week 8- aneurysms, sah, dissections and arteritis

Week 8- Week 8- Aneurysms, SAH, Aneurysms, SAH, Dissections and Dissections and

ArteritisArteritis

Week 8- Aneurysms, SAH, Week 8- Aneurysms, SAH, Dissections and ArteritisDissections and Arteritis

Week 8 Objectives-Week 8 Objectives-

Define Brain Aneurysm Define Pseudoaneurysms Recognize different types of aneurysm

radiographically Be familiar with the angiographic evaluation of

patients with cerebral aneurysms Be familiar with the angiographic evaluation of

patients with subarachnoid hemorrhage (SAH) Identify methods of surgical treatment of aneurysms Discuss aneurysm coiling Perform basic set-up for Aneurysm coiling Discuss the treatment of wide-necked aneurysm Discuss the balloon remodeling technique

What Is An Aneurysm?What Is An Aneurysm?

A cerebral aneurysm A cerebral aneurysm is a bubble like is a bubble like

outpouching from an outpouching from an artery which artery which

predisposes its predisposes its carrier to cerebral carrier to cerebral hemorrhage and hemorrhage and

stroke stroke

Images © Frank H. Netter, CIBA Collection of Medical Illustrations

HistoryHistory

19271927 Moniz - angiographyMoniz - angiography 19371937 Dandy describes the Dandy describes the

clipping of intracranial aneurysmclipping of intracranial aneurysm 19491949 Robertson described post-Robertson described post-

mortem lesions after aneurysmal mortem lesions after aneurysmal SAH.SAH.

Brain 72:150, 1949Brain 72:150, 1949

19511951 Ecker & Reimenschneider Ecker & Reimenschneider angiographic spasmangiographic spasm

Aneurysm DemographicsAneurysm Demographics

Aneurysms are found in 2-5% of the populationAneurysms are found in 2-5% of the population More likely to occur in adults age 40-60More likely to occur in adults age 40-60 There are as many as 27,000 aneurysms that could There are as many as 27,000 aneurysms that could

be diagnosed and treated per year in the U.S. be diagnosed and treated per year in the U.S. They are more common in women (Sharon Stone had They are more common in women (Sharon Stone had

an aneurysm that was treated with coils by an an aneurysm that was treated with coils by an interventional neuroradiologist)interventional neuroradiologist)

The annual rupture rate is approximately 1.5% The annual rupture rate is approximately 1.5% Rupture of an aneurysm results in approximately 50% Rupture of an aneurysm results in approximately 50%

mortality and 25% stroke incidence mortality and 25% stroke incidence

Aneurysm FactsAneurysm Facts Factors believed to contribute to Factors believed to contribute to

brain aneurysms:brain aneurysms: SmokingSmoking HypertensionHypertension Traumatic head injuryTraumatic head injury Alcohol useAlcohol use Use of oral contraceptionUse of oral contraception Post menopausal women > MenPost menopausal women > Men Family history of brain aneurysms Family history of brain aneurysms Other inherited disorders: Ehler’s syndrome, Other inherited disorders: Ehler’s syndrome,

polycystic kidney disease, and Marfan syndrome polycystic kidney disease, and Marfan syndrome

Aneurysm FactsAneurysm Facts

Symptoms of ruptured aneurysms:Symptoms of ruptured aneurysms: The worst headache of your The worst headache of your

lifelife Localized and intense headacheLocalized and intense headache Nausea and vomitingNausea and vomiting Stiff neck or neck painStiff neck or neck pain Blurred or double visionBlurred or double vision Pain above and behind eyePain above and behind eye Dilated pupilsDilated pupils Sensitivity to lightSensitivity to light Loss of sensation Loss of sensation

The Configuration of The Configuration of AneurysmsAneurysms

Aneurysms can be categorized by their Aneurysms can be categorized by their configuration. There are three basic distinctions configuration. There are three basic distinctions between aneurysms. They are as follows:between aneurysms. They are as follows:

Fusiform AneurysmsFusiform Aneurysms – Whole vessel – Whole vessel circumference involvedcircumference involved

Saccular AneurysmsSaccular Aneurysms – The lesion is eccentric. – The lesion is eccentric. PseudoaneurysmsPseudoaneurysms - Occur when the layers or - Occur when the layers or

wall has been perforated and the rupture is wall has been perforated and the rupture is contained by an extraluminal hematoma.contained by an extraluminal hematoma.

Terminology Associated Terminology Associated With Cerebral AneurysmsWith Cerebral Aneurysms

EctasiaEctasia is a mild dilatation of a segment of vessel is a mild dilatation of a segment of vessel but is not considered to be an aneurysm at this but is not considered to be an aneurysm at this point.point.

DissectionDissection is occurs when a tear in the lining of is occurs when a tear in the lining of the artery occurs and blood flows in between the artery occurs and blood flows in between layers of the blood vessel.layers of the blood vessel.

ArteritisArteritis is inflammation of the cerebral arteries is inflammation of the cerebral arteries that obstructs and occludes them.that obstructs and occludes them.

InfundibulumInfundibulum is a funnel-shaped origin of a is a funnel-shaped origin of a branch vessel.branch vessel.

Classifications of Classifications of AneurysmsAneurysms

Aneurysms of the Neurovascular Aneurysms of the Neurovascular system can also be classified into 4 system can also be classified into 4 main groupings. main groupings.

The groupings are as follows:The groupings are as follows: Extradural AneurysmsExtradural Aneurysms PseudoaneurysmsPseudoaneurysms Intradural AneurysmsIntradural Aneurysms Giant AneurysmsGiant Aneurysms

Classifications of Classifications of Aneurysms Extradural Aneurysms Extradural

Aneurysms Aneurysms Extradural AneurysmsExtradural Aneurysms occur occur

outside of the Dura Mater and are outside of the Dura Mater and are less likely to cause subarachnoid less likely to cause subarachnoid hemorrhage.hemorrhage.

Classifications of Classifications of Aneurysms Aneurysms

True Vs. PseudoaneurysmsTrue Vs. Pseudoaneurysms Other terms you will also hear are Other terms you will also hear are True AneurysmsTrue Aneurysms and and False False

(“pseudo”)Aneurysms(“pseudo”)Aneurysms

True AneurysmsTrue Aneurysms are when the intima, media and advential are when the intima, media and advential layers are all intact.layers are all intact.

False (Pseudoaneurysms)False (Pseudoaneurysms) occur when the layers or wall occur when the layers or wall has been perforated and the rupture is contained by an has been perforated and the rupture is contained by an extraluminal hematoma.extraluminal hematoma.

Causes of Pseudoaneurysm may include:Causes of Pseudoaneurysm may include:

TraumaTrauma DissectionDissection Surgical or Endovascular Interventional InjurySurgical or Endovascular Interventional Injury BiopsyBiopsy Adjacent InfectionAdjacent Infection

Classifications of Classifications of Aneurysms Aneurysms

Intradural AneurysmsIntradural Aneurysms There are several categories of There are several categories of Intradural Intradural

Aneurysms.Aneurysms. They are as follows: They are as follows:

FusiformFusiform - (Associated with tortuosity, - (Associated with tortuosity, hypertension, atherosclerosis and advancing age)hypertension, atherosclerosis and advancing age)

Mycotic and InflammatoryMycotic and Inflammatory – (Caused by – (Caused by bacteria)bacteria)

OncoticOncotic – (Caused by metastasis) – (Caused by metastasis) DissectingDissecting – (Caused by a disruption in the vessel – (Caused by a disruption in the vessel

walls)walls) Saccular (Berry)Saccular (Berry) – (Develop over time and – (Develop over time and

resemble a “berry”)resemble a “berry”) DeNovoDeNovo – (Caused by carotid occulsion or ligation) – (Caused by carotid occulsion or ligation)

Classifications of Classifications of AneurysmsAneurysms

Giant AneurysmsGiant Aneurysms Giant aneurysms are defined as Giant aneurysms are defined as

aneurysms that are 25 mm or larger aneurysms that are 25 mm or larger in size.in size.

Anatomy of an AneurysmAnatomy of an Aneurysm A cerebral aneurysm (also called an intracranial A cerebral aneurysm (also called an intracranial

aneurysm or brain aneurysm) is a bulging, weakened aneurysm or brain aneurysm) is a bulging, weakened area in the wall of an artery in the brain, resulting in area in the wall of an artery in the brain, resulting in an abnormal widening or ballooning. Because there an abnormal widening or ballooning. Because there is a weakened spot in the artery wall, there is a risk is a weakened spot in the artery wall, there is a risk for rupture (bursting) of the aneurysm.for rupture (bursting) of the aneurysm.

A cerebral aneurysm generally occurs in an artery A cerebral aneurysm generally occurs in an artery located in the front part of the brain which supplies located in the front part of the brain which supplies oxygen-rich blood to the brain tissue. A normal oxygen-rich blood to the brain tissue. A normal artery wall is made up of three layers. The aneurysm artery wall is made up of three layers. The aneurysm wall is thin and weak because of an abnormal loss or wall is thin and weak because of an abnormal loss or absence of the muscular layer of the artery wall, absence of the muscular layer of the artery wall, leaving only two layers.leaving only two layers.

The base is the “Neck and the top is the “fundus “ or “Dome"

Sites of Aneurysm Sites of Aneurysm FormationFormation

The most common sites of Cerebral The most common sites of Cerebral aneurysm are:aneurysm are:

The Circle of WillisThe Circle of Willis

Branch BifurcationsBranch Bifurcations

Sites of Aneurysm Sites of Aneurysm FormationFormation

Anatomical distribution and relative incidence of Intracranial Aneurysms.

Left: Vessels of the circle of Willis showing multiple aneurysms.Right: Inferior view of brain showing subarachnoid hemorrhage.

Hemodynamic Properties of Hemodynamic Properties of AneurysmsAneurysms

Aneurysms have the capacity to Aneurysms have the capacity to expand over time.expand over time.

The risk of rupture is related to the The risk of rupture is related to the size of the aneurysmsize of the aneurysm

The tensile strength of an aneurysm is The tensile strength of an aneurysm is assumed to decrease according to assumed to decrease according to Laplace’s formulaLaplace’s formula which is as follows: which is as follows: P = 2 T/rP = 2 T/r

Hunt and Hess ScaleHunt and Hess Scale(Clinical Grading of SAH)(Clinical Grading of SAH)

Grade DescriptionGrade Description

Hunt and Hess ScaleHunt and Hess Scale

1 Asymptomatic or minimal headache and slight nuchal 1 Asymptomatic or minimal headache and slight nuchal rigidityrigidity

2 Moderate to severe headache, nuchal rigidity, no 2 Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsyneurological deficit other than cranial nerve palsy

3 Drowsiness, confusion, or mild focal deficit3 Drowsiness, confusion, or mild focal deficit

4 Stupor, moderate to severe hemiparesis, possible 4 Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbancesearly decerebrate rigidity and vegetative disturbances

5 Deep coma, decerebrate rigidity, moribund 5 Deep coma, decerebrate rigidity, moribund appearanceappearance

Major Causes of SAHMajor Causes of SAH

Ruptured arterial aneurysmRuptured arterial aneurysm

Ruptured AVMRuptured AVM

Perimesenchymal vein or capillary Perimesenchymal vein or capillary bleedingbleeding

95% of cases

Clinical Manifestations of SAHRuptured aneurysm headache

stiff neck

focal deficit

Ribeiro JA., et al, Acta Medica Portuguesa. 11(12):1085-90, 1998 Dec.

Subarachnoid Subarachnoid Hemorrhage: Signs and Hemorrhage: Signs and

SymptomsSymptoms Decreased alertness, Confusion, or Decreased alertness, Confusion, or IrritabilityIrritability Temporary Temporary PersistentPersistent Progressively worse to coma and deathProgressively worse to coma and death

Syncope Syncope Mental Status ExamMental Status Exam Abnormal vital signs Abnormal vital signs

Respiratory variationRespiratory variation Hypertension Hypertension Irregular heart rateIrregular heart rate

Warning or “Sentinel” Warning or “Sentinel” BleedsBleeds

Up to 50% of patients with SAH Up to 50% of patients with SAH report a distinct, severe report a distinct, severe headache in the days or weeks headache in the days or weeks before the index bleed before the index bleed

Milder symptomsMilder symptoms

History of HeadachesHistory of Headaches J Neurosurgery 1987

Features of Features of Misdiagnosed PatientsMisdiagnosed Patients

JAMA. 2004;291:866-8

Who Needs Imaging?Who Needs Imaging?

Occipital locationOccipital location Worsens with ValsalvaWorsens with Valsalva Awakens from sleepAwakens from sleep Associated with syncope, nausea, or sensory Associated with syncope, nausea, or sensory

distortion.distortion. Patients with a sudden acute-onset headachePatients with a sudden acute-onset headache

Prospective studies report that 30% of patients Prospective studies report that 30% of patients complaining of the “worst headache of their life” complaining of the “worst headache of their life” had positive findings on CT.had positive findings on CT.

Computed TomographyComputed Tomography

Sensitive for blood Sensitive for blood day of the bleedday of the bleed 95%95% within 12 hours of symptom onset within 12 hours of symptom onset as high as as high as 98%.98%.

Sensitivity drops whenSensitivity drops when symptoms are days in durationsymptoms are days in duration amount of bleeding is small amount of bleeding is small 85%85% study is difficult to interpret study is difficult to interpret

Ruptured Ant CoA aneurysm

SAH 20 ruptured right PCA

Normal Circle of Willis 3-Normal Circle of Willis 3-D CTAD CTA

SAH 20 ruptured ACA aneurysm

3-D CTA3-D CTA

SAH 20 ruptured PCoA aneurysm

3-D CTA3-D CTA

Lumbar puncture and CSF Lumbar puncture and CSF ExamExam

LP whenever the CT or CTA is negative, LP whenever the CT or CTA is negative, equivocal, or technically inadequateequivocal, or technically inadequate

Blood or red blood cells in the first 8 hrs. Blood or red blood cells in the first 8 hrs.

Xanthochromia or an inflammatory Xanthochromia or an inflammatory reaction when CSF exam delayedreaction when CSF exam delayed

Lumbar Puncture (LP)Lumbar Puncture (LP)

SAH Survival Depends SAH Survival Depends On…On…

Elimination of risk of rebleeding by Elimination of risk of rebleeding by treating aneurysm treating aneurysm (Aneurysm clipping (Aneurysm clipping or coiling)or coiling)

Management of VasospasmManagement of Vasospasm Management of Intracranial Pressure Management of Intracranial Pressure

(ICP)(ICP) Management of HydrocephalusManagement of Hydrocephalus Manangement of Other ComplicationsManangement of Other Complications Management of Cardiac IssuesManagement of Cardiac Issues

Normal Caliber

Vasospasm

SAH Survival Depends On SAH Survival Depends On … Management of … Management of

VasospasmVasospasm

SAH Survival Depends On … SAH Survival Depends On … Management of VasospasmManagement of Vasospasm DiagnosisDiagnosis Hypervolemic-hypertensive therapyHypervolemic-hypertensive therapy Calcium channel blockersCalcium channel blockers Cerebral angioplastyCerebral angioplasty Intracisternal thrombolytic therapyIntracisternal thrombolytic therapy

SAH Survival Depends On … SAH Survival Depends On … Management of Management of

Intracranial PressureIntracranial Pressure

ICP monitoring

Raising head

Hypocarbia

Steroids?

Fluid restriction?

Hypothermia

Mannitol

Barbiturate coma?

Ventriculostomy

Major Cause of DeathMajor Cause of Death

Increased Increased Intracranial Intracranial

PressurePressureThe pressure exerted in the The pressure exerted in the cranium by its contents:the cranium by its contents:the

brain, blood and brain, blood and cerebrospinal fluid.cerebrospinal fluid.

Components of Cranial Components of Cranial Vault Vault (ICP can cause (ICP can cause herniation!!!)herniation!!!) MeningesMeninges

DuraDura Arachnoid Arachnoid PiaPia

BrainBrain Brain tissue 80-88%Brain tissue 80-88%

Blood Blood Blood 2-11%Blood 2-11%

CSFCSF CSF 9-10%CSF 9-10%

Elevated ICP = DangerElevated ICP = Danger

Animated GIF taken from http://www.artie.com

Other ProblemsOther Problems

Elevated ICP can also affect the Elevated ICP can also affect the perfusion of the brainperfusion of the brain

Cerebral Perfusion Pressure (CPP) is Cerebral Perfusion Pressure (CPP) is measured by taking the Mean measured by taking the Mean Arterial Pressure (MAP) and Arterial Pressure (MAP) and subtracting Intracranial Pressure subtracting Intracranial Pressure (ICP)(ICP)

What does this mean?What does this mean?

This shows that if the ICP goes up… This shows that if the ICP goes up… and MAP stays constant… then the and MAP stays constant… then the CPP decreases.CPP decreases.

This means the patient is not getting This means the patient is not getting as much blood flow to the brain.as much blood flow to the brain.

Poor OutcomesPoor Outcomes

Having an elevated ICP is one of the Having an elevated ICP is one of the most damaging aspects of most damaging aspects of neurological trauma, and is directly neurological trauma, and is directly related to poor prognosis.related to poor prognosis.

Normal ValuesNormal Values

A normal ICP in an adult ranges A normal ICP in an adult ranges from 0-15 mmHGfrom 0-15 mmHG

An ICP cannot surpass 40 without An ICP cannot surpass 40 without causing harm.causing harm.

Even values between 25-30 are Even values between 25-30 are considered fatal if they are considered fatal if they are prolonged.prolonged.

Causes of ICP?Causes of ICP? An elevated ICP can be caused by many An elevated ICP can be caused by many

different etiologies.different etiologies. Traumatic Brain InjuriesTraumatic Brain Injuries Lyme DiseaseLyme Disease HydrocephalusHydrocephalus Brain TumorBrain Tumor Severe HypertensionSevere Hypertension Venous Sinus ThrombosisVenous Sinus Thrombosis Restricting Jugular Venous flow (i.e. C-collars)Restricting Jugular Venous flow (i.e. C-collars) Etc.Etc.

Monitoring of ICPMonitoring of ICP

There are 4 main types of devices There are 4 main types of devices for monitoring ICPfor monitoring ICP

Intraventricular CathetersIntraventricular Catheters Fiber optic MonitorsFiber optic Monitors Subarachnoid BoltsSubarachnoid Bolts Epidural MonitorsEpidural Monitors

Stages of ICPStages of ICP

Initial compensatory Initial compensatory

Secondary compensatorySecondary compensatory

Final compensatoryFinal compensatory

ICP: Initial ICP: Initial CompensatoryCompensatory

Displacement of the cerebral spinal Displacement of the cerebral spinal fluid into the spinal canal or into fluid into the spinal canal or into venous blood through the arachnoid venous blood through the arachnoid matermater

Intercranial Pressure Intercranial Pressure RegulationRegulation

When BP increases, cerebral arterioles When BP increases, cerebral arterioles constrict; when BP falls, cerebral constrict; when BP falls, cerebral arterioles dilate to increase Cerebral arterioles dilate to increase Cerebral Blood Flow (CBF)Blood Flow (CBF)

Metabolic regulation: Low O2 and high Metabolic regulation: Low O2 and high CO2 cause vasodilation; CSF CO2 cause vasodilation; CSF reabsorption and decreased reabsorption and decreased Cerebrospinal Fluid (CSF) production Cerebrospinal Fluid (CSF) production

ICP: Secondary ICP: Secondary CompensatoryCompensatory

Reduction of blood volume to the Reduction of blood volume to the brain. This stage alters cerebral brain. This stage alters cerebral metabolism and produces brain metabolism and produces brain tissue hypoxia and necrosis.tissue hypoxia and necrosis.

ICP: Final CompensatoryICP: Final Compensatory

Displacement of brain tissue which is Displacement of brain tissue which is herniation and often leads to death.herniation and often leads to death.

Clinical Manifestation of Clinical Manifestation of ICPICP

Alteration in LOC – arousal and awarenessAlteration in LOC – arousal and awareness RestlessnessRestlessness IrritabilityIrritability ConfusionConfusion Dec.Glasgow coma score – scale for Dec.Glasgow coma score – scale for

evaluating the best motor, verbal and eye evaluating the best motor, verbal and eye opening response (score 3-15)opening response (score 3-15)

Changes in speechChanges in speech Pupillary reaction – dilation of pupil Pupillary reaction – dilation of pupil

ipsilateral to lesion, sluggish to respond to ipsilateral to lesion, sluggish to respond to lightlight

Clinical Manifestations Clinical Manifestations of ICPof ICP

BradycardiaBradycardia HAHA Vomiting – not preceded by nauseaVomiting – not preceded by nausea Double vision, ptosis of eyelid, Double vision, ptosis of eyelid,

inability to move eye upwardinability to move eye upward Vital Sign changes – Inc.systolic Vital Sign changes – Inc.systolic

pressure- widened pulse pressure pressure- widened pulse pressure SeizuresSeizures

SAH Survival Depends On … SAH Survival Depends On … Management of RebleedingManagement of Rebleeding Leading cause of death or morbidity Leading cause of death or morbidity

during the first 2 weeks after SAHduring the first 2 weeks after SAH Incidence: Incidence:

4-10% in 24 hours4-10% in 24 hours 15-25% in 2 weeks15-25% in 2 weeks 2-3% after 1 month for 10 years2-3% after 1 month for 10 years

Presents with sudden change in Presents with sudden change in neurological status, new headache and neurological status, new headache and coma. coma.

SAH Survival Depends On … SAH Survival Depends On … Management of Rebleeding Management of Rebleeding Aneurysmal ClippingAneurysmal Clipping Endovascular CoilingEndovascular Coiling Hematoma EvacuationHematoma Evacuation ProcoagulatantsProcoagulatants

Hematoma EvacuationHematoma Evacuation

Teaching PointsTeaching Points SAH is often misdiagnosed SAH is often misdiagnosed CT is sensitive but not fool-proof CT is sensitive but not fool-proof LP for patients with normal or equivocal LP for patients with normal or equivocal

CTCT Early angiography and IR/ Neurosurgery Early angiography and IR/ Neurosurgery

eval to facilitate interventioneval to facilitate intervention Treat to prevent multisystem and Treat to prevent multisystem and

neurological complications of SAH. neurological complications of SAH. Attend to the airway and BPAttend to the airway and BP Monitor and Control ICPMonitor and Control ICP Prevent Re-bleeding and VasospasmPrevent Re-bleeding and Vasospasm

Treatments for Cerebral Treatments for Cerebral AneurysmsAneurysms

Endovascular CoilingEndovascular Coiling

Surgical ClippingSurgical Clipping

Aneurysm TherapyAneurysm Therapy

Surgical clippingSurgical clipping (approximately 60-65% in (approximately 60-65% in the United States)the United States)

Endovascular coilingEndovascular coiling (approximately 30- (approximately 30-35% in the United States)35% in the United States)

In certain countries such as Finland, Great In certain countries such as Finland, Great Britain and France, close to 90% of Britain and France, close to 90% of aneurysms are treated with endovascular aneurysms are treated with endovascular coilingcoiling

After the release of the ISAT results, the After the release of the ISAT results, the percentage of aneurysm patients treated with percentage of aneurysm patients treated with coiling in England went from 40% to 90% coiling in England went from 40% to 90%

International Subarachnoid International Subarachnoid Aneurysm Trial (ISAT)Aneurysm Trial (ISAT) of of neurosurgical clipping neurosurgical clipping

versus endovascular coiling versus endovascular coiling in 2143 patients with in 2143 patients with ruptured intracranial ruptured intracranial

aneurysms: a randomized aneurysms: a randomized trialtrial

The LancetThe Lancet

Vol 360, October 26, 2002Vol 360, October 26, 2002

ISATISAT A recent large prospective study of 2143 A recent large prospective study of 2143

patients with ruptured aneurysms who patients with ruptured aneurysms who could equally be treated with clipping or could equally be treated with clipping or coiling had to be prematurely stopped short coiling had to be prematurely stopped short of planned enrollment of 2500 patients of planned enrollment of 2500 patients because the coiled patients suffered because the coiled patients suffered significantly less death and dependency as significantly less death and dependency as compared to clipped patients (6.9% compared to clipped patients (6.9% absolute difference, 22.6% relative absolute difference, 22.6% relative difference) and it would have been difference) and it would have been unethical to continue the study unethical to continue the study

ISAT StudyISAT Study Patients with ruptured Patients with ruptured

intracranial aneurysmsintracranial aneurysms Dependency or Death at 1 Dependency or Death at 1

yearyear Neurosurgical Clipping Neurosurgical Clipping

243/793 (30.6%)243/793 (30.6%) Endovascular Coiling 190/801 Endovascular Coiling 190/801

(23.7%)(23.7%)

Lancet. 2002;360(9342):1267-74

Aneurysm ClippingAneurysm Clipping

Done under general Done under general anesthesia through a anesthesia through a craniotomy (hole in craniotomy (hole in the head)the head)

The brain is gently The brain is gently retracted in order to retracted in order to gain visual access to gain visual access to the aneurysmthe aneurysm

A clip is placed at the A clip is placed at the neck of the aneurysmneck of the aneurysm

1 week in the hospital1 week in the hospital 1 month recovery1 month recovery

Right Cerebellar Right Cerebellar

AneurysmAneurysm

Surgical Clipping - Step 1: Surgical Clipping - Step 1:

Identify Vessels at RiskIdentify Vessels at Risk

Aneurysm

exposed &

PCA and SCA

are identified

as vessels at

risk.

Optic nerve

ICA

ACA

MCA

Oculo-motornerve

Aneurysm

Right Cerebellar AneurysmRight Cerebellar Aneurysm


Measure Baseline FlowsMeasure Baseline Flows

Baseline SCA & PCA flows are measured

SCA = 18 cc/minPCA = 36 cc/min

Basilar a

Flowprobe

SCA

PCA

Aneurysm


Surgical Clipping - Step 3: Clip Surgical Clipping - Step 3: Clip

and Re-measureand Re-measure

Positioning of Clip

Temporary Clip

Flow Integrity Checked

SCA = 2-4 cc/minPCA = 55-60 cc/min



Check Flow Integrity Post-ClipCheck Flow Integrity Post-Clip

Clip Repositioned

Clip Repositioned

Flow Integrity Checked

SCA = 16 cc/minPCA = 33 cc/min

Where is the aneurysm?Where is the aneurysm?

SAHSAH

Where is the aneurysm?Where is the aneurysm?

Surgical clipSurgical clip

BeforeBefore AfterAfter

ClipsClips

ANEURYSM ANEURYSM COILINGCOILING

A minimally invasive procedure usually A minimally invasive procedure usually performed under general anesthesia by an performed under general anesthesia by an interventional neuroradiologistinterventional neuroradiologist

A very small plastic tube (microcatheter) is A very small plastic tube (microcatheter) is threaded from the groin to the aneurysm in threaded from the groin to the aneurysm in the brain, and fine platinum threads (coils) the brain, and fine platinum threads (coils) are inserted into the aneurysm to fill it from are inserted into the aneurysm to fill it from the inside, much like filling a potholethe inside, much like filling a pothole

The catheter is then removed and the small The catheter is then removed and the small groin incision covered with a Band-Aidgroin incision covered with a Band-Aid

For an unruptured aneurysm, the patient is For an unruptured aneurysm, the patient is discharged home within 24 to 48 hours discharged home within 24 to 48 hours

The History of The History of CoilingCoiling

1987-19891987-1989: Dr. Guido : Dr. Guido Guglielmi (University of Guglielmi (University of Rome) visits Dr Viñuela Rome) visits Dr Viñuela (Interventional (Interventional Neuroradiologist) at UCLA Neuroradiologist) at UCLA and research work on coiling and research work on coiling concept startsconcept starts

1989: Dr Guglielmi comes 1989: Dr Guglielmi comes permanently to UCLApermanently to UCLA

1989-19901989-1990: Bench and animal : Bench and animal researchresearch

March 6, 1990March 6, 1990: First clinical : First clinical use of Guglielmi Detachable use of Guglielmi Detachable Coil Coil

FDA approval in 1995FDA approval in 1995

Imaging of the AneurysmImaging of the Aneurysm Non-invasive imaging (CT) has already been Non-invasive imaging (CT) has already been

done. The Physician probably has a good done. The Physician probably has a good idea where the aneurysm is located prior to idea where the aneurysm is located prior to angiography.angiography.

A diagnostic angiogram is performed and A diagnostic angiogram is performed and the aneurysm is localized.the aneurysm is localized.

A 3-D rotational spin can be performed A 3-D rotational spin can be performed while on the patient is still on the procedure while on the patient is still on the procedure table prior to coiling the aneurysm.table prior to coiling the aneurysm.

Rotational/3D AngiogramRotational/3D Angiogram


The above image can then be The above image can then be transferred to another computer transferred to another computer which will take the acquired images which will take the acquired images and information and transform it and information and transform it into a 3-D image, as pictured below.into a 3-D image, as pictured below.


Measurements of the aneurysms can Measurements of the aneurysms can be obtained from these 3-D images.be obtained from these 3-D images.

Procedure Set-UpProcedure Set-Up

As you will note, the beginning set-As you will note, the beginning set-up is the same for all interventional up is the same for all interventional cases.cases.

The following slides will review the The following slides will review the following:following: Pressure Bag Set-upPressure Bag Set-up Sheath or Guide Catheter positioningSheath or Guide Catheter positioning

Pressure Line Set-UpPressure Line Set-Up

Don’t Forget To Label Both Don’t Forget To Label Both Ends!Ends!

Tuohy-Borst AdapterTuohy-Borst Adapter

Three-Way StopcockThree-Way Stopcock

Before Screwing to Sheath Before Screwing to Sheath or Guide Catheter…or Guide Catheter…

Carefully FlushCarefully Flush Check for bubblesCheck for bubbles Hook to Pressure Bag LineHook to Pressure Bag Line Check and Re-Check for BubblesCheck and Re-Check for Bubbles

The Flow of things…the The Flow of things…the Pressure BagPressure Bag

Most times the pressure bags are Most times the pressure bags are even done ahead of time due to the even done ahead of time due to the non-invasive studies already done non-invasive studies already done prior to angiography.prior to angiography.

The Flow of things…The Flow of things…Placement of the Catheter, Placement of the Catheter,

Shuttle Sheath or Guide Shuttle Sheath or Guide CatheterCatheter Depending on the Physician and the situation, the Depending on the Physician and the situation, the

Physician may either leave the diagnostic catheter Physician may either leave the diagnostic catheter in place or exchange for either the Shuttle Sheath in place or exchange for either the Shuttle Sheath or Guide Cath.or Guide Cath.

If the diagnostic catheter is left in a If the diagnostic catheter is left in a microcathetermicrocatheter is selected and placed inside the diagnostic is selected and placed inside the diagnostic catheter.catheter.

If either a Guiding Catheter or Shuttle Sheath is If either a Guiding Catheter or Shuttle Sheath is chosen, they are placed in the Common Carotid chosen, they are placed in the Common Carotid and the diagnostic/microcatheter combo is and the diagnostic/microcatheter combo is reinserted after being properly flushed with saline.reinserted after being properly flushed with saline.

The Flow of Things…The The Flow of Things…The Shuttle SheathShuttle Sheath

The Shuttle Sheath is a The Shuttle Sheath is a

long (usually 90 cm) sheath long (usually 90 cm) sheath

used to engage the Commonused to engage the Common

Carotid artery.Carotid artery.

It provides stiffness andIt provides stiffness and

stability when coiling.stability when coiling.The Pressure Bag line is attached to the sideport of the Shuttle Sheath

MicroCathetersMicroCatheters This is one of several types of This is one of several types of

microcatheters (there are also microcatheters (there are also microwires used with the microwires used with the microcatheters).microcatheters).

They are ideally positioned directly They are ideally positioned directly within the aneurysm sac where the within the aneurysm sac where the coils will be delivered.coils will be delivered.

Roadmapping and Steering Roadmapping and Steering of Coaxial Systemof Coaxial System

Use of Bi-plane fluoroscopyUse of Bi-plane fluoroscopy Use of Roadmapping feature may be Use of Roadmapping feature may be

helpfulhelpful Advance system carefully Advance system carefully

(Intracranial arteries are thinner than (Intracranial arteries are thinner than peripheral arteries- less media and peripheral arteries- less media and adventitia)adventitia)

Hand injections should be done Hand injections should be done carefully so as not to rupture any carefully so as not to rupture any perforators.perforators.

Roadmap During CoilingRoadmap During Coiling

The Flow of Things…The Flow of Things…Aneurysm CoilingAneurysm Coiling

Once the aneurysm is identified and Once the aneurysm is identified and analyzed,the microcatheter is placed analyzed,the microcatheter is placed within the aneurysm and the coiling within the aneurysm and the coiling process is started.process is started.

Follow-up DSA runs are periodically Follow-up DSA runs are periodically acquired to check the progression of acquired to check the progression of the coilingthe coiling

The Coiling ProcessThe Coiling Process

The Flow of Things…The Flow of Things…Aneurysm CoilingAneurysm Coiling

The coiling process will probably last for The coiling process will probably last for several hours, so one thing to consider, several hours, so one thing to consider, does the patient have or require a Foley does the patient have or require a Foley catheter?catheter?

Another note about the drugs. During Another note about the drugs. During the coiling process, it’s a good idea to the coiling process, it’s a good idea to have Protamine Sulfate readily available have Protamine Sulfate readily available in case of aneurysm perforation and the in case of aneurysm perforation and the need to reverse Heparin.need to reverse Heparin.

GDC Coil Detachment GDC Coil Detachment DeviceDevice

Cable AttachmentCable Attachment

Black and Red Cablesare placed in the corresponding holes of thedetachment mechanism

Coil PreparationCoil Preparation

An Aneurysm Coiling Seen An Aneurysm Coiling Seen Step-By-StepStep-By-Step

The next several slides will The next several slides will demonstrate an Aneurysm Coiling demonstrate an Aneurysm Coiling step-by-step.step-by-step.

SAHSAH

Rupture of an Rupture of an aneurysm at the tip of aneurysm at the tip of the basilar arterythe basilar artery

Tip of Ventriculostomy

beforebefore afterafter

Pros and Cons of CoilingPros and Cons of Coiling

PROSPROS

Minimally invasive Minimally invasive Short recoveryShort recovery Safer than surgerySafer than surgery Cheaper than Cheaper than

surgery surgery

CONSCONS

Shorter track Shorter track record record

Possibly less Possibly less durabledurable

Requirement for Requirement for follow-up follow-up angiography angiography

The FutureThe Future

Increased percentage of patients treated with Increased percentage of patients treated with coiling, in large volume referral centerscoiling, in large volume referral centers

Use of adjunctive maneuvers increases the Use of adjunctive maneuvers increases the percentage of aneurysms treatable with percentage of aneurysms treatable with endovascular techniquesendovascular techniques

Increased efficacy of coiling therapy (new, Increased efficacy of coiling therapy (new, bioactive materials, tissue healing strategies) bioactive materials, tissue healing strategies)

Development of non-invasive follow-up techniques Development of non-invasive follow-up techniques with CT or MR scanningwith CT or MR scanning

Better educated population will actually demand Better educated population will actually demand availability and discussion of both endovascular availability and discussion of both endovascular coiling and surgical clipping optionscoiling and surgical clipping options

What about Aneurysms with What about Aneurysms with Wide Necks?Wide Necks?

Aneurysms with wide necks must be Aneurysms with wide necks must be treated in a slightly different manner.treated in a slightly different manner.

The use of a Neuroform stent or some The use of a Neuroform stent or some similarsimilar

stent must first be placed across the stent must first be placed across the base or neck of the aneurysm. This is base or neck of the aneurysm. This is done so that the coils will remain done so that the coils will remain within the aneurysm sac.within the aneurysm sac.

Wide neck mid basilar aneurysm

Stent + CoilStent + Coil

Wide-Neck Aneurysm Wide-Neck Aneurysm Coiling with Stent Coiling with Stent

AssistanceAssistance

Stent + coils

Balloon RemodelingBalloon Remodeling

Balloon remodeling is the use of a Balloon remodeling is the use of a balloon while placing coils within the balloon while placing coils within the aneurysm.aneurysm.

The balloon is inflated while the coil The balloon is inflated while the coil is placed and then deflated once coil is placed and then deflated once coil is in place.is in place.

Onyx is another possible Onyx is another possible choice to treat aneurysmschoice to treat aneurysms

Take Home PointsTake Home Points

The ISAT study recently demonstrated The ISAT study recently demonstrated a substantially better clinical outcome a substantially better clinical outcome (22.6% less death and dependency (22.6% less death and dependency relative difference, 6.9% absolute relative difference, 6.9% absolute difference) in patients with ruptured difference) in patients with ruptured aneurysms treated with endovascular aneurysms treated with endovascular coiling compared to patients treated coiling compared to patients treated with surgical clipping with surgical clipping

Take Home PointsTake Home Points

All patients with aneurysms should be All patients with aneurysms should be informed of the availability of both informed of the availability of both endovascular coiling and surgical endovascular coiling and surgical clipping by a neurosurgeon and an clipping by a neurosurgeon and an interventional neuroradiologistinterventional neuroradiologist

The death and complication rate for The death and complication rate for aneurysm therapy is dramatically aneurysm therapy is dramatically reduced in high volume centers that reduced in high volume centers that offer both surgical clipping and offer both surgical clipping and endovascular coiling endovascular coiling

Information and LinksInformation and Links

American Society of Interventional andAmerican Society of Interventional andTherapeutic Neuroradiology (Therapeutic Neuroradiology (ASITNASITN))

http://www.asitn.org/

Homework AssignmentsHomework Assignments

Read Chapter 16 (pp. 311-347)and Read Chapter 16 (pp. 311-347)and Chapter 25 (pp. 467-481)Chapter 25 (pp. 467-481)

ReferencesReferences

Morris, P.P. Morris, P.P. Practical NeuroradiographyPractical Neuroradiography, 2nd , 2nd Edition, 2007Edition, 2007

Osborn, A.G. Osborn, A.G. Handbook of NeuroradiologyHandbook of Neuroradiology, 2, 2ndnd Edition, 1999Edition, 1999

Bontrager, K.L. Bontrager, K.L. TEXTBOOK of Radiographic TEXTBOOK of Radiographic Positioning and Related AnatomyPositioning and Related Anatomy , 5 , 5thth Edition, Edition, 20012001

Snopek, A.M Snopek, A.M Fundamentals of Special Fundamentals of Special Radiographic ProceduresRadiographic Procedures, 5, 5thth Edition, 2006 Edition, 2006

Tortorici, M.R. Tortorici, M.R. Fundamentals of AngiographyFundamentals of Angiography, , 19821982

Various other Internet sourcesVarious other Internet sources

week 8- aneurysms, sah, dissections and arteritis

Documents

aneurysm coiling

aneurysm results

necked aneurysm

cerebral aneurysms

population aneurysms

aneurysm facts factors

different types of aneurysm

marfan syndrome slide