Duncan, Ian C

Fourie, Pieter A

English

South African Medical Journal (SAMJ)

EDITORIALWe have recently encountered several misunderstandings andmisconceptions concerning the local endovascular treatment ofintracranial aneurysms. As such we feel compelled to respondand to issue a statement on the current status of this treatmentmodality in South Africa.The first misconception is that the endovascular treatment ofcerebral aneurysms is an experimental procedure. The firstdescription of the endovascular treatment of cerebralaneurysms dates back to 1974 when Serbinenko et al.1 reportedon the occlusion of cerebral vessels using detachable balloons.The next major breakthrough in endovascular aneurysmmanagement was reported in 1991 with the introduction of theGuglielmi Detachable Coil system (GDC, Target Therapeutics,Fremont, Calif., USA).2 The GDC  system was approved  forclinical use in Europe in 1992 and was approved by the FDAfor use in the USAin 1995.  The first GDC case in South Africawas performed in 1994.  Since then centres offeringneurointerventional expertise have been established in Pretoria,Durban, Bloemfontein and Cape Town. From 1994 to 2002 atotal of 73 such cases have been performed by our practice inPretoria.During 2002 we treated a total of 20 cases of intracranialaneurysm using endovascular occlusion, compared with 10such cases in 2001. Reasons for this increase include: (i) ourincreased ability to manage more complex aneurysms withballoon-remodelling and stent-scaffold techniques; (ii) furtherimprovements in catheter and coil technology; and (iii) agreater number of cases referred primarily or preferentially forendovascular treatment by our referring neurosurgeons.  Wefeel this reflects the increased understanding and acceptance ofthe role of endovascular treatment of cerebral aneurysmsamong both the local neurosurgical fraternity and the generalpublic.Worldwide acceptance of the endovascular treatment ofintracranial aneurysms has recently been further validated bythe publication of the International Subarachnoid AneurysmTrial (ISAT) in October 2002.3 This was an internationalmulticentre randomised trial comparing the efficacy and safetyof endovascular coiling versus neurosurgical clipping inpatients with a recently ruptured intracranial aneurysm.  Atotal of 2 143 out of 9 559 patients presenting withsubarachnoid haemorrhage were assessed as being suitable fortreatment by either surgical or neurointerventional techniquesand were randomised accordingly.  Interim analysis in April2002 showed that 23.7% of patients who underwentendovascular treatment were dependent or dead (as defined bya modified Rankin scale4,5 of 3 - 6) at 1 year compared with30.6% of patients who underwent neurosurgical treatment.The relative and absolute risk reductions in dependence ordeath for endovascular versus surgical treatment were 22.6%and 6.9% respectively.  Based on these interim results the trialsteering committee decided in May to halt recruitment into thetrial, but to continue follow-up of existing cases.  Within thegroup of cerebral aneurysm cases included in the study thecase fatality rates were similar for both the endovascular andsurgical groups, and re-bleeding rates within 1 year were 2.4%in the endovascular group and 1% in the surgical group.Despite this, the ISAT group’s interpretation of the results wasthat the outcome in terms of survival free of disability at 1 yearwas statistically better with endovascular coiling.  Thisindicates that as an optional treatment modality, endovascularcoiling of cerebral aneurysms is at least technically as efficientas neurosurgical management, and that the short-term outcomerelated to the former method is significantly better than thatafter surgery.  Of note is that 97.3% of aneurysms treated in thetrial were in the anterior circulation, as most participatingcentres already considered endovascular treatment to be thefavoured option for posterior circulation aneurysms, whichmirrors our own experience. These data must surely confirmthat the endovascular treatment of intracranial aneurysms is awell-established and universally accepted method of treatmentand can hardly be termed ‘experimental’ at this stage.The second  problem we have encountered relates toassociated economic issues.  As the majority of cases in ourpractice are ‘private’ we often face a lack of understanding byvarious funders about the nature of these endovascularprocedures. This creates problems when requestingauthorisation for these procedures.  One issue concerns theclassification of the coils used as ‘prostheses’.  Coils are embolicagents and as such are designed to occlude a blood vessel oraneurysm lumen.  Dorland’s Medical Dictionary defines aprosthesis as ‘an artificial substitute for a missing body part,such as an arm or leg, eye or tooth, used for functional orcosmetic reasons or both’.6 Clearly embolic agents cannot beconsidered ‘prostheses’,  and the prosthetic allowance limitsapplied by many medical aid schemes may therefore only beapplicable in those cases where stent-scaffolding is used inaddition to coil placement for the treatment of complex wide-necked aneurysms.  Funding for endovascular cases is a thornyissue, with bills in excess of R100 000 being issued  when largeor complex wide-necked aneurysms are treated this way.This is primarily due to the cost of the coils and otherconsumable items imported from Europe and the USA, with allof the usual associated economic issues.  The cost issue is oneof the main reasons why endovascular treatment is oftenlimited to a  select number of South African patients who can597Endovascular management of intracranial aneurysms —current status in South AfricaAugust 2003, Vol. 93, No. 8  SAMJAugust 2003, Vol. 93, No. 8  SAMJEDITORIALafford this method of treatment.  The lack of availableendovascular expertise in many state and academic hospitals isrelated in part to the high costs related to these cases, but alsoto a lack of neurointerventional expertise within manyacademic and state institutions. Neither interventionalradiology nor neurointervention is recognised locally as asubspeciality despite the availability of such expertise in thefour major centres.  As a result there is extremely limitedexposure by radiologists or  neurosurgeons-in-training to thesetechniques in South Africa.We trust that this article will serve to dispel some of themisunderstandings and misconceptions surroundingendovascular treatment of cerebral aneurysms in South Africa.Despite these high-tech methods of treatment lying somewherenear the pinnacle of quaternary-level medicine in a countrywhere there are far more pressing health-related and socio-economic problems, it is nevertheless important  thatneurointerventional expertise be retained and indeed promotedlocally to ensure equity with the rest of the world andimproved  access to these treatment methods by all SouthAfricans.Ian C DuncanPieter AFourieUnitas Interventional UnitLytteltonCenturion, Gauteng1. Serbinenko FA. Balloon catheterisation and occlusion of major cerebral vessels. J Neurosurg1974; 41: 125-145. 2. Guglielmi G, Vinuela F, Dion J, Duckwiler G. Electrothrombosis of saccular aneurysms via anendovascular approach. Part 2: Preliminary clinical experience. J Neurosurg 1991; 75: 8-14.3. The International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. InternationalSubarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coilingin 2 143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360:1267-1274.4. Rankin J. Cerebrovascular accidents in patients over the age of 60: prognosis. Scott Med J1957; 2: 200-215.5. Lindley RI, Waddell F, Livingstone M, Warlow C, Dennis M, Sandercock PAG. Can simplequestions address outcomes after stroke? Cerebrovasc Dis 1994; 4: 314-324.6. Dorland’s Illustrated Medical Dictionary. 29th ed. Philadelphia: WB Saunders, 2000: 1472.598How severe is what has authoritatively and eloquently beencalled ‘this staggering epidemic of obesity ’?1According to the World Health Organisation (WHO),  morethan 300 million adults worldwide are obese; about 115 millionlive in developed countries.2 Obesity is such that in the USA,now deemed ‘the fattest nation on earth ’, it results in 300 000deaths annually.1 Indeed, the ominous belief is that obesity willsoon replace smoking as the most powerful preventable riskfactor.3 Its severity in certain countries and populations isindicated in an official Australian report, published in 2001, 4which states that about 40% of Australians are overweight and20% obese. As to sequelae, for example the occurrence ofdiabetes, which is very largely precipitated by weight gain,5 1in 4 Australians aged 25 or older has diabetes or is at high riskof developing the disease in the next 5 - 10 years.4 A furtherillustration, particularly in relation to obesity’s rising trend, isthat in the USAthe age-adjusted prevalence of the condition(body mass index (BMI) > 30) was 22.9% in 1986 - 1994,whereas by 1999 it had risen to 30.5%.6 In the particular sectionof the US population most affected, namely African Americanwomen, more than half of those aged 40 years and older werefound to be obese, and more than 80% overweight.6What was the situation in the past? Historically, obesityremained uncommon in developed populations7 until early inthe 20th century. Since then there have been major rises in itsoccurrence in numerous countries, although to a highlyvariable degree. Thus, in a comparison undertaken in 1990 -1994, prevalences in US white men and women were found tobe 20% and 22.4%, respectively,8 while in France prevalenceswere far lower at 6.5% and 7.0%. 9 In Japan, remarkably,prevalences were uniformly very low at 1.8% and 2.9%, despitea considerable rise in the country’s socio-economic state. 10Two or more generations ago there was very little weightgain with age in African populations.11 This is still the case in anumber of less advanced countries, e.g. Tanzania, where theprevalence of obesity in black women is very low at 1.9%.12 InSouth Africa the mean prevalence of obesity among blackwomen in North West province, predominantly rural dwellers’has risen to 28.6%,13 while among women in Cape Town it hasrisen to 34.4%,14 and in Durban to 22.6%. 15 One of the puzzlingfeatures in the occurrence of obesity in African populations isthat the proportion of men affected is much lower, for example,2.9% in North West,13 7.9% in Cape Town,14 and 3.7% inDurban.15As for sequelae, previously in rural areas in South Africa theassociation between obesity and hypertension was slight.16 In1988 this was also the case with regard tohypercholesterolaemia and hyperglycaemia where, in a studyof obese African women and controls in the city of Soweto, theproportion affected by these parameters did not differsignificantly.17 However, in recent years the association betweenobesity and the parameters mentioned has become moreWorld pandemic of obesity — any hope of its beingcontrolled?

Endovascular management of intracranial aneurysms - current status in South africa

http://samj.org.za/index.php/samj/article/download/2286/1553

Endovascular management of intracranial aneurysms - current status in South africa

Abstract

Similar works

Full text

Available Versions

South African Medical Journal (SAMJ)