Managing Complexity: Multiple Cerebral Aneurysms Treated in a Single Operation
Carol Kruse did not want anyone “messing with” her brain. At 67 years old, she is an avid golfer and a fantastic cook with plenty of energy and humor to spare. But in November 2009, a slight stroke led to a diagnosis that threatened to slow her down, or stop her altogether.
A few months later, the contrast CT scan, which she had postponed for her golf tournament, illuminated not one, but five cerebral aneurysms. Ranging between two and six millimeters in diameter, three of the aneurysms were clustered around the left side of her carotid artery. Another was located between the two halves of the brain, while the smallest of the five was located on the right side. A plaque buildup near the aneurysms likely caused the stroke.
“I just didn’t understand why I had five,” Kruse recalled. “It sounded so ridiculous. Being symptom-free -- I don’t even get headaches, I was shocked to learn that a craniotomy was my only option.”
The largest and most fragile aneurysm had bubbled into a heart shape, forming two bulges. If it were to burst, the resulting stroke would likely lead to paralysis, even death. But Kruse and her family also had concerns about treating the aneurysms with surgery. “She’s a very active, go-go-go, upbeat person,” said Kruse’s daughter, Katherine Nigro. “She was concerned about a ‘whoops’ or that she would have a massive stroke during the surgery and lose the functioning of her brain and her body.”
Mixed feelings about neurosurgeons at other hospitals, and complicated opinions only heightened Kruse’s concerns -- until she came to the University of Chicago Medicine campus. Kruse, her husband and her daughter spent nearly two hours talking with Issam Awad, MD, FACS, professor of surgery and director of neurovascular surgery, about options and possible risks. Thirty percent of patients with a ruptured aneurysm either die or become severely disabled, Awad told Kruse.
The key to Kruse’s case was to choose the safest procedure that would provide her the greatest benefit with the least risk. “One aneurysm was bad enough, but several aneurysms, including two particularly worrisome larger ones posed a significant risk of bleeding,” he said. “It’s a fight we had to take on together. We could secure all the dangerous aneurysms in a single operation. She had to decide whether she wanted to eliminate the risks of bleeding from these aneurysms through surgery.”
“I told her we would get her through this, no matter what,” said Darlene Prusa, RN, neurovascular surgery nurse coordinator. “Giving her family a detailed description of what they could expect, from the morning they came in for surgery until she was discharged, gave them a sense of ease.”
One week later, Kruse canceled her appointments at other hospitals and scheduled her surgery with Awad for June 24.
In a four-hour procedure, Awad, who has performed more than 800 such surgeries in his 25-year career, secured four of Kruse’s five aneurysms while Prusa stopped in periodically to get an update for the family. Awad began by detaching a small, palm-sized piece of Kruse’s skull on the left side and inserting a microscope in the slit of space between the brain and the eye socket. This allowed access to the carotid artery where the aneurysms were located. Using tiny clips, Awad pinched the aneurysms to prevent them from bursting. He left the fifth aneurysm on the right side for observation during yearly follow-up exams since it was much smaller and less threatening than the others.
Four days later, Kruse was back at home. “She was doing laundry two days after she came home,” said Nigro, Kruse’s daughter. “I was racing to empty the dishwasher before she’d do it.” When Kruse called Prusa at the University of Chicago to ask about driving, Prusa said to wait one month. Exactly one month later, Kruse was pulling up to her local grocery store.
Despite being eager to resume her regular activities, Kruse said she now has a stronger appreciation for taking care of herself. That might mean a long nap during the day, or simply passing on an activity. “I’m focusing more on myself than I ever have in my whole life,” Kruse said. “If I’m tired, the dishwasher can wait until the morning.”