2. • A brain aneurysm (also called a cerebral aneurysm or
intracranial aneurysm) is a bulging, weakened area in the
wall of an artery in the brain, resulting in an abnormal
widening, ballooning, or bleb. Because there is a
weakened spot in the aneurysm wall, there is a risk for
rupture (bursting)of the aneurysm.
3.
4. Behavioral:
– Hypertension
– Smoking
– Alcohol abuse
– Sympathomimetic drugs such as cocaine and meth
Family History
Gender and Race
– 1.24 X more likely in women
– Rate slightly higher in African Americans
and Hispanics compared to Caucasians
5. • Genetic Syndromes
– Autosomal Dominant Polycystic Kidney Disease
– Type IV Ehlers Danlos Syndrome
• Aneurysm Morphology
– Larger aneurysm size
– Bottleneck morphology
– Increased ratio of size of
aneurysm to parent vessel
6. • Peak age for aneurysm rupture is 55-60 years.
• Estimated 10-50% of patients may have sentinel
hemorrhage resulting in warning headache prior
to major rupture.
• May be accompanied by intraparenchymal
hemorrhage (20-40%), intraventricular
hemorrhage (13-28%), or subdural hemorrhage
(2-5%).
• Seizures may occur in up to 20% of patients,
usually within the first 24 hours of rupture.
7. • Headaches occur in 97% of cases.
– “Thunderclap” headache – often
described as the
“worst headache of my life”
– Associated with vomiting in 50%.
9. • Diagnose SAH:
– Non contrast high resolution CT
– If CT is negative, may consider MRI
scan or a lumbar puncture in suspicious
cases to look for xanthochromia.
• Diagnose source of SAH:
– CTA, MRA, angiography
12. • The Modified Fisher Scale is used to quantify the
severity of hemorrhage on radiographic imaging.
• The higher the score, the higher the
potential risk of vasospasm
17. • Ideal blood pressure is controversial
• Typically, we recommend < 120-140 until
the aneurysm has been secured to
reduce the risk of rebleeding.
• After the aneurysm is secured, it is okay
to allow passive hypertension to assist
with perfusion.
18. • 10-15% of patients die before reaching
medical care.
• Mortality rate is 10% within the first few days.
• 30-day mortality rate is 46-50%.
– 25% die as a result of medical complication
– 8% die from progressive deterioration from the initial
hemorrhage
• About 30% of survivors have moderate to
severe disability.
• Patients over 70 years of age fare worse for
each neurological grade.
• The severity of clinical presentation is the
strongest prognostic factor.
21. • Rebleeding is the major cause of morbidity and
mortality
• Risk is 15-20% within two weeks without
treatment.
– 4% risk on day 1 and 1.5% risk daily for 13 days.
– 50% risk of rebleed within six months
– 3% risk per year
• The goal of early intervention is to reduce the risk
of repeat hemorrhage!
• May consider use of tranexamic acid (TXA) 1000
mg Q6H following rupture until secured (not to
exceed 72 hours).
28. • Factors that favor surgical clipping
– Younger age (lower risk of surgery, lower
lifetime risk of recurrence)
– Aneurysm location (i.e. MCA bifurcation)
– Small blister aneurysms
– Symptoms due to mass effect from
aneurysm dome.
– Wide aneurysm neck
– Patients with residual filling despite coil
embolization
29. Cerebral arteriovenous malformations
(cAVMs) are the vascular abnormality
composed of a complex, tangled web of
afferent arteries and draining veins linked by
an abnormal dysplastic intervening capillary
bed or no capillary bed
30. Cerebral arteriovenous malformations are rare, found in
around 0.1% of the population and one-tenth (1/10th) of
the incidence of the brain aneurysms.
About 15% of cAVMs remain asymptomatic based on
autopsy series.
The majority (90%) of cAVMs are found in the
supratentorial region, the remaining 10% occur in the
posterior fossa.
cAVMs commonly occur as single lesions, and in 9% of
the patients, there are multiple AVMs.
cAVM has no gender preference.
cAVM causes subarachnoid hemorrhages in 9% of the
patients.
The mean age of presentation is 30–40 years;
3% of young patients had stroke due to cAVM.
It also causes primary intracerebral hemorrhage in 33%
31. Luessenhop-Gennarelli anatomical grading This is the anatomical
grading of supratentorial cAVM described in 1977, according to the
degrees of surgical difficulty for total obliteration, graded into I–IV.
Luessenhop-Gennarelli grading of cAVM is based upon the number
of directly participating arteries for which there is a standardized
nomenclature
