“It’s A Very, Very Bad Thing To Have Happen To You.”

So those who have been hanging around here for at least a year may remember The Event, my six-part writeup of what happened when I had a small (~3mm), undetected (as they usually are) cerebral aneurysm rupture (as they usually don’t). A few days after the rupture I underwent an emergency coiling procedure to basically stuff the aneurysm with tiny platinum steel wool, thus making my noggin slightly more valuable than it had been previously.

Since The Event, I periodically find myself searching the Internet for information about aneurysms. Sometimes this is triggered by aneurysms in the news, as with the recent hospitalization of the famous rapper Dr. Dre, and sometimes it’s triggered by, say, looking up information about the author of a book I’m reading and discovering that she suffered a fatal head injury after collapsing in her driveway due to a stroke. This being the Internet, which, although it has a long memory, very much favors the short term, usually what you find when doing a search will be recent; but sometimes I find old news, an example of which is this piece from The New York Times, which ran nearly 20 years ago:

I don’t believe this article is currently behind a paywall (possibly because it’s so old), but if it is, there’s a reprint available as a PDF here. To summarize, the article discusses the then-new coiling procedure, which had been invented in the United States but, at the time of the article’s writing, hadn’t really caught on here. Instead, it had been adopted in Europe, where, in the early 2000s, 75% of aneurysms were treated with coiling, vs. only 25% in the U.S.

Cerebral aneurysms do not kill as many people as strokes or heart attacks do, but they are spectacularly fatal: 15 percent of all victims die in minutes, and half are dead in a month.

”It’s a very, very bad thing to have happen to you,” Dr. Kieran Murphy of Johns Hopkins Medical Institutions, one of the participants in the Lancet study, said with gentle understatement.

The New York Times, “Fixing Aneurysms Without Surgery”

The main point of the article is a Lancet study comparing outcomes in the case of coiling vs. the traditional treatment of clipping, in which the skull is sawed open and a clamp is placed at the opening of the aneurysm to pinch it off ― an aneurysm vasectomy, if you will. The trial was halted when it became apparent that the coiling group was having much better sort-term outcomes than the clipping group.

A medical trial was stopped on ethical grounds when it became clear that a year after treatment 31 percent of the surgical patients were disabled or dead compared with 24 percent of the ”coiled” patients.

The New York Times, “Fixing Aneurysms Without Surgery”

At the time of the study, some American neurosurgeons remained reluctant to endorse the coiling method, either because of concerns about the long-term stability of coils:

Dr. Robert E. Harbaugh, director of cerebrovascular surgery at the Dartmouth-Hitchcock Medical Center in New Hampshire, agreed that the seven percentage point difference in good outcomes after one year was significant, but he said he wanted to see longer studies to prove that coiling would prevent rebleeding over the long run.

”You need to use what’s safer over a lifetime, not safer over one year,” he said, while agreeing that the study was ”a historical piece of work” and that ”both options should be available” to all patients.

The New York Times, “Fixing Aneurysms Without Surgery”

Or, this being America, because of pecuniary reasons:

”In Europe, a doctor has a monthly salary regardless of the procedures he does. But in America, if the neurosurgeon doesn’t clip an aneurysm, he doesn’t get the money. Economics could be a factor.”

The New York Times, “Fixing Aneurysms Without Surgery”

But whatever questions neurosurgeons once had about coiling, it seems to have proven itself over the last couple of decades, with studies such as this one showing little or no difference in rebleeding between the types of treatments as well as significantly higher rates of complication and disability with clipping, which might, you know, be related to the whole cutting-open-your-skull thing. (This study also mentions in the discussion that internal carotid artery aneurysms are difficult to treat via clipping; that was the type of aneurysm I had, which no doubt factored into my treatment plan.)

At this point, the reader may be wondering why I’ve just spent so much time writing about a story that’s nearly 20 years old. Well, there are a couple of reasons. One is that, despite the fact that coiling is now a well-established procedure, it’s quite possible that there remain hospitals and practitioners who still automatically fall back to the old standby of clipping even when coiling might be the better option—not all aneurysms can be coiled—and so I thought a little history from distant era of Pets.com and the Y2K bug might someday be of use to a patient or their family member. Another is that it sort of illuminates, once again, just how fortunate I was that my experience happened in a place (the highly-populated Southern California region; much as I dislike crowds, crowds do mean large hospitals and a big pool of medical professionals trained in a wide variety of techniques) and a time (late 2019) that allowed me to be treated via coiling, and to subsequently get very close attention from the ICU nursing staff. If the rupture had happened years earlier, before coiling was widely accepted, when we lived out in the woods in upstate New York, or if it had happened a year later, when Southern California ICUs were filled up with COVID-19 patients and the staff were stretched and stressed to the breaking point, who knows what would have happened? I may not have had nurses keeping such a close eye on me that they could immediately handle the rather rough time I had coming out of anesthesia after the coiling procedure (which, despite the title of that Times article, I’m pretty sure still counts as surgery, though of the minimally-invasive variety) or, less seriously, fetching me emergency copies of Esquire to read; nor would I have had the steady stream of friends and cousins dropping by to cheer me up and help my wife out. Also, the pet therapy program would have been shut down, so during my stay I wouldn’t have gotten a visit from this sweet girl, whose business card I still retain:

And two weeks would definitely have been too long to go without seeing a dog.