grand rounds cranial aneurysm treatment advance seris

Supervisior / VS Chen shiu-jau Presenter / R2 Chiang kuan-yu

Introduction• Prevalence 1-5%• Incidence of rupture

– 1/10000

• Female:Male = 2: 1• Peek 55-60 years-old

• Etiology– Genetic– Sporadic– Hemodynamic

• Hypertension

Jonathan L, et al NEJM, 2006Jonathan L, et al NEJM, 2006

Ruptured aneurysm• 30 days mortality rate: 45 %• Survival with 1/3 moderate or severe disability• Rebleeding

– 4 % in first hour– 20 % in 2 weeks

Jonathan L, et al NEJM, 2006Jonathan L, et al NEJM, 2006

Introduction-Treatment

Craniotomy and clippingCraniotomy and clipping Endovascular coilingEndovascular coiling

Hunt and Hess Classification

Grade 1 Asymptomatic or minimal headache with slight nuchal rigidity

Grade 2 Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy

Grade 3 Drowsiness, confusion, or mild focal deficit

Grade 4 Stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity, and vegetative disturbances

Grade 5 Deep coma, decerebrate rigidity, moribund appearance

Case 1

• 47 y/o male• History: HTN• Chief Complaint :

– Acute onset and persisted headache

Physical examinationConsciousness: alert, E4V5M6Nausea or vomiting(+)

Hunt and Hess scale 1 WFNS grade 1

Image study

Diffuse SAH

r/o A-Com aneurysm

A 15.88x10.34x11.83mm aneurysm at A-com with 7.43mm base

3D Reconstruction Cerebral Angiography3D Reconstruction Cerebral Angiography

Operation

Left pterional approach aneurysm clipping

– Intraoperative ICG study [Video]

Residual neck : 2.91x1.57x3.67 mm

Parent artery stenosis (-)

Angiographic vasospasm (-)

Electrolyte imbalance (-)

Rebleeding (-)

Residual neck : 2.91x1.57x3.67 mm

Parent artery stenosis (-)

Angiographic vasospasm (-)

Electrolyte imbalance (-)

Rebleeding (-)

Case 2

• 74 y/o male• History: BPH• Chief Complaint : –Persisted Headache with Dizziness

Physical examinationConsciousness: alert, E4V5M6Neck stiffness(+)Nausea or vomiting(+)

Hunt and Hess scale 2 WFNS grade 1

Image study

• Diffuse SAH

Ruptured saccular aneurysm 7.8x7.3x12.2mm at A-com. a.

Operation

Right pterional approach clipping aneurysm

–Intra-operative sonography [Video]

Residual neck : Nil

Parent artery stenosis (-)

Angiographic vasospasm (-)

Electrolyte imbalance (-)

Rebleeding (-)

Residual neck : Nil

Parent artery stenosis (-)

Angiographic vasospasm (-)

Electrolyte imbalance (-)

Rebleeding (-)

Our Experiences

From 2009 Jan to 2014 May

Mackay Memorial Hospital, Medical Center

Sample : 50 aneurysms (47 patients)4 unruptured

Craniotomy and aneurysm clipping

Case Series: DemographyTable1 Patient’s demographic and selected characteristics

N %

Age 35-44 7 14.9

45-54 13 27.7

55-64 11 23.4

>65 15 31.9

Case Series: Demography

Table1 Patient’s demographic and selected characteristics

N %Sex Female 31 66

Male 16 34

Case Series: Demography

Table1 Patient’s demographic and selected characteristicsvariable N %

size mm< 5 22 44> 5 28 56

< 7 32 64> 7 18 36

Case Series: DemographyTable1 Patient’s demographic and selected characteristics

N %LocationAnterior circulation Anterior communicating a. 21 44.7

L’t A2A3 Juction 1 2.1MCA bifurcation 6 12.8

Posterior circulation

Post. communicating a. 16 34.1

PICA 2 4.2

ComplicationsComplications nParent artery stenosis 4 Pcom * 1, ACA *2, ICA *1

Residual neck 13 One received TAE

Vasospasm

Angiography 4

Transcranial Doppler 7

Hydrocephalus 21 16 received V-P shunt

Electrolyte imbalance 29 Sodium & Potassium

Perioperative Rebleeding 18

Patient Outcome

GOS Patient Number

1 6

2 7

3 2

4 8

5 24

Age / Sex / Lesion size

Predictors

Complications

Patient OutcomeVariable GOS Total

N=47N(%)

p

1-3n=15n(%)

4-5n=32n(%)

Age (years) 0.093≦54 5(10.6) 16(3.1) 17(2.1)55-64 2(4.3) 9(19.1) 11(14.9)≧65 8(17) 7(14.9) 15(31.9)

SexF 10(21.3) 21(44.7) 31(66) 0.944M 5(10.6) 11(23.4) 16(34)

Patient OutcomeVariable GOS Total

N=47N(%)

p

1-3n=15n(%)

4-5n=32n(%)

Size 0.119

≦6 9(19.1) 26(55.3) 35(74.4)

≧6 6(12.8) 6(12.8) 12(25.6)

Patient Outcome

Variable OR (95% CI) p value

WFNS

1-2 1 (reference)

3-5 1.310 (0.005-0.727) 0.027

Hunt and Hess

1-3 1 (reference)

4-5 1.310 (0.016-1.288) 0.083

Table. Multiple logistic regression associated with Poor outcome (GOS1-3)

(n=47) OR, odds ratio; CI, confidence interval.

Patient OutcomeVariable GOS Total

N=47N(%)

p1-3

n=15n(%)

4-5n=32n(%)

Parent artery stenosisYes 3(6.5) 6(13) 9(19.5) 0.833No 11(23.9) 21(56.5) 37(80.4)

Residual neckYes 5(10.9) 8(17.4) 13(28.3) 0.458No 9(19.6) 24 (52.2) 33(71.7)

VasospasmYes 5(10.9) 6(13) 11(23.9) 0.215No 9(19.6) 26(56.5) 35(76.1)

Patient OutcomeVariable GOS Total

N=47N(%)

p1-3

n=15n(%)

4-5n=32n(%)

HydrocehpalusYes 11(23.4) 10(21.3) 21(44.7) 0.007**No 4(8.5) 22(46.8) 24(55.3)

EncephalomalaciaYes 6(12.8) 9(19.1) 15(31.9) 0.416No 9(19.1) 23(48.9) 32(68.1)

Patient OutcomeVariable GOS Total

N=47N(%)

p1-3

n=15n(%)

4-5n=32n(%)

HypernatriemiaYes 14(29.8) 15(31.9) 29(61.7) 0.002No 1(2.1) 17(36.2) 18(38.3)

HyponatriemiaYes 7(14.9) 3(6.4) 10(21.3) 0.004No 8(17) 29(61.7) 37(78.7)

HyperkalemiaYes 6(12.8) 11(23.4) 17(36.2) 0.708No 9(19.1) 21(44.7) 30(63.8)

HypokalemiaYes 3(6.4) 2(4.3) 5(10.6) 0.154No 12 (25.2) 30(63.8) 42(89.4)

Patient Outcome

Variable GOS TotalN=47N(%)

p1-3

n=15n(%)

4-5n=32n(%)

Peri-Operative Rebleeding

Yes 11(23.4) 7(14.9) 18(38.3) 0.001No 4(8.5) 25(53.2) 29(61.7)

DiscussionDiscussion

Treatment of Aneurysm

• Craniotomy with Clippingdistal location, wide base, young age, mass effect

• Endovascular with Coil posterior circulation, dissecting aneurysm

Controversial Recannulization / Intraoperative rupture / InfarctionCoil material migration stenosis

Controversial Recannulization / Intraoperative rupture / InfarctionCoil material migration stenosis

Vasospasm

Treatment of Vasospasm– Medical strategies

• Nimodipine• Hypertension, Hypervolemia,

Hemodilution

– Endovascular balloon angioplasty techniques*

By Andrew M. Bauer* and Peter A. Rasmussen, 2014By Andrew M. Bauer* and Peter A. Rasmussen, 2014

WFNSGrading

Hunt and HessGrading

Good (GOS 4,5) Poor (GOS 2,3) Death (GOS 1)

Grade 1-3 (GCS 13-15)

Grade 1-3 25 (89.3%) 1 (3.6%) 2 (7.1%) 28

Grade 4 (GCS 7-12)

Grade 4 4 (40%) 4 (40%) 2 (20%) 10

Grade 5 (GCS 3-6)

Grade 5 3 (33%) 3 (33%) 3 (33%) 9

32 (68%) 8 (17%) 7 (15%) 47

Harsimrat Bir Singh Sodhi, et al, Journal of Neurosciences in Rural Practice, 2014

Complications During Aneurysm Surgery

• Diagnosis– 3D reconstruction

cerebral angiography

• Treatment– Endovascular

Coil, stent

• Surgery– Intraoperative

sonography– Intraoperative ICG– Intraoperative cerebral

angiography

THANKs !!