Endovascular management of internal Carotid Artery Aneurysm

Endovascular management of Intracranial aneurysms is gaining popularity worldwide. It is especially useful in the management of Cerebral Aneurysms that are difficult to access or whose surgery has a high morbidity rate. It is also very useful in elderly patients and patients who are in a poor neurological state. 

Microcatheters placed in the carotid and vertebral arteries through the femoral route outline the aneurysm and then deliver coils which are placed into the aneurysmal sac. The size and configuration of the aneurysm determines the number and type of coils used. 

A 65 year old lady presented with repeated attacks of unawareness and loss of vision suggestive of TIA and TMB. An MRI with MR angiogram revealed an Internal Carotid artery aneurysm. A Digital Subtraction Angiogram (DSA) was done which showed the aneurysm to be arising from the ventral wall of the Cavernous Sinus segment of the ICA. Embolisation of the Aneurysm using 3D coils was performed after placing a balloon across the neck of the aneurysm to prevent distal embolus of the coil. 

The procedure was successful with the post-coiling angiogram showing complete obliteration of the aneurysm. 

The lady was discharged three days after the procedure without any symptoms or deficits.

Special points of interest

• Aneurysms can present in many ways including TIA
• All symptomatic aneurysms and some incidental aneurysms require treatment
• The choice of management between surgery and endovascular management depends on many factors
• A microcatheter placed in the carotid and vertebral arteries through the femoral route helps delineate the configuration of the aneurysm
• The size and configuration of the aneurysm decides the type and number of coils used
• It is essential that the Neurosurgical team be on stand by during the pro-cedure in case of any eventuality

SMART PRACTICE

Now we are in a SMART world, SMART CARD, SMART PHONE, SMART DOCUMENTATION etc. Perhaps it is time for Physicians to be SMART. It is not that they are not SMART hitherto. But the SMART what we perhaps intend to say is with regard to the modern Medical Practice. There is virtual explosion in the technology and to keep abreast is difficult within the current resources and ambiance. It is equally true that both media and Government have special focus always on medical professionals, often not so pleasant. Legal issues against medical professionals are growing in geometrical proportions. Society adores doctors but recently, there is increase in the admonishes for the practitioners many times for no fault. Medical professionals, no longer enjoy the unequivocal faith of their patients. Further, unhealthy practices, unethical competitions are leading to annihilation of the people involved. Sometimes, we wonder, whether we have evolved as human race in right direction. Hence we need to be SMART PRACTITIONERS, what do we mean by that? 

To be a SMART Physician, we need to follow the following FIVE: 

AWARE: One must be aware of their skills, limitations and the availability of the resources. A patient can never be over promised and the doctor under performing. 

BEHAVIOUR: A physician’s conduct is a model for society. He is simple, soft, sensitive and compassionate. Behavior should be socially acceptable and exemplary. 

CONFIDENCE: Whatever one says and commits one should be courageous to implement, and practice. Real courage lies just not in righteous practice but also in skillful management. 

DEDICATION: Dedication is a word that reflects the comprehensive submission of skills and knowledge in the service of the patients. 

ENDURANCE: Lasting endurance is hall mark of a good physician. Trying to control one self in all adversities is an inevitable virtue of medical professionals. 

FRIENDSHIP: Trying to be friendly with peers is part of professionalism. Gaining friends is strength and losing them is weakness. If we note and practice the above grammar rules for a Physician, we are bound to be SMART.

Professionals and Promotions

Ethics have always been an issue, now-a-days in every field, more so in medicine. When we repeatedly speak of ethics, means we are stepping out frequently. If not checked at right times, some of the actions of the professionals become objectionable by public. It is unfortunate, that professionals take oath, more as ritual than a conscious affirmation. This is seen in every sphere; public or private, proportions may vary.

Recently, from Harvard to Stanford a notable instruction was sent out to medical professionals, banning them from receiving samples, participation on behalf of pharmaceuticals as promoters of their products etc. This is welcomed by all, though not totally. The issue of ethics is only a small part but the umpteen numbers of related issues that amount to intellectual or monetary corruption. It may be rude to conclude and many professionals are innocent and see only the scientific part of it. It is not universal, the higher the cadre, greater is their role in the promotion of a given product. What is that Professionals who indulge get, pleasure trips, rewards, continuous support of the company, including some personal gains. Managements of Harvard noticed the malady of such practices. Weeks of absence from the place of work by travelling to several places across the continents, promoting the products cause serious inconvenience to the services.

Apart from this is the greatest damage caused by identification of the said professionals with some companies. Let us not dwell on the quality of the products, which is a different issue. Medical professionals opting to write protocols, promotional literature, release product information, and above all making some claims that are intended to attract peers, are all questioned by both public and colleagues. The image of the entire professional fraternity is at stake sometimes. To have a bias for a product may not be objectionable but selection and dropping any product irrationally creates problems. This is not restricted to drugs, but to many biomedical equipment, disposables, catheters etc.

Medical ethics is categorical in admonishing such practices.

But, unfortunately, they continue in some form or other. For example advertising, particular professional or services as information is different from publishing photos and pictures. Medical Profession is noble, no doubt, are the professionals noble?, is the question asked by public. As responsible citizens, Medical professionals need to practice and project up-right personality. In Greek, persona means, Mask, at the same time, Persona in Latin is divine. I do not know what becomes applicable in this situation.

Patients and/or Patents? – The Saga of Drug Molecule from Bench to Bedside

Patents are given to protect the interests of the inventor(s) for a period of 17-20 years and the patent shall not be exploited or copied by anybody else during this period for commercial purposes. It is expected that this period gives enough time to realize the value of the invention/patent. Pharmaceutical companies which own patents for new drug molecules enjoy an exclusive marketing right during this patent period and usually some such drugs become block-busters for the company. Drug discovery is expensive and time consuming.

Unless the new drug fails in the market due to unexpected fatal side effects, the company makes a premium in the first few years of sales. To maintain a monopoly on the drug and prevent other companies from introducing similar or better drugs many companies have resorted to what is called “ever-greening” of block buster drugs. This means the original drug molecule is re-patented claiming under the existing patent law, some unique features and presumed benefits, the sole intention being to extend the monopoly on the original drug.

This practice is in vogue in many advanced countries and hence it is possible to “ever-green” and to extend monopoly on the original drug, albeit under a new “dress-up”. India is extremely good in reverse engineering and it showed the world how basic chemistry skills could be used for the benefit of the (economically poor) society. Till today, India is the largest manufacturer and supplier in the world of drugs which have gone-off patent (the generics), the largest beneficiary being HIV-AIDS patients in the world. Indian companies ventured to extend this strategy for anti-cancer drugs, the costs of which are prohibitive throughout the world. This practice is being opposed by the patent holding companies. In 2005 our parliament introduced Indian Patent Act with some modifications to protect the interest of the poor people. One such modification introduced as section 3(d) emphasizes that “mere discovery of a new form of a known substance which does not result in the enhancement of the known efficacy of that substance” is not an invention — for the purpose of patenting.

The Swiss pharmaceutical giant, Novartis, has been fighting a case, for seven years now, against Government of India and other stakeholders for the anti cancer drug the beta crystalline form of “Gleevec” or “Glivac” as superior and better compared to originally patented as Imatinib mesylate. No data was submitted to substantiate “better or improved therapeutic efficacy” and hence the Supreme Court rejected the petition and denied patent to the newer version. This is a landmark judgment and it will open the gates for Indian pharmaceutical companies to go for generic version of all off-patent drugs and make them affordable to the society. The generic version of the drug Glivac is made available by Indian pharmaceutical company at “a tenth” of the cost to the patients. The cry of “end to R & D”, “drug discovery”, “innovation” have no basis and on the contrary this judgment will ensure that money is spent on original inventions and entirely new drugs and not on frivolous claims on existing molecules for newer specifications. Many countries, I am sure, will follow India in this and make drugs affordable to poor people in their country.