GRAND RAPIDS, MI - As surgeons operated on the aneurysm in Ronald Courter's brain, his heart stopped for about 20 seconds.
That was according to plan - part of an advanced medical technique used to treat the large, complex aneurysm that had formed in the center of Courter's brain.
The technique involves using a drug to temporarily stop the heart - and the blood flow - making it safer to place tiny, clothespin-like clips on the ballooning blood vessel, said Dr. Justin Clark, a neurosurgeon with Great Lakes Neurological Associates.
Clark and Dr. Bryan Figueroa, both with specialty training in cerebrovascular neurosurgery, performed the operation in October at Metro Health on Courter, a 61-year-old man from Six Lakes. Since then, Courter has returned to his job driving a forklift at Federal Mogul, spending time with family and golfing when he can find the time.
"That is exactly what we hoped for," said Clark, who grew up in Ada and returned a year ago to practice in his hometown. "Brain aneurysms are incredibly dangerous, but cutting-edge techniques like these literally can make the difference between life and death."
The technique using the drug adenosine to stop the heart, introduced about 15 years ago, "is pretty well documented at this point," he said. But it is not a common procedure.
At the Barrow Neurological Institute in Phoenix, Clark did a fellowship in cerebrovascular surgery under Dr. Robert Spetzler, a neurosurgeon known for operating on more than 6,000 brain aneurysms. At Barrow, Clark estimates the procedure was used in about one in every 40 or 50 aneurysm surgeries, he said.
Courter's operation was the first time he and Figueroa have used it in West Michigan. Clark said several factors made the 7.5-millimeter aneurysm complex - "it was located at the top of the basilar artery in the center of the brain, it had a wide neck and it was posteriorly projecting, which means that numerous delicate perforating' arteries were draped over the dome of the aneurysm. Damage to any one of the perforating arteries could cause a devastating stroke.
"That is where the most dangerous aneurysms form," Clark said.
Courter's first sign of the aneurysm came on the evening of Sept. 30.
He and his brother had just cleaned the garage and were behind the house talking about the flowers that Courter's wife, Patricia Richards, was planting.
"Then I just got dizzy, and I couldn't see," he said. "I was going to go into the house and lie down and take a nap. But my wife said, 'No, I think you're having a stroke.'"
She insisted he go to the hospital, and Courter is glad he listened.
An MRI revealed an aneurysm, a weakening or balloon-like bulging in the artery wall. The lifetime risk that it would rupture was calculated at 25 to 65 percent, depending on the database used, Clark said.
BRAIN ANEURYSMS
• About 6 million people in the U.S. have an unruptured brain aneurysm
• About 30,000 a year suffer a brain aneurysm rupture.
• A ruptured brain aneurysm is fatal in 40 percent of cases. Of those who survive, 66 percent suffer some permanent neurological deficit.
• Most aneurysms develop after age 40, but they can occur in children.
• Women suffer more brain aneurysms than men, at a ratio of 3:2.
• The median age of a hemorrhagic stroke caused by an aneurysm is 50.
• An article on the history of cardiac standstill in the treatment of brain aneurysms was published in April 2014 by the Journal of Neurosurgery
About 40 percent of ruptured brain aneurysms are fatal, and of those who survive, about 66 percent suffer some permanent neurological deficit, according to the Brain Aneurysm Foundation.
Courter's dad had undergone surgery 40 years ago on an aneurysm. Courter was 18 then and doesn't know the details, but said the surgery was successful.
When the surgeons explained how they planned to operate, and that the heart may be stopped temporarily, Courter's wife was frightened.
"It was terrifying, actually," she said.
Courter just said, "Do what you got to do."
Due to advances in endovascular therapies, most aneurysms located at the top of the basilar artery are treated with coils and/or stents, inserted through the femoral artery, Clark said.
When that is not possible, surgeons in the past have created a "cardiac standstill" to stop blood flow by hooking the patient up to a heart-lung machine, a complicated and time-consuming procedure, with a high death rate.
Adenosine, a drug used to slow a fast heart rate, can be used during surgery to stop the heart for 20 to 60 seconds.
During the operation, Clark and Figueroa stopped the heart twice and put two clips on the aneurysm. In both cases, the heart began beating again on its own.
The doctors were unable to clip the blood vessel all the way across without risking damage to delicate vessels surrounding it, but they were able to narrow the opening.
In December, Dr. Jay Morrow, a neurointerventional radiologist, did an endovascular procedure to place coils in the aneurysm to prevent blood flow.
Courter said he was back to work in January. Although he still feels more tired than normal, he is working a full shift - including lots of overtime hours.
"He's doing amazing," his wife said.
"Having him do so well is the most important thing," Clark said.
Sue Thoms covers health care for MLive/The Grand Rapids Press. Email her at sthoms1@mlive.com or follow her on Twitter, Facebook or Google+.