm surgeries this way. However, we have a history of expertise in open surgery as well, and there are still aneurysms that are just not good candidates for coiling. So we also do about half with open techniques, where we clip the aneurysm.

With the coiling procedures, some centers do them awake, but we put people asleep under general anesthesia. It’s just more comfortable for the patient, and it’s easier to make sure there’s no motion of the head while we do the procedure. We also typically do stroke interventions under general anesthesia. The coiling of an unruptured aneurysm is pretty quick, maybe an hour, maybe two hours. A stroke case can take a longer time depending on how difficult it is to open up the vessel.

In neurosurgery, the surgical procedures carry a significant risk. It is crucial to make sure that the natural history of what you’re treating is worse. It’s one thing if you’re going to risk giving a patient a small stroke with surgery if you know that he or she is likely to have a major stroke next week. But it’s another thing if there’s a tiny chance of it happening 20 years from now – in that case, isn't it better just to put surgery off? Understanding what you’re treating and putting the patient’s needs first, I think, is the key.

One thing would be awareness of the TIA [transient ischemic attack or mini-stroke], where you get some numbness or some weakness. That can be an early sign that the brain's not getting enough blood flow, and it should be a warning to come to the emergency room and not to wait. If you wait, the vessel occludes, the symptoms don’t go away, they become permanent, since the brain can only tolerate for a certain period of time being without blood. People may also want to pay attention to headaches. The sudden onset of a severe headache, or a new onset of headaches when you haven't had headaches before, is potentially a worrisome condition. That should be attended to sooner rather than later.

It’s an initiative through the American Heart Association, the Joint Commission for Accreditation of Hospital Organizations, and even the state legislature in Texas, that people who have an acute stroke should be transferred to centers where they take care of a lot of patients with strokes. The acute stroke is really an emergency. If the stroke is due to closed-off arteries, you have about a six-hour window to try to bust open the arteries. In many ways, a comprehensive stroke center is a way of directing ambulances to appropriate facilities in town.

The reason people do well when they come here is not because of any one procedure or technique – it’s because there is a system in place. The people who do the admitting know who needs to be admitted quickly and who doesn’t, and who needs to go to the ICU and who doesn’t. The nurses in the ICU know how to take care of people so that patients are in tiptop shape before surgery. In the operating room, patients get a surgery performed by a surgeon who's done the procedure numerous times. The scrub technicians and nurses in the room have also done it many times. It’s a well-rehearsed activity – everybody's contributing so that the thing goes as smoothly as possible. Post-operatively, the rehab people come early into the ICU and check to see who needs what. As soon as you get to the regular hospital floor, you already have a therapy plan, and people are already getting you into rehab. You get early assessment of whether you need to go to in-patient rehab, whether you need rehab at home, or whether you’re doing fine and you don't need any rehab. That whole chain of care is why people do better here than anywhere else.