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Cerebral aneurysms 2010-2012

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A Michigan SIR presentation on Cerebral Aneurysms by Saud Ahmed.

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Cerebral aneurysms 2010-2012

  1. 1. Cerebral Aneurysm & Treatment Saud Ahmed, MD
  2. 2. Overview •Anatomy –Internal Carotid Arteries –Vertebrobasilar Arteries •Pathology –Aneurysm •Treatment –Coiling
  3. 3. Circle of Willis
  4. 4. Homunculus
  5. 5. Cerebral Arteries • ACA –Weakness & Sensory Loss • Contralateral Leg and Arm • Spares face • Incontinence • MCA – MCA syndrome • Contralateral Face and Arm • Dominant lobe -> Broca and Wernicke Aphasia • Non Dominant lobe -> Neglect • Homonymous hemianopsia (contralateral) • Deviation Conjegee • PCA – Visual defect – Contralateral Pain/Temperature – Effects facial nerve, occulomotor (ipsilateral) – Horner’s Syndrome
  6. 6. Intracranial ICA Ophthalmic a. ICA MCA Pcom a. ACA
  7. 7. Intracranial ICA ICA Ophthalmic a. MCA ACA PCom a.
  8. 8. Intracranial ICA ICA MCA Ophthalmic a. ACA
  9. 9. Intracranial ICA ICA Ophthalmic a. ACA MCA
  10. 10. Vertebrobasilar Arteries
  11. 11. Vertebrobasilar Arteries Vertebral a. SCA PICA Basilar a. AICA PCA
  12. 12. Vertebrobasilar Arteries PICA Vertebral a. Basilar a. AICA SCA PCA
  13. 13. Aneurysm •Bulge in the vascular wall • Involves all three layers • Intima • Media • Adventitia
  14. 14. Aneurysm •Epidemiology –5% lifetime risk of development –Age • 55 years –75% risk of rupture  Subarachnoid Hemorrhage • 1 in 10,000 people a year
  15. 15. Aneurysm • Risks –ADPKD –Marfan’s –Diabetes –Obesity –Hypertension –Copper Deficiency
  16. 16. Aneurysm •Locations –Anterior Circulation – 90% • Anterior Communication Artery –Most common • Posterior Communication Artery • Middle Cerebral Artery –Posterior Circulation – 10%
  17. 17. Aneurysm • Size Classifications –Small •Less than 15mm –Large •15 – 25mm –Giant •25 – 50 mm –Super Giant •Greater than 50mm
  18. 18. Aneurysm •Shape Classifications –Saccular a.k.a. berry –Fusiform
  19. 19. Aneurysm
  20. 20. Aneurysm
  21. 21. Aneurysm •RUPTURE!! –Risk increases as size increases –Leads to subarachnoid hemorrhage –Also stroke and vasospams
  22. 22. Subarachnoid Hemorrhage •Symptoms (Hunt & Hess Scale) –Grade 1: Asymptomatic, mild headache, slight nuchal rigidity –Grade 2: Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy –Grade 3: Drowsiness / confusion, mild focal neurologic deficit –Grade 4: Stupor, moderate-severe hemiparesis –Grade 5: Coma, decerebrate posturing –Grade 6: Death
  23. 23. Subarachnoid Hemorrhage
  24. 24. Subarachnoid Hemorrhage
  25. 25. Subarachnoid Hemorrhage •CT Appearance –Grade 1: No hemorrhage –Grade 2: Less than 1 mm thick. –Grade 3: Greater than 1 mm thick. –Grade 4: Any thickness with intra-ventricular hemorrhage or parenchymal extension.
  26. 26. Treatment • Medical –Stabilize patient –Reduce intracranial pressure • Invasive –Aneurysmal clipping • Interventional –Aneurysmal coiling
  27. 27. Treatment • Coils –Invented in 1991 by Guido Guglielmi –Material • Platinum based • Hydrocoil –Types • Simple Coils • Guglielmi Detachable Coil (GDC)
  28. 28. Treatment • Technique –Access femoral artery –Insert a sheath –Catheter is place via the sheath • Obtain roadmap –Microwire and Microcatheter • Selective access of vessels –Coils • Deployment • Detachment
  29. 29. Treatment Video from Terumo
  30. 30. Treatment • Complications – Dissection –Perforating vessel – Dislodge plaque and clot formation – Coil prolapse
  31. 31. Treatment • International Subarachnoid Hemorrhage Trial –Since 1995 –Comparison with clipping: • Lower mortality • Shorter recovery period • Higher risk of reoccurrence • Risks of clipping previously coiled aneurysm high
  32. 32. Follow Up • Regular imaging via CTA, MRA or angiography – Assess for reoccurrence • If reoccurrence seen –Repeat coiling – Clipping
  33. 33. Case • 55 year old female with altered mental status
  34. 34. Case
  35. 35. Case
  36. 36. Case
  37. 37. Case
  38. 38. Case
  39. 39. Case
  40. 40. Case
  41. 41. Case
  42. 42. Case
  43. 43. Case
  44. 44. Case
  45. 45. Case
  46. 46. References • Raja PV, Huang J, Germanwala AV, Gailloud P, Murphy KP, Tamargo RJ. Microsurgical clipping and endovascular coiling of intracranial aneurysms: A critical review of the literature. Neurosurgery 62: 1187-1202, June 2008 • Piotin, M; Spelle, L, Mounayer, C, Salles-Rezende, MT, Giansante-Abud, D, Vanzin-Santos, R, Moret, J (May 2007). "Intracranial aneurysms: treatment with bare platinum coils—aneurysm packing, complex coils, and angiographic recurrence.". Radiology 243 (2): 500–8. • Campi, A; Ramzi N, Molyneaux AJ, Summers, PE, Kerr, RS, Sneade, M, Yarnold, JA, Rischmiller, J, Byrne, JV (May 2007). "Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT).". Stroke 38 (5): 1538–44

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