Georgia Marianthe Mesbouris takes a moment to herself before a follow-up procedure at Sunnybrook.

One weekend in August 2020, on a morning when Georgia Marianthe Mesbouris and her family were planning to leave for a family vacation, the 42-year-old resident of Scarborough, Ont., woke up with an incredible pain at the back of her neck. Knowing how much this vacation meant to her kids, she took a pain reliever and hoped the throbbing and sensation of burning hot ears would go away.

It didn’t.

Georgia, a mother of two and a tech expert on a national TV channel, considers herself a healthy person. “I don’t have high blood pressure. I don’t smoke. I [rarely] drink,” she says. So it was a complete shock when – after a trip to the emergency room – she was told that the pain she was experiencing was the result of two aneurysms in her brain.

One was small, but the other was very large. Aneurysms occur when a blood vessel wall weakens and bulges out, and the largest ones, called “giant aneurysms,” are typically no more than 2.5 centimetres across. Georgia’s was 3.5 centimetres long – one of the biggest the team at Sunnybrook had ever seen.

As long as the aneurysms remained in her head, Georgia’s life was at risk. One quarter of people with a ruptured aneurysm die within 24 hours, while another 25 per cent die within six months. For those who survive, many are left with permanent neurological damage.

Fortunately, Georgia’s care was in the hands of a Sunnybrook neurosurgeon whose expertise and ingenuity led to a novel approach to treatment that saved her life.

 An X-ray shows the metal clips in Georgia’s brain following her crainotomy.

A problem with no easy solution

When faced with an aneurysm of this size, Sunnybrook neurosurgeon Dr. Leo da Costa knew he needed to come up with a unique treatment plan. Most aneurysms are berry-shaped, called saccular. But in Georgia’s case, the aneurysm was what’s called fusiformed – wide in the middle and tapered at both ends.

Another complication was that the larger aneurysm was located in the left hemisphere of Georgia’s brain, in the middle cerebral artery. This artery is responsible for providing much of the blood flow to the hemisphere, including the area of the brain responsible for speech. A rupture could have been devastating for Georgia, but she could not be treated using routine techniques.

“The easiest treatment for such large aneurysms is to close the vessel, which was not an option in this case. She could have a stroke on the left side of the brain and be paralyzed on the right side and unable to speak,” says Dr. da Costa, medical director of Sunnybrook’s Centre for Neurovascular Intervention.

Georgia says it was “surreal” to learn that her medical condition could be fatal or debilitating. But she felt hopeful that she would come through it all.

“My husband turned to me and he held my hand and [said], ‘Don’t die.’ So I told him, ‘I’m not going to die.’”

The neurovascular team’s initial treatment for Georgia was a craniotomy – brain surgery to reconstruct the affected blood vessel with metal clips. But while surgery was successful and Georgia went home, a month later an angiogram showed the aneurysm had grown again.

With Georgia’s life once again in jeopardy, Dr. da Costa decided that the situation called for another approach involving flow diverter stents. These special, tiny stents are made of mesh with very fine holes that change the way the blood flows around a vessel.

“If you imagine a tunnel, the blood goes mostly inside, and the [aneurysm] outside will slowly clot and shrink,” explains Dr. da Costa.

The problem with this approach was that Georgia’s aneurysm was far too long for these stents.

So, Dr. da Costa decided to try something unprecedented. He would telescope three miniscule stents into one another to bridge the distance of Georgia’s aneurysm.

Sunnybrook neurosurgeon Dr. Leo da Costa.

A unique approach

On October 2, 2020, Dr. da Costa and his team accessed Georgia’s brain through a small incision in her groin. Using a combination of catheters and wires, he navigated the tiny stents through her aorta and into the brain vessels where the aneurysm was located.

Dr. da Costa placed one stent from the edge of the healthy area of the blood vessel into the aneurysm, then placed another just inside that one to extend into the middle part of the aneurysm. Finally, a third stent was placed to complete the “bridge” to the other side.

“This has not been done before using these small stents; [we] were the first globally to telescope three flow diverters to successfully treat a small vessel middle cerebral artery aneurysm,” Dr. da Costa says.

In total, the surgery was just over an hour. Georgia woke up to hear a nurse complimenting her toenail polish. “That made me laugh, and when I laughed, they exclaimed, ‘She’s awake!’” she recalls.

She was released from the hospital shortly after the surgery and is recovering well. Last Christmas, Georgia sent Dr. da Costa a video with her two kids, thanking him for all he’d done to save her life.

“He’s so modest,” says Georgia. “He responded, ‘It wasn’t me. It was all you.’”

Less invasive and more efficient

Georgia and her children enjoy a sunny day in the park.

Dr. da Costa says the procedure will have a significant impact on how his team handles difficult aneurysms.

“Until very recently, open surgery was often the safest option for these very large aneurysms, and the procedures are often complex,” he says. “Finding out that we can add one very small stent to the other in a chain to cover longer distances will allow us to treat these aneurysms in a much less invasive and efficient manner.”

In fact, after Georgia’s treatment, Dr. da Costa said they did another similar one, using the same technique, and he is convinced more and more cases will be done in a similar fashion worldwide. That patient also did well and was discharged the next morning.

Dr. da Costa says that his team’s personalized and precise treatments work hand-in-hand with the constant evolution of technology in this space.

“Many improvements in existing devices and new, disruptive technology are launched every year, allowing us to push the boundaries of what can be treated and how we do it.”

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About 18 hours after an ambulance rushed his wife to Sunnybrook, Dean Kirkhus faced a decision that he knew could spell the difference between life and death for his partner of more than 33 years.

Tracy Kirkhus had a ruptured aneurysm, which meant that a ballooning blood vessel in her brain had burst and was leaking blood into the space around her brain. The 56-year-old was unconscious and unresponsive by the time Dr. Victor Yang, a neurosurgeon and senior scientist at Sunnybrook, took her into the operating room.

“She was in a deep, deep coma,” Dr. Yang says. “Because of the location of her aneurysm and her deteriorating condition, by the time I saw her, the options available to her were limited.”

The initial line of treatment for a brain aneurysm is endovascular coiling, which involves pushing a platinum coil through a catheter to induce clotting and prevent blood from getting through the aneurysm.

In Tracy’s case, the aneurysm occurred right against the brain stem, with a shape that makes it difficult to receive the coil at the rupture point. Though Dr. Yang tried the endovascular coiling procedure, it failed to fully repair the aneurysm, he says.

The next option was a stent, but this would require blood thinner medications because the metal in conventional stents can cause blood clots. For Tracy, who had hemorrhaged badly, blood thinners were not advisable.

“After the [initial] surgery, Dr. Yang came to me and told me it didn’t work out,” says Dean. “Then, he said he had another idea.”

Dr. Yang’s idea was to implant a flexible stent with a special polymer surface designed to mimic the natural properties of blood cells. At that time, the stent – called a Pipeline Flex Embolization Device with Shield Technology – was not approved for clinical use, so Dr. Yang needed Health Canada’s permission to use the device on a compassionate basis.

“And of course, they needed our consent,” Dean says. “I didn’t think twice. I knew we had little choice but to go ahead with this other method and I felt that we could trust Dr. Yang.”

He waited anxiously to see whether Dr. Yang’s creative manoeuvre would be successful.

A harrowing journey

The events leading up to Tracy’s surgery at Sunnybrook started in February 2019, just two days before Valentine’s Day.

She was in Toronto with Dean, an Air Canada pilot who was attending a work training course. (Tracy, a manager at an air traffic control centre, first met Dean back in the ’80s when he was a bush pilot). After taking in a movie with her daughter, who lives in Toronto, Tracy headed to her home near Minden, Ont., located about 2.5 hours northeast of the city. She was hoping to dodge a snowstorm expected to hit Toronto that night.

As Tracy drove north on Highway 400, the headache that had been bothering her all day went from tolerable to excruciating. She stopped at a roadside service centre just off the highway and went to the washroom.

She was in a stall when her aneurysm ruptured.

“It felt like the top of my head exploded and I hit the floor,” Tracy recalls. She managed to get herself up and out of the washroom, but then she fell again.

“That’s when I noticed people were looking at me strangely – they probably thought I was drunk,” Tracy says. “I went to the counter and bought myself a pop and some chips, somehow thinking that if I did that, everything would be fine.” Tracy went to her car and then began vomiting.

Dean had texted his wife earlier to check that she had made it home safely. She responded after midnight, but her text came through as jumbled letters. When Dean called her, she told him she was at a service centre along the 400, but could not tell him which one. He immediately got in his car and went from service station to service station, searching for his wife.

“When I found her, I thought she was having a stroke, so I drove her to the nearest urgent care clinic,” he says. The doctor who saw Tracy ordered a CT scan of her brain. At around 4:30 a.m., she was taken by ambulance to Sunnybrook.

Tracy Kirkhus and her husband, Dean, at their home near Minden, Ont. (Photography by Kevin Van Paassen)

‛Cutting-edge approaches’ that save lives

The Pipeline flex shield stent is made with a synthetic version of an organic compound found in the outer membrane of red blood cells. This mesh-like biomaterial prevents blood cells from reacting to the stent implant. Once implanted, the Pipeline flex shield stent acts as a scaffold and helps rebuild the damaged blood vessel.

To get the Pipeline flex shield stent to Tracy’s brain, Dr. Yang used a flexible catheter, inserted into an artery in the groin region and sent up through the body. He also employed innovative imaging technology called Doppler Optical Coherence Tomography (OCT), which uses infrared light waves to create images of tissue, cells and molecules.

With OCT to guide him, Dr. Yang was able to see and accurately position the stent in the damaged blood vessel.

“My research lab was the first in Canada to do OCT research 20 years ago, and at Sunnybrook we are still the only group in the world capable of doing Doppler OCT in neurovascular patients,” says Dr. Yang.

Sunnybrook was also the first in Canada to implant the Pipeline flex shield stent, which is now Health Canada approved. To date, says Dr. Yang, Sunnybrook is one of the leading hospitals in the country for treating complex ruptured aneurysms using this technology.

“As part of the hospital’s mandate to innovate and stay at the forefront of treatment technology, Sunnybrook has led research in brain sciences with cutting-edge approaches to treating neurovascular diseases,” Dr. Yang says. “At the same time, Sunnybrook has also advanced its application of image-guided, minimally invasive therapies.”

By combining these two strategic directions, doctors at Sunnybrook have been able to treat more and more patients who would have previously been quite difficult to treat, he adds.

For Tracy Kirkhus, Sunnybrook’s innovations in neurovascular treatment have meant a second chance at life.

After spending 25 days in intensive care at Sunnybrook, Tracy spent another five months in hospital, both in Toronto and in Lindsay, Ont. By August 2019, she was able to return home, where she continued to receive physiotherapy and occupational rehabilitation. Now, she is able to walk and goes to rehab sessions twice a week.

Tracy says her vision is still impaired, and sometimes she forgets things. Talking at length can take a toll on her.

“But I’m alive, and I’m home,” Tracy says. “Dr. Yang and all the great people at Sunnybrook are my heroes.”

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