Dr. Vishal Jani, center, prepares to insert a tiny mesh cage inside an aneurysm in Nicci Smith's brain at Omaha's Immanuel Medical Center.Â
CHI HEALTH PHOTOS
Dr. Vishal Jani uses 3D X-ray imaging to measure an aneurysm in Nicci Smith’s brain.
CHI HEALTH PHOTOS
A tiny mesh cage is placed inside the aneurysm to block it off and prevent bleeding or rupture.
Dr. Vishal Jani, center, and a catheterization lab team at Immanuel Medical Center.Â
CHI HEALTH
Doctors measure an aneurysm in Nicci Smith's brain, seen on 3D X-ray imaging, in order to choose the right size of the WEB device to treat the bulged blood vessel.Â
CHI HEALTH
Dr. Vishal Jani, center, navigates a procedure to place a mesh cage called a WEB device in Nicci Smith's brain aneurysm.Â
One day in early October, Nicci Smith began experiencing numbness and tingling in her arms, hands and head while at work at a post-acute rehabilitation facility in the Omaha area.
A nurse checked her blood pressure, which was high. Smith, 38, called her husband, who drove the Omaha woman to an emergency room.
When they couldn’t pinpoint a cause, health care providers did an MRI to make sure they hadn’t missed anything. But the scan found something Smith wasn’t expecting: a large aneurysm, or bulge, in a blood vessel behind her forehead.
Later, Dr. Vishal Jani, system stroke and neurointervention director for CHI Health, recommended filling the aneurysm with a device that’s relatively new in the United States but has been used in Europe since 2011.
Called the WEB device, it’s a tiny, spherical mesh cage that comes compressed inside a long thin tube called a microcatheter. It’s fed through a larger catheter that is snaked through a vein in the groin and up into the brain.
Once deployed inside the aneurysm, the device opens like an umbrella. If sized properly, Jani said, it hugs the inside wall of the bulge, blocking off the opening and keeping blood from flowing in.
Some 6.5 million Americans have aneurysms, and upward of 30,000 bleed or rupture each year. That can cause stroke, disability and even death.
For some time, doctors have been using coils of tiny wires, or a combination of coils and mesh tubes called stents, to fill and block off aneurysms. In the right patient, the technique can be a less-invasive alternative to the other common treatment: surgically opening the skull and placing a small metal clip across the neck of an aneurysm. All are part of an ongoing evolution in the treatment of aneurysms.
But Smith’s aneurysm was what’s known as a wide-necked aneurysm, a type that makes up between 26% and 36% of brain aneurysms, according to a January 2020 review in the Journal of NeuroInterventional Surgery. As the name suggests, such aneurysms have a wide opening. Coils literally can fall out, Jani said.
Smith, a mother of five, said she knew she also had the option to monitor rather than treat her aneurysm.
“But it was large enough that not treating it was not the best option,†she said. Even during the month and a half between her diagnosis and the procedure, she said, she felt like a “ticking time bomb.†Her 9-year-old named the bulge Professor Umbridge after the evil, pink-garbed, bureaucrat-turned-headmaster in the Harry Potter series.
On Nov. 15, Jani threaded a series of catheters and wires through Smith’s veins as she lay prone in a catheterization lab at Omaha’s Immanuel Medical Center. Jani used three-dimensional X-ray imaging as a guide.
He and Dr. Bharathi Jagadeesan, a neurointerventional radiologist and associate professor at the University of Minnesota Medical School, carefully measured the aneurysm in the images — 7 millimeters by 6 millimeters — so they could select the correctly sized WEB device.
Jagadeesan, one of Jani’s mentors, has performed the procedure multiple times and served as a proctor for the procedure.
Once they had chosen the device, Jani threaded the tip of the microcatheter into the aneurysm and steered the WEB device into it. As he deployed it, the device opened like a flower, expanding to fit the space.
“Nicely done,†Jagadeesan said. “You did great.â€
Jani said the process is faster than coiling, which typically involves inserting and placing between four and 10 wires. The longer the procedure, the more likely a patient is to experience complications.
He noted, nonetheless, that only a select subset of patients will be eligible for the treatment. He performed a second procedure the same day on a patient with a slightly larger aneurysm.
“It has to be the right size and the right place to use this device,†said Jani, an assistant professor of neurology at Creighton University’s School of Medicine.
Chris Schneider, territory manager and clinical support for device-maker MicroVention, said Jani is the only physician in Nebraska currently performing the procedure. The nearest centers where the device is used regularly are in Kansas City, Iowa City, Minneapolis and Denver.
“At least we can offer a full spectrum of treatment at our doorstep,†Jani said.
Dr. William Thorell, a neurosurgeon with Nebraska Medicine, said that health system also has access to the device. Doctors there haven’t yet seen a case in which the WEB device is the favored treatment.
Instead, he said, they use other techniques, including coiling with stents and surgical clipping, which must be done by a neurosurgeon. While the less-invasive inside-the-vein treatments require less recovery time, up to 20% require retreatment — with large aneurysms, that increases to 40%. That can be an issue for younger patients.
“You’ve really got to tailor your options to each individual patient,†Thorell said.
Smith spent a night after the procedure in the intensive care unit at Immanuel. By the next morning, she was feeling good and relieved to have the procedure completed. She also was ready to get home to her children and husband, Chris Smith, a youth pastor at a Papillion church.
She said she has had a few mild headaches since the procedure but no other symptoms. Doctors will continue to monitor the aneurysm.
A certified nursing assistant and medication aide, Smith said she was surprised at how unaware people are of aneurysms. Most people who have unruptured aneurysms don’t know they’re there.
Most aneurysms, according to the Cleveland Clinic, are small — about ⅛ inch to nearly an inch — and an estimated 50% to 80% of all aneurysms do not rupture.
“As much as people thought, ‘How could you live knowing you have this,’ “ she said, “I just feel so blessed that we found out about it.â€
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Doctors measure an aneurysm in Nicci Smith's brain, seen on 3D X-ray imaging, in order to choose the right size of the WEB device to treat the bulged blood vessel.Â