Management of SAH- What is working for us?

1. MANAGEMENT OF SAH:
WHAT IS WORKING FOR ME (US)
Vipul Gupta
Interventional Neuroradiology/
Neurointerventional Surgery
Institute of Neurosciences
Medanta the Medicity

2. SAH…
 We work as part of neurosurgery
 Common ICU rounds and counseling
 Ward rounds separate
 OPD in neurosciences area
 On pay, group practice
 Stroke and neurovascular reporting
done by us
 Called – neurointerventional Surgery
(Interventional Neuroradiology)

3.  SAH reports to emergency,
 Neurosurgery on call and NI on call
 At night NS on call
 Co-admission – NI and NS , even directly
referred ones
 Standard medications
 ICU admission, Neuro-critical care review ,
PAC
 Detailed counseling by NI team about course
of management
 Repeat NCCT if needed

4. Aneurysmal management
 Planned for DSA with 3D , If late evening,
then for next day (90% within 24 hours)
 Repeat bleed – early
 Hematoma – CTA/DSA and surgery
 Neurointerventional Lab
 Regular angiogram – 2D based on 3D
 Family counselled, clearence
 Coiling if possible in same session

5. Aneurysmal management
 General anesthesia
 3000IU of heparin
 Long sheath in all
 Guiding as high as possible (DAC)
 DAC – co-axial
 NTG before guiding placement
 First coil – another 1500-2000 IU heparin
bolus

9.  large-/giant aneurysms

10. Aneurysmal management
 Balloon (more and more) – Sceptre,
Transform , Synchro wire – double curve
 Echelon , SL 10
 First coil – balloon deflated and check
 Thereafter – longer inflations
 All coils –Target, Microplex, G2, Axium, Orbit

11. Aneurysmal management
 Tight packing is the key – frequently 1.5 mm
as last coil
 Increasing heaprinization – ACT >250, in
broad neck > 300
 MC removal with wire
 AP & lat runs
 DynaCT
 Repeat run in working projection – for 20 min
after the removal of catheter

12. Very small berry
aneurysms

14. Aneurysmal management
 Very careful shaping
 Mostly straight tip in ACOM,DACA, MCA,
Basilar top, (ophthalmic, blister)
 Reverse curve in poster-superiorACOMs
 Double curve – sup hypohsyeal, PCOM, ICA
bifrucation
 Most > 90% we donot wire the aneurysm
(ophthalmic, sup hypopsheal, ICA bifurcation)

15. DYSPLASTIC BIFURCATION ANEURYSMS

16. Flow diverters (stents)-
Giant/large aneurysms

18. Fusiform dissecting aneurysms

20. 38 yr old male patient, 2-day old SAH
Known hypertensive
Clinically grade II
Small Blister/dissecting
Friable, continued growth, re-rupture

22. F
A

23. Clot formation
 Look for fuzziness
 Increase heaprinization – ACT 350 sec
 Reopro – 10 mg over 10 min intra-arterial
through microcatheter
 Post – Heparin, followed by aspirin
 If coil – heparin +/- anti-platelet

25. Immediate
5 min 8 min-Reopro
25 min Post
reopro 7 mg
35 min Post
reopro 10 mg
Post reopro 10
mg- after 50
min

26. Aneurysmal management
 Extubation on table
 Delayed extubation – significant filling, poor
grade, difficult airway etc
 Discharge 10-days
 Grade I/II earlier
 Advised to say nearby
 Follow-up DSA – 6-months
 Partially coiled/dissecting/blister – earlier

29. Preventive
 Oral nimodipine
 Hydration
Strict monitoring
 Clinical,TCD, CTP
 Training staff, relatives, direct calls
Therapeutic - “It is stroke”
 HHH therapy (bridging)
 IV Milrinone
 IA Nimodipine and IA Milrinone
 Continuous Intra-arterial dilatations
Our ProtocolVasospasm

30. 1 ampoule of
milrinone (10 mg)
Dissolve it in
40ml of saline(
total volume 50
ml)
Start at rate of 9ml
/hour and can
increase up to 22
ml/hour
Dose Simplified

31. Our IAVD approach..
• We do as soon as possible – like acute stroke
• HHH – bridging therapy
• Local anesthesia
• Anesthesia cover
• Diagnostic catheter
• 3 mg of nimodipine
• Followed by 6-8 mg of Milrinone
• Duration as important as amount
• Followed by HHH and IV milrinone
• High rate of angiographic success (90%)

32. Vasospasm- 15-25% morbidity and mortality

34.  28 y.o female
 SAH 1 day
 H & H Grade II

35. Day 6 Confused, weak
on right side
CBF CBV MTT
CTP
• Poor grade
• Existing hemiparesis
• Early or delayed

37. When nothing works

38. Day
5
Post
Nimod
ipine

39. Day 7
Continuous intra-arterial dilatation
Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic
Vasospasm After Subarachnoid Hemorrhage
Musahl, Christian; Henkes, Hans; Vajda, Zsolt; Neurosurgery. 68(6):1541-1547, June 2011.

41. 20 mg milrinone 20 mg nimodipine
Start at rate of 50
ml/hour can be
increased to 100 ml/
hour
1000ml saline

42. Day 11

43. Most probably partially thrombosed
Will need stent…. Will recur
Referred for surgery

44. Patient not agreeing for follow-up and re-treatment

48. Embolization
Surgery
95%
5%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 87.6 % mRS 0-2

49. Conclusion
 Integrated team with NS – clinically and
financially
 Dedicated team
 Neurovascular center approach
 Clinical responsibility
 Management outcome approach
 Aggressive vasospasm management
 Awareness programs, direct referrals

56. B/L MCA aneurysms

57. Most probably partially thrombosed
Will need stent…. Will recur

58. Dysplastic bifurcation aneurysms
- Needing complicated stenting
- Partially thrombosed

60. “COMPLEX” ANEURYSMS
•Giant aneurysms
• Dissecting fusiform
•Blister aneurysms
•Aneurysms with near the neck rupture/lobules
•Dysplastic bifurcation aneurysms
•Aneurysm with artery from the sac
May be..
• Aneurysm with vasospasm
•Aneurysm with tortuosity
•Small aneurysms
•Multilobulated aneurysms
•Aneurysm with thrombus

61. Giant/large aneurysms
 Stent-assisted coiling – safe,
follow-up and possible repeat
treatment
 Flow diverters - evolving,
paraclinoidal aneurysms, ?risk
 (Parent vessel occlusion – may
be the ideal treatment for
cavernous aneurysms)

62. Flow diverters (stents)-

64. 38 yr old male patient, 2-day old SAH
Known hypertensive
Clinically grade II
Small Blister/dissecting
Friable, continued growth,
re-rupture

65. Classical blister aneurysm

66. F
A

67. Very small berry
aneurysms

71. Complex aneurysms…
 Important to recognize and analyze (3D)
 Comfortable with all approaches and
techniques
 Strategy with back-up plan
 Better outcomes in high volume centres
with expertise, technology (Biplane) and
teamwork
 Vascular Neurosurgery co-ordination

72. Issue- stent thrombosis on
pasugrel ? too much metal,
flow change opening;
control- ???, ? staged

73. Large – giant aneurysms ISUIA Trial

74. Flow diverters (stents)-

77. Giant
fusiform, no
collateral,
mass effect

78. Thrombosed after a week
Decompression
Independent, mild UL weakness

79. Giant/large aneurysms
 Stent-assisted coiling – safe,
follow-up and possible repeat
treatment
 Flow diverters - evolving,
paraclinoidal aneurysms, ?risk
 (Parent vessel occlusion – may be
the ideal treatment for
cavernous aneurysms)
 Fusiform giant ICA with no
collaterals– need bypass

80. Fusiform dissecting aneurysm…

85. 56 yr old,
ischaemic
stroke

87. Fusiform-dissecting aneurysms & blister
aneurysms
Extremely difficult to treat
 Overlapping stents with coils as much as
possible to buy time/promote thrombosis
 Continued growth common- early check
 Flow diverter
 However ,
 Distal fusiform dissecting aneurysms..
 Stent/FD not possible --- bypass/surgical
reconstruction..

88. Small Blister/dissecting
Friable, continued growth, re-
rupture

89. F
A

90. Very small berry
aneurysms

92.  Near the neck rupture

93. Catheter reposition

94. 1-mm
coil

95. A B C
DYSPLASTIC BIFURCATION ANEURYSMS

98. Hemtoma –
not conscious
Hematoma ….
M6

101. Thank you

102. For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
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Dr Vipul Gupta