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Rupture of cerebral aneurysms: Current Management and
Prevention
Erik F. Hauck, MD, PhD
Cerebrovascular & Endovascular NeurosurgeryOregen Neuroscience Institute & OHVI
Riverbend Hospital, Springfield ORphone 541 -222-2880
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Objective
Background & brief literature review
Presentation of advanced endovascular and surgical strategies to successfully treat ruptured and unruptured aneurysms
Case illustrations
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Disclosure
Nothing to disclose
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What is a “cerebral aneurysm”?
• 49 yo F, Ruptured left ICA aneurysm
• H&H grade I
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Intra-operative view
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Seven days after surgery
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Introduction - Terminology
Aneurysm Size
- Cooperative study of aneurysms and SAH (1966):
Class ‘5’ aneurysms ≥ 2.5 cm, ‘unusually large’. 100%
symptomatic, highest risk of bleeding
- Defined as ‘massive’ aneurysm ≥ 2.5 cm (1 inch) 1969
- First series of ‘giant’ aneurysms with management
strategies reported (1969); AN ≥ 2.5 cm
- Dr. Drake’s series with 174 giant aneurysms (1979)
Locksley HB. Cooperative study of intracranial aneurysms and subarachnoid hemorrhage.
J neurosurg 1966; 25: 321-368.
Morley TP, Barr HWK. Giant intracranial aneurysms: Diagnosis, course and management.
Clin Neurosurg 1969; 16: 73-94.
Drake CG. Giant intracranial aneurysms: experience with surgical treatment in 174 patients.
Clin Neurosurg. 1979;26:12-95.
Bull J. Massive aneurysms at the base of the brain. Brain. 1969;92(3):535-70.
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Aneurysm Size
Small & Giant
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Aneurysm Size
Small & Giant
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‘Saccular’(based on a ‘normal’ parent vessel)
Introduction - Terminology
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‘Fusiform’(no ‘normal’ parent vessel)
Introduction - Terminology
Drake CG, PeerlessSJ. Giant fusiform intracranial aneurysms:
review of 120 patients treated surgically from 1965 to 1992. J
Neurosurg. 1997 Aug;87(2):141-62.
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Epidemiology
Aneurysm prevalence ~ 3% [1% - 6%]~ 9.000.000 in USA~ 100.000 in OR
Giant aneurysms ~ 3% [3% - 13%]~ 270.000 in USA~ 3.000 in OR
Introduction - Epidemiology
Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review.
Stroke. 1998 Jan;29(1):251-6.
Barrow DL, Alleyne C. Natural history of giant intracranial aneurysms and indications for intervention.
Clin Neurosurg. 1995;42:214-44. Review.
Wiebers et al. ISUIA investigators. Unruptured intracranial aneurysms: natural history, clinical outcome,
and risks of surgical and endovascular treatment. Lancet. 2003 Jul 12;362(9378):103-10.
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Projected number of strokes vs. aneurysm ruptures
in US: 2002 -2025
Source: Stroke, January 2004; J. P. Broderick, MD
30,000 Aneurysms
30,000Aneurysms:
Epidemiology
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Epidemiology
Introduction
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Aneurysm locations
Brisman JL, Song JK, Newell DW. Cerebral aneurysms. NEJM 2006; 355:928-939
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Natural history
1) Risk of SAH
2) Disabling mass effect
3) Ischemic stroke
4) HCP
5) Seizures
Introduction
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Risk of Rupture (ISUIA)Introduction
ISUIA. Lancet. 2003 Jul 12;362(9378):103-10.
Size Anterior Circ Posterior Circ
0 - 6 0% 2.5%
7 – 12 2.6% 14.5%
13 - 24 14.5% 18.4%
25+ 40% 50%
5 year cumulative risk
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Outcome after Rupture
Introduction
~ 50 % mortality
~ 25 % disability
~ 25 % good outcome
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Treatment Goals
Introduction
~ Prevent Rupture
~ Prevent Spasm
~ Prevent Stroke
~ Treat ICP
~ Ensure Functional
Survival
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Treatment Option
• Endovascular (needle puncture in the groin)
• Surgery
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Neuro-biplane Room
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Vascular ORs
• Currently Smart OR design with DSA capability
• In August/September: Hybrid Angio-OR
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Treatment Options (ISAT)
• Reduced morbidity/mortality at 1 year f/u:
Coil (23.5%) vs clip (30.9%); p = 0.0001, n = 2118
• Reduced mortality at 5 year f/u:
Coil (11%) versus clip (14%); p = 0.03, n=2087
Lancet Neurol. 2009 May;8(5):427-33. Epub 2009 Mar 28.
Lancet. 2005 Sep 3-9;366(9488):809-17.
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Clip vs Coil
• Reduced morbidity/mortality at 1 year f/u:
Coil (23.5%) vs clip (30.9%); p = 0.0001, n = 2118
• Reduced mortality at 5 year f/u:
Coil (11%) versus clip (14%); p = 0.03, n=2087
Lancet Neurol. 2009 May;8(5):427-33. Epub 2009 Mar 28.
Lancet. 2005 Sep 3-9;366(9488):809-17.
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Unruptured basilar apex aneurysm
Aneurysms, Case #1
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• 58 yo man
• Previous ‘TIA’ with LOC and confusion for days
• Complete recovery
• No neurological deficit
• History of hypertension
Clinical summary
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DSA R VAPCA?
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DSA R ICAFetal R PCA!
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DSA L ICAShort M1 segment
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• No treatment
• Clip
• Coil (stent/coil)
Options?
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• All options discussed
• Pt chose surgery
• Risk slightly higher?
• Protection from rupture likely better?
• Less to no follow-up required?
• Pt trusts surgeon!
Decision
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- Supine
- Head turned 40 degrees
- Pteryonal craniotomy
- Temporal craniectomy/cranioplasty
- Complete opening of arachnoid cisterns
- No uncus resection
- Pretemporal exposure
- Temporary occlusion x3 < 10 min
- Barbiturate burst suppression
Surgical Procedure (<3hrs)
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R Pteryonal Approach
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- Patient did well
- No neurological deficit
- D/c home POD #3
Outcome
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# Sex Age Size Side TAO IOAR 3rd nerve paresis f/u LOS comp symptom GOS
[mm] [min] temporary permanent [months] [days]
1 F 29 5 R 14 no Yes no 12 3 - - 5
2 F 37 3 R none no No no 1 6 - - 5
3 M 38 4.4 L 20 no No no 6 5 - - 5
4 F 42 6 R 10 no No no 1 4 - - 5
5 F 45 4.2 R 11 no No no 6 5 - - 5
6 F 46 3.3 R 2 no Yes no 12 3 small ICH - 5
7 F 48 5 L 9 no No no 12 4 - - 5
8 F 50 3.8 R none no No no 24 6 post op ileus resolved 5
9 F 51 6 R 11 no No no 2 4 - - 5
10 F 52 2 R none no No no 12 4 - - 5
11 M 52 2.5 L 5 no Yes no 12 4
4th nerve
palsy
intermittent double
vision 4
12 F 54 5 R none no No no 6 4 - - 5
13 F 55 4 R none no No no 12 5 -
unchanged minor
preoperative
disability 4
14 F 55 2.6 R 7 no Yes no 1 5 -
overall 'less energy' as
prior to surgery 4
15 F 63 6 R 8 no No no 12 5 - - 5
16 F 65 5 R 10 no Yes no 12 4 -
unchanged minor
preoperative
disability 4
17 M 65 4 R 8 no No no 2 4 - - 5
18 F 70 3 L 8 yes Yes no 2 5 small infarct
temporary weakness,
completely
resolved 5
19 F 70 6 R 8 no Yes no 12 5 - - 5
20 F 71 4.5 R 5 yes Yes no 12 7 - - 5
21 F 74 5.1 L none no No no 24 4 - - 5
Clip
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The endovacular alternative
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• Surgery is still an option
• Permanent 3rd nerve paresis possible
• Surgical risk increases with size
• RESPECT THE THALAMOPERFORATORS
• Surgery involves surgery with longer recovery
• Endovascular is done under conscious sedation
• Ev Tx requires multiple f/u angios
• Choose endovascular if it is a good option
Conclusions
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Right ophthalmic giant aneurysm
Aneurysms, Case #2
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• 63 yo F from Puerto Rico• s/p left ICA sacrifice,• tx of left giant carotid opthalmic aneurysm• Now new right visual problems• Pt is other wise fairly healthy
Clinical background
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DSA R ICA
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• No treatment• Carotid sacrifice• Direct clip reconstruction• Stent/coil• Bypass
Options
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Carotid ligation
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Direct coiling
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Waffle Cone Technique
Please, avoid the ‘leaky cherry’ !
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Surgical Options
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Directclipping
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TraditionalBypass-Interposition
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So, what did we do?
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Elana Technique
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Elana ‘High flow bypass’
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Elana ‘High flow bypass’
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Outcome
- Patient had an excellent recovery
- D/c home after 1 week
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Aneurysm, case #3
Rescue of the ‘lost’ Pipeline(PED)
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Clincal summary
HPI: - 64 yo F from Puerto Rico- s/p minor head injury
PMH: GERDMEDS: Nexium, AmbienPE: No neurological deficit
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MRI -> 3 cm L IC cav mass
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DX angio
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Pipeline Embolization Device
- Braided mash cylinder
- 48 microfilaments
- platinum and cobalt chromium strands
- mounted on a flexible microwire
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PED delivery & stacking,How you do it
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Neuron in horiz. Petrous ICA
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First PED deployed
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Significant change in flow
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Looks good, but …
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Looks good, but …
…looks can be deceiving!!!
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The ‘lost’ PED
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Hours of frustrating fishing for the ‘lost’ PED go by…
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Strategies attempted1. Different catheters were used:
2. ‘C’ shaped, ‘J’ shaped, straight, angled, Enzo-modifiable tip
3. Different wires (stiff, soft)
4. Wrap-around technique
5. Grabbing the PED and retrieving into the aneurysm sack with different sized Alligators, Snares
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NO SUCCESS
Think outside the box
Re-access of the PED proves impossible
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Exploration of collaterals
acom pcom
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Options
1. Quit
2. Sacrifice without BTO (no change in SSEPs)
3. BTO the next day
4. Bypass
5. Trans pcom or acom rescue
6. No further treatment, see what happens
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Rescue Intervervention - Outline1. One week later
2. Dual access (bilateral groin)
3. Transbasilar, transpcom wire
4. Transcarotid, intraaneurysmal snare
5. Capture
6. Re-access PED from proximal to distal
7. Finish the job
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
- Trans-basilar,trans-pcom, retrograde catheterization of the ‘lost’ PED & aneurysm
- SL 10, synchro-2
lateral
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Step 1
lateral
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Step 2
- Trans-carotid catheterization of the aneurysm
- Marksman, Snare
VA
ICA
pcom
PEDBA
Contra-lateral oblique
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Step 3 – Capture
Contra-lateral oblique lateral
ICA
ICA BABA
pcom
pcom
PED
PED
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Step 4 – Pull down
Contra-lateral oblique lateral
ICA
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Step 4
Pull down of transbasilarcatheter
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Step 5
Open snare, advance transcarotid catheter over transbasilar catheter through and beyond PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
Trans-basilar wire, snare assissted rescue of the lost PED
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Step 5
-Trans-basilar wire, snare assissted rescue of the lost PED
- Repositioning of the Marksman catheter
- Note tortuosity
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Step 6 – More PEDs
Stasis – Half Moon Sign
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Significant instent stenosis
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Angioplasty
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CCF
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Salvage – More PEDs
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PRE – POST
a/p view
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PRE – POST
Lateral view
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Outcome
- Patients headaches resolved
- Small amount of SAH (distal cave segment injury post angioplasty)
- Temporary hydrocephalus
- Temporary minor right sided weakness
- Pt is doing now well 2 wks after procedure
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Pearl
Giant aneurysms are a class of their own.
The treatment remains complex.
All options, surgical and endovascular need careful consideration
All modalities, including the newest and latest technology, are available right here at Riverbend Hospital
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THANKS!!!