As Endovascular Options Explode, Experts Produce New Guide to Understanding and Treating Brain Aneurysms

Andrew Ringer, MD, a neurosurgeon at Mayfield Brain & Spine, is editor of an essential new reference book for physicians who treat brain aneurysms. Intracranial Aneurysms, published by Academic Press, is the collaborative work of the Endovascular Neurosurgery Research Group (ENRG), an organization of 43 neurosurgeons with endovascular training who practice at leading academic and hospital centers. ENRG is pronounced "energy."

The 700-page book outlines the latest strategies for evaluation and treatment of patients with life-threatening cerebrovascular disease. From the emergency room to the operating room to the ICU, ENRG experts are on the front lines of care for patients with a blockage or bleeding in a brain aneurysm that can lead to a life-threatening stroke. In Intracranial Aneurysms, the authors have formulated their strategies for medical, surgical, and endovascular care.

Estimates of the prevalence of unruptured intracranial aneurysms in the United States vary, ranging from 3 to 6 million people to as high as 20 million people.

"When an aneurysm ruptures, the right care must be quick," says Dr. Ringer, who also serves as Chief of Neurosciences for TriHealth. "Treatment focuses on stopping the bleeding and repairing the aneurysm with clipping, coiling, or bypass. ENRG has been committed to establishing standards for clinical care and training others in the latest surgical techniques and endovascular devices. This book project captures the spirit of the ENRG collective for creativity and collaboration in aneurysm research."

Photo of Dr. Ringer, with the new reference book
Andrew Ringer, MD, with the new reference book. The cover was designed by Martha Headworth, MS, of Mayfield Brain & Spine.

The publication of Intracranial Aneurysms is timely, as innovations in endovascular treatments have exploded and surgical options have become more refined.

Since ENRG's founding in 2004, its members have met regularly to share their research and clinical outcomes. They have helped lead advances in aneurysm treatment as the traditional surgical approach – which involved opening the skull and shutting off the aneurysm's blood supply with a clip – found an increasingly favorable alternative in minimally invasive, endovascular (in-the-artery) treatments.

Endovascular treatments eliminate some of the risks associated with opening the patient's skull to expose the brain. Instead, a catheter is passed from an artery in the groin up to the brain, allowing the physician to treat the aneurysm with coils as tiny as a human hair, a special glue, or a stent. Coiling, the first endovascular treatment, was at first used only occasionally as an alternative to clipping. But its momentum gained.

Today, rates of endovascular aneurysm treatments vary widely by center. "Most centers in the United States will treat about 60 to 80 percent by endovascular, but some centers (or surgeons) still treat the majority by clipping," Dr. Ringer says. "A study from the United Kingdom, just published last month, found that rates of coiling varied among the 24 centers that treat aneurysms, from about 55 percent to 98 percent, but those centers that coiled around 60 to 70 percent had the best outcomes for all patients."

No individual can keep attuned to all the changes in techniques, devices, and materials, so as a collective, ENRG pooled its resources. "When the publishers approached me about the need for a new authoritative text on the subject, I could not think of a more qualified group of experts than the members of ENRG," Dr. Ringer says.

"For years, my career has been tremendously enhanced by the collaboration that I've enjoyed among these genuine friends. As we began discussing the epoch breakthroughs and innovative endovascular devices, the book idea began to form. We wanted to create a contemporary reference that could smooth the way for one another and help those who will follow in this field."

The book project began to take shape, and work continued up until May 2018. The book includes online surgical videos to enhance its value as a teaching tool. The book's co-authors include Lincoln Jiménez, MD, a Mayfield neurosurgeon.

Intracranial Aneurysms will become an essential reference, giving clinicians and researchers the latest information on the disease. "Each aneurysm is uniquely affected by the patient's anatomy, genetics, underlying medical conditions, and lifestyle choices, while their treatment options are invariably influenced by personal priorities," Dr. Ringer says. "Therefore, strategies for diagnosis, treatment, and outcome may vary depending on the type of aneurysm, its specific location and the patient's goals for treatment."

Adds Arthur Arand, MD, a neurosurgeon and Chairman of Mayfield Brain & Spine, "We congratulate Dr. Ringer and his ENRG colleagues on this effort. It took years of work, research, and writing. Our cerebrovascular neurosurgeons are leaders in their field and continue the mission of Mayfield's future in research and education."

Mayfield Brain & Spine is the full-service patient care provider of the Mayfield Clinic, one of the nation's leading physician organizations for neurosurgical treatment, education, and research. With more than 20 specialists in neurosurgery, interventional neuroradiology, physical medicine and rehabilitation, pain management, and physical therapy, Mayfield Brain & Spine treats 25,000 patients from 35 states and 13 countries in a typical year. Mayfield physicians specialize in the treatment of back and neck pain, sciatica, Parkinson's disease, essential tremor, NPH, epilepsy, brain and spinal tumors, stroke, moyamoya, brain aneurysms, Chiari malformation, scoliosis, kyphosis, facial pain, facial twitch, trauma, concussion, spinal cord injury, and carpal tunnel. As leading innovators in their field, Mayfield physicians have pioneered surgical procedures and instrumentation that have revolutionized the medical art of neurosurgery for spinal diseases and disorders, brain tumors, and neurovascular diseases and disorders. For more information, visit