This document summarizes endovascular treatment options for large and giant cerebral aneurysms 15mm or larger. It discusses techniques like parent vessel occlusion with coils or balloons, selective coil occlusion with or without supporting devices, and occlusion with Onyx. Factors like aneurysm location, size, and anatomy determine the best approach. Internal carotid artery occlusion is commonly used for cavernous aneurysms. Vertebral and basilar trunk aneurysms can now often be treated with selective coiling and stenting rather than parent vessel occlusion. Bypass surgery is rarely needed preceding endovascular parent vessel occlusion.
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis. The document discusses the indications for and procedures involved in carotid revascularization. It summarizes several key studies comparing stenting to endarterectomy. For symptomatic patients, stenting was found to be non-inferior to surgery with the risk of stroke or death below 6%. Recent advances discussed include new embolic protection devices, stent designs like double layer mesh stents, and the transradial approach to reduce manipulation of complex aortic arches. Overall the document provides an overview of carotid stenting procedures and updates on recent technology improvements aimed at reducing risks.
This document discusses complications of diagnostic and therapeutic cerebral angiography procedures and their management. Some key points:
- Neurological complications like ischemic stroke are most common, caused by thrombosis, embolization, or vessel disruption. Transient global amnesia and cortical blindness can also occur.
- Risk factors for complications include age over 70, referral for stroke/TIA, extensive vessel disease, long/complex procedures, multiple catheters, hypertension, renal impairment, or recent surgery.
- Treatment depends on the complication but may include thrombolysis, hyperbaric oxygen, induced hypertension, lidocaine/nicardipine for vasospasm. Recognition and use of available treatments is important for air e
This document discusses various factors that contribute to lesion complexity in coronary arteries, which can impact outcomes of percutaneous coronary intervention (PCI). It describes several scoring systems that classify lesions based on characteristics like vessel patency, morphology, length, location, calcification, and thrombus presence. Specific lesion features discussed in detail include ostial and angulated lesions, bifurcations, degenerated saphenous vein grafts, calcification, thrombus, total occlusions, and the coronary collateral circulation. Assessing these complexity factors can help identify risks for procedural complications and recurrent events.
Transeptal access is an integral skill for interventional cardiologists for a multitude of cardiac interventions including,
balloon mitral valvotomy a commonly performed procedure
in India and south Asia. The procedure was first performed by
Braunwald, Ross and Morrow and later refined by Brockenbrough
and Mullins, whose names have been intricately
linked with this procedure.1e3 The procedure, however,
evokes considerable trepidation in many young interventionalists due its steep learning curve and potential catastrophic complications. However, the procedure is relatively
simple in most patients, barring patients with extremely distorted
anatomy like aneursymally dilated left/right atria
where the anatomy of the interatrial septum is often grossly
altered.
Stereotactic radiosurgery in arterio venous malformationsumesh V
Stereotactic radiosurgery (SRS) is an effective treatment for arteriovenous malformations (AVMs). SRS precisely delivers high doses of radiation to the AVM nidus, resulting in progressive occlusion of vessels within 1-3 years. Obliteration rates after SRS range from 35-92%, with higher rates for smaller AVMs receiving higher radiation doses. Careful targeting of the AVM nidus using fusion of imaging modalities is important for treatment planning. Long-term follow up with MRI is needed to monitor for obliteration and potential radiation-related effects.
This document discusses basilar tip aneurysms. It begins with an introduction on the causes and presentation of intracranial aneurysms, noting that basilar tip aneurysms make up about 15% of cases. It then covers the epidemiology, risk factors, clinical presentation, evaluation, and management options for basilar tip aneurysms. Surgical approaches like the subtemporal approach are described in detail. Clipping and coiling are discussed as specific management options.
cerebral aneurysm mohammad abu sad (1).pptxMohamadAbusaad
This document discusses cerebral aneurysms, including their anatomy, types, causes, presentation, diagnosis, and management. It describes the three main types of aneurysms - saccular, fusiform, and dissecting. Risk factors for rupture include size, shape, location, and multiple aneurysms. Diagnosis is typically made using CT, CTA, MRI/MRA, or DSA imaging. Management involves stabilizing patients and then treating aneurysms either surgically via clipping or endovascularly via coiling to prevent rebleeding. Endovascular coiling is now the preferred initial approach for many aneurysms.
This document summarizes endovascular treatment options for large and giant cerebral aneurysms 15mm or larger. It discusses techniques like parent vessel occlusion with coils or balloons, selective coil occlusion with or without supporting devices, and occlusion with Onyx. Factors like aneurysm location, size, and anatomy determine the best approach. Internal carotid artery occlusion is commonly used for cavernous aneurysms. Vertebral and basilar trunk aneurysms can now often be treated with selective coiling and stenting rather than parent vessel occlusion. Bypass surgery is rarely needed preceding endovascular parent vessel occlusion.
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis. The document discusses the indications for and procedures involved in carotid revascularization. It summarizes several key studies comparing stenting to endarterectomy. For symptomatic patients, stenting was found to be non-inferior to surgery with the risk of stroke or death below 6%. Recent advances discussed include new embolic protection devices, stent designs like double layer mesh stents, and the transradial approach to reduce manipulation of complex aortic arches. Overall the document provides an overview of carotid stenting procedures and updates on recent technology improvements aimed at reducing risks.
This document discusses complications of diagnostic and therapeutic cerebral angiography procedures and their management. Some key points:
- Neurological complications like ischemic stroke are most common, caused by thrombosis, embolization, or vessel disruption. Transient global amnesia and cortical blindness can also occur.
- Risk factors for complications include age over 70, referral for stroke/TIA, extensive vessel disease, long/complex procedures, multiple catheters, hypertension, renal impairment, or recent surgery.
- Treatment depends on the complication but may include thrombolysis, hyperbaric oxygen, induced hypertension, lidocaine/nicardipine for vasospasm. Recognition and use of available treatments is important for air e
This document discusses various factors that contribute to lesion complexity in coronary arteries, which can impact outcomes of percutaneous coronary intervention (PCI). It describes several scoring systems that classify lesions based on characteristics like vessel patency, morphology, length, location, calcification, and thrombus presence. Specific lesion features discussed in detail include ostial and angulated lesions, bifurcations, degenerated saphenous vein grafts, calcification, thrombus, total occlusions, and the coronary collateral circulation. Assessing these complexity factors can help identify risks for procedural complications and recurrent events.
Transeptal access is an integral skill for interventional cardiologists for a multitude of cardiac interventions including,
balloon mitral valvotomy a commonly performed procedure
in India and south Asia. The procedure was first performed by
Braunwald, Ross and Morrow and later refined by Brockenbrough
and Mullins, whose names have been intricately
linked with this procedure.1e3 The procedure, however,
evokes considerable trepidation in many young interventionalists due its steep learning curve and potential catastrophic complications. However, the procedure is relatively
simple in most patients, barring patients with extremely distorted
anatomy like aneursymally dilated left/right atria
where the anatomy of the interatrial septum is often grossly
altered.
Stereotactic radiosurgery in arterio venous malformationsumesh V
Stereotactic radiosurgery (SRS) is an effective treatment for arteriovenous malformations (AVMs). SRS precisely delivers high doses of radiation to the AVM nidus, resulting in progressive occlusion of vessels within 1-3 years. Obliteration rates after SRS range from 35-92%, with higher rates for smaller AVMs receiving higher radiation doses. Careful targeting of the AVM nidus using fusion of imaging modalities is important for treatment planning. Long-term follow up with MRI is needed to monitor for obliteration and potential radiation-related effects.
This document discusses basilar tip aneurysms. It begins with an introduction on the causes and presentation of intracranial aneurysms, noting that basilar tip aneurysms make up about 15% of cases. It then covers the epidemiology, risk factors, clinical presentation, evaluation, and management options for basilar tip aneurysms. Surgical approaches like the subtemporal approach are described in detail. Clipping and coiling are discussed as specific management options.
cerebral aneurysm mohammad abu sad (1).pptxMohamadAbusaad
This document discusses cerebral aneurysms, including their anatomy, types, causes, presentation, diagnosis, and management. It describes the three main types of aneurysms - saccular, fusiform, and dissecting. Risk factors for rupture include size, shape, location, and multiple aneurysms. Diagnosis is typically made using CT, CTA, MRI/MRA, or DSA imaging. Management involves stabilizing patients and then treating aneurysms either surgically via clipping or endovascularly via coiling to prevent rebleeding. Endovascular coiling is now the preferred initial approach for many aneurysms.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
1) Prosthetic heart valve thrombosis can occur with both mechanical and biological valves and is influenced by surface factors, hemodynamic factors, and hypercoagulability.
2) Clinical presentation may include heart failure symptoms or embolic events, and imaging with TEE is the standard for evaluation.
3) Treatment depends on severity of symptoms and includes anticoagulation, fibrinolytic therapy, or emergency surgery for severe cases.
Coronary aneurysm: At a glance and Management.pptxabhishek tiwari
This document discusses coronary artery aneurysms (CAAs). It defines a CAA as a dilatation of the coronary artery exceeding 50% of the reference vessel diameter. CAAs can be classified based on their morphology, vessel wall composition, and the vessels affected. Common risk factors include atherosclerosis, vasculitis, and intracoronary manipulation. CAAs are often asymptomatic but can occasionally cause symptoms. Diagnosis is typically via coronary angiography. Management involves medical therapy, percutaneous interventions such as stenting, or surgery, with challenges that include proper sizing and coverage of aneurysmal segments.
intracranial vascular bypass is done to maintain blood flow to region of interest. this slideshow entails the indications, various categories, types as per flow, their advantages and disadvantages
This document discusses interventions for saphenous vein graft (SVG) disease. It covers the natural course of SVG pathology over time, techniques for SVG interventions like thrombectomy and stenting, and complications. Distal protection devices can reduce complications by preventing embolic debris from distal vessel occlusion during interventions. Proximal occlusion devices provide embolic protection by occluding inflow before any wires or devices cross the lesion. Filter wires are frequently applicable alternatives to occlusive distal protection with advantages of maintaining blood flow.
bleeding in pancreatitis and its management.pptxmohitdocjain
This document discusses bleeding complications in pancreatitis, which occur in 1.2-14.5% of cases and can be fatal if untreated, with a mortality rate of up to 52.4%. Bleeding can result from local inflammation and necrosis damaging blood vessels, abscesses weakening vessel walls, pseudocyst compression, or splenic vein thrombosis. Angiography is used to diagnose arterial pseudoaneurysms or extravasation. Endovascular embolization with coils or glues is the primary treatment, while surgery may be needed for venous bleeding or if embolization fails. Prompt diagnosis and management of bleeding are critical to prevent fatal outcomes.
Aneurysms of Visceral arteries, Splenic Artery Aneurysm in Childbearing.KHALID ALRAJHI
Splenic Artery Aneurysm is one of the vascular anomalies of visceral arteries.
Her's seminar of visceral artery aneurysms, and in pregnancy period.
Visceral aneurysms are clinically important that affect population and health socio-economical systems.
- Introduction
- Definition
- Classifications
- Causes
- Risk Factors
- Symptoms
- Diagnosis
- Management
- Endovascular Surgery
- Case Presentation
Mechanical complications Post AMI and the role of CABG.pptxNora Albogami
Mechanical complications such as ventricular septal rupture, left ventricular free wall rupture, and papillary muscle rupture are lethal complications of acute myocardial infarction. While rare, occurring in only a small fraction of AMI cases, they carry extremely high mortality rates even with optimal treatment. Ventricular septal rupture has a mortality rate of 19-54% with surgery and is almost uniformly fatal with medical management alone. Left ventricular free wall rupture presents with sudden cardiac tamponade and is also rapidly fatal without surgery. Surgical repair techniques aim to exclude the injured myocardium with patches, though outcomes remain poor. Early stabilization is crucial to improving survival from these catastrophic AMI complications.
Interventional radiology in renal vascular lesionssMohamed Shaaban
This document discusses various endovascular procedures for treating renal issues. It describes how renal bleeding can occur from trauma or iatrogenic causes like biopsy. This can result in pseudoaneurysms or arteriovenous fistulas, which can bleed into the retroperitoneum or collecting system. It provides examples of patients presenting with these issues. It also discusses how renal artery embolization was introduced to help surgery or palliate tumors by reducing bleeding. Indications for embolization include preoperative or for life-threatening hemorrhage. Renal artery stenosis is another issue that can be treated with percutaneous transluminal renal angioplasty.
This document discusses post-myocardial infarction ventricular septal rupture (VSR). It notes that VSR incidence has decreased with improved reperfusion therapies. Surgical repair is the definitive treatment but is high risk, while percutaneous closure and mechanical support have improved outcomes. The timing and presentation of VSR depends on its pathophysiology, which can include acute or delayed rupture. Diagnosis is via echocardiography. Management involves surgical closure if stable, while unstable patients may be supported with devices or surgery delayed. Percutaneous closure is an option for inoperable cases.
Percutaneous nephrolithotomy (PCNL) carries risks of several access-related complications. Prevention involves ensuring sterile urine, adequate imaging for access planning, and backup equipment. Initial puncture can lead to hemorrhage, arterial or venous puncture, or injury to surrounding structures. Bleeding is typically controlled with tamponade but may require angioembolization. Delayed hemorrhage can also occur from arteriovenous fistulas or pseudoaneurysms. Careful patient selection, access planning and technique can minimize complication risks.
Digital Subtraction Neuroangiography: What a Resident Should Know Dr. Shahnawaz Alam
This document provides an overview of digital subtraction neuroangiography for residents. It begins with an introduction to the principles and importance of neuroangiography. It then provides detailed descriptions of normal neurovascular anatomy and angiographic views of the extracranial carotid system, anterior and posterior circulations. It discusses indications, contraindications, patient preparation, technique, complications and case examples to illustrate pathologies. The goal is to equip residents with the basic knowledge to interpret images and safely perform neuroangiography.
The document discusses cerebrovascular anomalies or malformations, which are conditions characterized by malformed blood vessels that can lead to hemorrhages, stroke, blood clots, and other complications. It covers the classification, epidemiology, clinical presentation, investigations, management, and treatment of various types of cerebrovascular anomalies, including arteriovenous malformations (AVMs), venous angiomas, and cavernous malformations. It also presents a case study example of a patient who experienced bleeding from a left parietal AVM and was treated surgically.
Both the remodeling and reimplantation techniques aim to preserve the native aortic valve in patients with aortic root aneurysms. The remodeling technique involves excising the diseased sinuses and reattaching the valve within a graft, reconstructing the sinuses. The reimplantation technique reimplants the valve within a graft anchored at the aortoventricular junction. Studies have found slightly better long-term outcomes with reimplantation, especially in conditions like Marfan syndrome or dissection, though both techniques have good results. Neither technique fully restores the normal biomechanics and stress patterns of the native aortic root.
The document summarizes various potential complications that can occur during or after cardiac catheterization. The major complications discussed include death, myocardial infarction, stroke, bleeding, vascular injury, and contrast induced nephrotoxicity. Risk factors for complications include patient demographics, cardiovascular anatomy, clinical situation, and operator experience. Local vascular complications like hematoma, pseudoaneurysm, arterial thrombosis are also described. Strategies to prevent complications involve careful technique, minimizing contrast and anticoagulation.
This document provides an overview of carotid cavernous fistulas (CCFs), which are abnormal connections between the carotid artery system and cavernous sinus. It describes the classification, symptoms, diagnosis and treatment of direct (high flow) and indirect (low flow) CCFs. For direct CCFs, endovascular management such as detachable balloon occlusion, coil embolization or covered stent placement is the preferred treatment to occlude the fistula while preserving carotid artery patency. Indirect CCFs are typically treated via transvenous coil embolization or liquid embolic agents to occlude the abnormal cavernous sinus connection. Conservative management, compression therapy or radiosurgery may be options for low
Radical nephrectomy for locally advanced renal cell carcinoma (RCC) involves complete removal of the kidney, surrounding tissue, and regional lymph nodes. It may also include adrenalectomy. The surgical procedure is complex due to the need for careful dissection near major blood vessels and organs. While lymph node dissection and adjuvant therapy were once used widely, current evidence does not support a survival benefit. For RCC with inferior vena cava involvement, preoperative imaging and planning is important. Recent trials found that adjuvant pembrolizumab improved disease-free survival compared to placebo after surgery for locally advanced RCC.
This document provides an overview of mesenteric vascular occlusion including:
- It affects the blood supply to the gastrointestinal tract and has high mortality.
- CT scanning is the preferred diagnostic method and can detect bowel wall thickening or lack of enhancement.
- Treatment involves resuscitation, antibiotics, surgery to remove clots or place stents, and resecting non-viable bowel.
- Goals are to diagnose the cause, restore blood flow, and assess bowel viability.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
1) Prosthetic heart valve thrombosis can occur with both mechanical and biological valves and is influenced by surface factors, hemodynamic factors, and hypercoagulability.
2) Clinical presentation may include heart failure symptoms or embolic events, and imaging with TEE is the standard for evaluation.
3) Treatment depends on severity of symptoms and includes anticoagulation, fibrinolytic therapy, or emergency surgery for severe cases.
Coronary aneurysm: At a glance and Management.pptxabhishek tiwari
This document discusses coronary artery aneurysms (CAAs). It defines a CAA as a dilatation of the coronary artery exceeding 50% of the reference vessel diameter. CAAs can be classified based on their morphology, vessel wall composition, and the vessels affected. Common risk factors include atherosclerosis, vasculitis, and intracoronary manipulation. CAAs are often asymptomatic but can occasionally cause symptoms. Diagnosis is typically via coronary angiography. Management involves medical therapy, percutaneous interventions such as stenting, or surgery, with challenges that include proper sizing and coverage of aneurysmal segments.
intracranial vascular bypass is done to maintain blood flow to region of interest. this slideshow entails the indications, various categories, types as per flow, their advantages and disadvantages
This document discusses interventions for saphenous vein graft (SVG) disease. It covers the natural course of SVG pathology over time, techniques for SVG interventions like thrombectomy and stenting, and complications. Distal protection devices can reduce complications by preventing embolic debris from distal vessel occlusion during interventions. Proximal occlusion devices provide embolic protection by occluding inflow before any wires or devices cross the lesion. Filter wires are frequently applicable alternatives to occlusive distal protection with advantages of maintaining blood flow.
bleeding in pancreatitis and its management.pptxmohitdocjain
This document discusses bleeding complications in pancreatitis, which occur in 1.2-14.5% of cases and can be fatal if untreated, with a mortality rate of up to 52.4%. Bleeding can result from local inflammation and necrosis damaging blood vessels, abscesses weakening vessel walls, pseudocyst compression, or splenic vein thrombosis. Angiography is used to diagnose arterial pseudoaneurysms or extravasation. Endovascular embolization with coils or glues is the primary treatment, while surgery may be needed for venous bleeding or if embolization fails. Prompt diagnosis and management of bleeding are critical to prevent fatal outcomes.
Aneurysms of Visceral arteries, Splenic Artery Aneurysm in Childbearing.KHALID ALRAJHI
Splenic Artery Aneurysm is one of the vascular anomalies of visceral arteries.
Her's seminar of visceral artery aneurysms, and in pregnancy period.
Visceral aneurysms are clinically important that affect population and health socio-economical systems.
- Introduction
- Definition
- Classifications
- Causes
- Risk Factors
- Symptoms
- Diagnosis
- Management
- Endovascular Surgery
- Case Presentation
Mechanical complications Post AMI and the role of CABG.pptxNora Albogami
Mechanical complications such as ventricular septal rupture, left ventricular free wall rupture, and papillary muscle rupture are lethal complications of acute myocardial infarction. While rare, occurring in only a small fraction of AMI cases, they carry extremely high mortality rates even with optimal treatment. Ventricular septal rupture has a mortality rate of 19-54% with surgery and is almost uniformly fatal with medical management alone. Left ventricular free wall rupture presents with sudden cardiac tamponade and is also rapidly fatal without surgery. Surgical repair techniques aim to exclude the injured myocardium with patches, though outcomes remain poor. Early stabilization is crucial to improving survival from these catastrophic AMI complications.
Interventional radiology in renal vascular lesionssMohamed Shaaban
This document discusses various endovascular procedures for treating renal issues. It describes how renal bleeding can occur from trauma or iatrogenic causes like biopsy. This can result in pseudoaneurysms or arteriovenous fistulas, which can bleed into the retroperitoneum or collecting system. It provides examples of patients presenting with these issues. It also discusses how renal artery embolization was introduced to help surgery or palliate tumors by reducing bleeding. Indications for embolization include preoperative or for life-threatening hemorrhage. Renal artery stenosis is another issue that can be treated with percutaneous transluminal renal angioplasty.
This document discusses post-myocardial infarction ventricular septal rupture (VSR). It notes that VSR incidence has decreased with improved reperfusion therapies. Surgical repair is the definitive treatment but is high risk, while percutaneous closure and mechanical support have improved outcomes. The timing and presentation of VSR depends on its pathophysiology, which can include acute or delayed rupture. Diagnosis is via echocardiography. Management involves surgical closure if stable, while unstable patients may be supported with devices or surgery delayed. Percutaneous closure is an option for inoperable cases.
Percutaneous nephrolithotomy (PCNL) carries risks of several access-related complications. Prevention involves ensuring sterile urine, adequate imaging for access planning, and backup equipment. Initial puncture can lead to hemorrhage, arterial or venous puncture, or injury to surrounding structures. Bleeding is typically controlled with tamponade but may require angioembolization. Delayed hemorrhage can also occur from arteriovenous fistulas or pseudoaneurysms. Careful patient selection, access planning and technique can minimize complication risks.
Digital Subtraction Neuroangiography: What a Resident Should Know Dr. Shahnawaz Alam
This document provides an overview of digital subtraction neuroangiography for residents. It begins with an introduction to the principles and importance of neuroangiography. It then provides detailed descriptions of normal neurovascular anatomy and angiographic views of the extracranial carotid system, anterior and posterior circulations. It discusses indications, contraindications, patient preparation, technique, complications and case examples to illustrate pathologies. The goal is to equip residents with the basic knowledge to interpret images and safely perform neuroangiography.
The document discusses cerebrovascular anomalies or malformations, which are conditions characterized by malformed blood vessels that can lead to hemorrhages, stroke, blood clots, and other complications. It covers the classification, epidemiology, clinical presentation, investigations, management, and treatment of various types of cerebrovascular anomalies, including arteriovenous malformations (AVMs), venous angiomas, and cavernous malformations. It also presents a case study example of a patient who experienced bleeding from a left parietal AVM and was treated surgically.
Both the remodeling and reimplantation techniques aim to preserve the native aortic valve in patients with aortic root aneurysms. The remodeling technique involves excising the diseased sinuses and reattaching the valve within a graft, reconstructing the sinuses. The reimplantation technique reimplants the valve within a graft anchored at the aortoventricular junction. Studies have found slightly better long-term outcomes with reimplantation, especially in conditions like Marfan syndrome or dissection, though both techniques have good results. Neither technique fully restores the normal biomechanics and stress patterns of the native aortic root.
The document summarizes various potential complications that can occur during or after cardiac catheterization. The major complications discussed include death, myocardial infarction, stroke, bleeding, vascular injury, and contrast induced nephrotoxicity. Risk factors for complications include patient demographics, cardiovascular anatomy, clinical situation, and operator experience. Local vascular complications like hematoma, pseudoaneurysm, arterial thrombosis are also described. Strategies to prevent complications involve careful technique, minimizing contrast and anticoagulation.
This document provides an overview of carotid cavernous fistulas (CCFs), which are abnormal connections between the carotid artery system and cavernous sinus. It describes the classification, symptoms, diagnosis and treatment of direct (high flow) and indirect (low flow) CCFs. For direct CCFs, endovascular management such as detachable balloon occlusion, coil embolization or covered stent placement is the preferred treatment to occlude the fistula while preserving carotid artery patency. Indirect CCFs are typically treated via transvenous coil embolization or liquid embolic agents to occlude the abnormal cavernous sinus connection. Conservative management, compression therapy or radiosurgery may be options for low
Radical nephrectomy for locally advanced renal cell carcinoma (RCC) involves complete removal of the kidney, surrounding tissue, and regional lymph nodes. It may also include adrenalectomy. The surgical procedure is complex due to the need for careful dissection near major blood vessels and organs. While lymph node dissection and adjuvant therapy were once used widely, current evidence does not support a survival benefit. For RCC with inferior vena cava involvement, preoperative imaging and planning is important. Recent trials found that adjuvant pembrolizumab improved disease-free survival compared to placebo after surgery for locally advanced RCC.
This document provides an overview of mesenteric vascular occlusion including:
- It affects the blood supply to the gastrointestinal tract and has high mortality.
- CT scanning is the preferred diagnostic method and can detect bowel wall thickening or lack of enhancement.
- Treatment involves resuscitation, antibiotics, surgery to remove clots or place stents, and resecting non-viable bowel.
- Goals are to diagnose the cause, restore blood flow, and assess bowel viability.
Similar to Anterior circulation aneurysm.pptx (20)
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
2. Decision making for treatment of Intracranial
Aneurysm
• Two important goals in treatment of patients with intracranial
aneurysm:
• 1. complete, permanent aneurysmal occlusion
• 2. optimal preservation or restoration of patient’s neurological
function.
3. Factors associated with aneurysm rupture
• Aneurysm specific factors
• Size>7mm
• Irregular shape
• Posterior circulation
• Acom artery location
• Flow straight into aneurysm
• Associated with Av malformation
• High aspect ratio: dome-neck ratio> 1.6
• Previous SAH
• Wall shear stress
4. • Patient factors
• Female
• Age
• Smoking
• Hypertension
• Alcohol
• Family history of SAH
5. Neuroradiological evaluation
• Computed tomography
• MRI sequences
• CT Angiography: low sensitivity for aneurysm that are<5 mm in size
• MR Angiography
• Cerebral Angiography
• 3D rotational Angiography
• DSA is the gold standard
• 4 dimensional CTA and volume rendering and spin rotational, and 3D
DSA are used for surgical planning
7. Associated with poor surgical outcome
• Increased aneurysm size: four fold poor outcome when compared with
small aneurysm due to intimate association with small perforators, broad
aneurysm neck, intraluminal thrombosis, atherosclerosis in aneurysm neck
or dome
• Aneurysmal location: giant basilar, Acom , ICA bifurcation have greatest risk
• Calcification in aneurysm neck
• Atherosclerosis
• Aneurysm orientation and neck configuration
• Advanced patient age
• SAH
• Intracerebral haemmorhage
8. Aneurysm rebleeding
• 70-90% of patients who rebleed die
• Risk is greatest on day 1 and perhaps in first 6 hours after SAH
• It then occurs at a constant rate of 1-2% per day during subsequnent
4 weeks
• Factors associated are premorbid hypertension, poor clinical grade,
ICH, IVH, greater radhiographic severity of SAH, large aneurysm
size>10mm, and posterior circulation aneurysm
• Rebleeding reduced by administration of antifibrinolytic drugs
11. Intracerebral hemorrhage
• ICH complicates about 30% of ruptured aneurysm and increases
mortality after SAH
• Factors such as young age and better clinical grade, small ICH volume
25-50 ml and intrasylvian ICH are associated with better outcome
whereas decreasing percentage of ICH evacuations IVH and need for
EVD aggravate outcome.
• Improved patient outcome is seen when emergency ICH evacuation is
performed, particularly with simultaneous and successful aneurysm
obliteration.
• CTA obtained after head Ct is useful and can detect > 90% of
aneurysm > 3-5 mm in diameter.
• The spot sign on CTA is an indicater of active bleeding within ICH and
associated with increased risk of intraoperative aneurysm rupture.
12. Ruptured aneurysm and early vasospasm
• The cause of cerebral vasospasm still remains obscure. Several substances such as
serotonin, prostaglandins, catecholamines appear to have a vasoconstrictive effect on the
cerebral vessels.
• Recent evidence indicates that erythrocyte lysis within the subarachnoid spaces may play
a major role in the genesis of delayed clinically relevant cerebral vasoconstriction
following aneurysmal subarachnoid hemorrhage (SAH).
• The pathophysiology of brain ischemia following aneurysmal rupture, and the correlation
between angiographic vasospasm, neurological condition, intracranial pressure (ICP)
value, cerebral blood flow and CT findings. It is concluded that, at present, blood volume
expansion and/or induced hypertension, and pharmacological control of increased ICP
provide the best basis for clinical management of the cerebral ischemic complications of
SAH.
• Vasospasm is associated with poor outcome and between 10-15 % of patients will have
angiographic evidence of vasospasm within 48 hours of aneurysm rupture.
• Early surgery with aneurysm obliteration followed by immediate angioplasty (continuous
nimodipine infusion during embolization procedure) reduced the risk of poor outcome
13. Endovascular approaches to intracranial
aneurysm
Core principles are :
1. Create a stable construct: primary goal is to occlude the aneurysm from the
parent circulation while maintaining patency of parent vessels
2. Balance anticoagulation: unlike open approaches, endovascular occlusion
involves both physical occlusion and thrombus formation. And the balance can
shift depending on clinic scenario like in ruptured aneurysm, endovascular
construct selected on rapid aneurysm occlusion without the need for adjuvant
antiplatelet therapy such as primary coil or ballon assisted coil construct.
3. Promote endothelization: healing process that excludes the aneurysm from
circulation is dynamic and slow. Within the first week after coil occlusion, an
unorganized thrombus composed of cell mass and fibrin forms within coil mass
and in subsequent week collagen deposition occurs and over 3-12 months
tissue vascularization occurs
14.
15.
16. • Associated with better short term outcomes whereas surgical
techniques are more durable and associated with better aneurysm
occlusion and rebleeding
• Complete or >90% occlusion observed in 50-90% of small aneurysm
with narrow neck with endovascular technique
• Technical complications like intraprocedural aneurysm perforation,
distal embolization, parent vessel occlusion, coil migration are
observed
• Risk factors for thromboembolic complications are older age, MCA
location, longer procedural time, female gender, while
intraprocedural rupture risk are more asso with Acom aneurysm small
aneurysm size.
• Antiplatelet agents are required when stents are deployed and limit
the utility of stent after SAH
19. • EVT is the first methodology for any narrow necked aneurysm regardless of
rupture status.
• Anterior communicating aneurysm: here, difficulties may arise from
successful catheterization of the A1 segment or may be caused by
torturosity of a1-A2 segement ( due to catheter stability) and due to
angiomorphology of aneurysm because of presence of presence of
multiple arterial branches. Well orientation of aneurysm related to parent
vessel must be delineated. Status of contralateral a1 segment influence the
choice of EVT. If the contralateral A1 segment is absent, it is paramount
that the ACoA is not impigned by the coil massin order to preserv blood
flow to distal contralateral ACA. acoA directed inferiorly or posteriorly are
difficult to treat. Selecting an angled catheter or custom steam shaping a
microcatheter decrease the kick out during coil embolization. Frequent
manipulation may increase the chances for iatrogenic perforation or
rupture of aneurysm. Ballon remodelling technique may provide distinct
advantages. Often the a1 segment providing the dominant inflow is the
best route for the approach of microcatheter. If the vessel is too torturous
to accomadate a ballon microcather, a bilateral approach is necessary.
20. • Opthalmic artery aneurysm: more readily treated with EVT. Clipping
often requires drilling of ACP and optic strut to completely delineate
the aneurysm neck and due to proximity with ICA to dural ring and
cavernous sinus, surgical exposure of carotid artery is required and
lastly the proximity with optic nerve. The origin of opthamic artery
must be identifiedto minimize chances of iatrogenic occlusion. The
risk of monocular vision loss should prompt consideration of surgical
treatment. If identified as distinct from neck of aneurysm, EVT is
ideal. The use of ballon microcatheter help in support of
microcatheter during deployment of coils. The risk of ischemic events
with ballon inflation can be mitigated by patent PcoA and AcoA.
21. • MCA aneurysm: when located at Mca bifurcation, an aneurysm may
be intimately related with M2 branches, precluding successful coil
embolization. Compromise of these branch by impringement from
the coil mass can result in significant ischemia or thrmoembolic
complications.location close to surface of brain makes surgical
treatment attractive. For EVT, it is difficult to obtain clear working
angle and distal locate makes the navigation challenging. Often the
MCA is 2 mm or less at bifurcation , increasing the chance of vessel
injury during balloon catheter inflation.
• Flow diverting stents such as PED, are used to teat distal circulation
aneurysms and small, narrow necked aneurysm. Other devices like
WEB help treat wide neck bifurcation aneurysm withoutneed for
adjunctive devices or stents
22. Wide neck aneurysm
• Necks greater than 4 mm or dome to neck ratio <2
• There is inverse relationship between increasing neck width beyond
4mm and ultimate coil packing density.
• Wide opening at neck leaves the parent artery at risk of
thromboembolic complications.
• As for ruptured aneurysm, it is better managed with EVT. But
maintain balance between risk of coil herniation associated TEC and
packing density become more difficult as CSF diversion procedure are
required in setting of SAH (dual antiplatelet therapy is required for
EVT) and SAH creates prothrombotic state and risk of TEC increases.
23. • Dual coiling catheter technique prevent coil herniation: framing coil is
advanced through one of catheters and not detatched to provide stability
during embolization. The other catheter is then advancedinto frameand
the second catheter is used to pack the frame with progressively smaller
and softer coils. The framing coil is then detatched after the other catheter
has been removed
• Balloon assisted coiling techniques: allowing the aneurysm neck to be
temporarily obstruct withballon inflation while coils are advanced. The
balloon is then deflated and if coils appears stable, it can be deattched.
• Temporary stenting technique: retrievable stent is partially deployed across
the neck of aneurysmwith second catheter jailed in aneurysm. Following
embolization, stent is resheated and removed, provided no coil loops are
herniating.
• Flow diversion: deploying stent of lower porosity in the parent artery
spanning the aneurysm neck. Luminal metal coverage is generally around
30-40% the struts distrupts the normal arterial flow into aneurysm fundus,
creating stasisand serves as scaffols for endothelization eventually leads to
thrombosis and exclusion of aneurysm
• Stent assisted coilingembolization
24. Anterior circulation aneurysm
• 85-95% of all aneurysm
• Acom and DACA (30-35%)
• MCA (20-25%)
• Pcom (25-30%)
• ICA bifurcation (5%-7%)
25. Anterior communicating artery aneurysm
• The single most common site of aneurysms presenting with SAH.
• May also present with diabetes insipidus (DI) or other hypothalamic dysfunction.
• CT scan SAH in these aneurysms results in blood in the anterior interhemispheric
fissure in essentially all cases, and is associated with intracerebral hematoma in
63% of cases
• Intraventricular hematoma is seen in 79% of cases, with the blood entering the
ventricles from the intracerebral hematoma in about one–third of these.
• Acute hydrocephalus was present in 25% of patients (late hydrocephalus, a
common sequelae of SAH, was not studied).
• Frontal lobe infarcts occur in 20%, usually several days following SAH.
• One of the few causes of the rare finding of bilateral ACA distribution infarcts is
vasospasm following hemorrhage from rupture of an ACoA aneurysm. This results
in prefrontal lobotomy-like findings of apathy and abulia.
26. • Aneurysm are situated deeply and in midline, have bilateral
anterograde arterial supply from paired A1 segments.
• Increased risk of ishemic complications stems from close proximity of
aneurysm to paired A1 and A2 segments, 2 recurrent arteries of
heubner, 2 orbitofrontal A, 2 frontopolar A, and ACoA
• Tackling of aneurysm should be done from the side of dominant A1
segment.
• Acess to AcoA junction gained through opening of 3 arachnoid
cisterns: carotid, chiasmatic and lamina terminalis
• AcoA complex is most common location of ruptured aneurysm
27.
28. • Angiographic considerations Essential to evaluate contralateral carotid, to determine if
both ACAs fill the aneurysm. If the aneurysm fills with one side only, it is desirable to
inject the other side while cross compressing the side that fills the aneurysm to see if
collateral flow is present. Also, determine if either carotid fills both ACAs, or if each ACA
fills from the ipsilateral carotid injection.
• If additional views are needed to better demonstrate aneurysm. Try oblique 25° away
from injection side, center beam 3–4 cm above lateral aspect of ipsilateral orbital rim,
orient X-ray tube in Towne’s view. A submental vertex view may also visualize the area
but the image may be degraded by the large amount of interposed bone.
• Surgical treatment
• Approaches
• 1. pterional approach: the usual approach
• 2. subfrontal approach: especially useful for aneurysms pointing superiorly when there
is a large amount of frontal blood clot (allows clot removal during approach)
• 3. anterior interhemispheric approach contraindicated for anteriorly pointing
aneurysms as the dome is approached first and proximal control cannot be obtained
• 4. transcallosal approach
29.
30. • Pterional approach
• Side of craniotomy: A right pterional craniotomy is used with the
following exceptions (for which a left pterional crani is used):
• 1. large ACoA aneurysm pointing to right: left crani exposes neck
before dome
• 2. dominant left A1 feeder to aneurysm (with no filling from right A1):
left craniotomy provides proximal control
• 3. additional left sided aneurysm(use shoulder roll, rotate head 60°
from vertical).
• Craniotomy (slightly more frontal lobe needs to be exposed than,
e.g. for a p-comm aneurysm).
• Lumbar drain assists with brain relaxation
31. • Microsurgical dissection
• Dissect down Sylvian fissure with gentle retraction of frontal lobe away from base of skull.
Olfactory nerve visualized first, then optic nerve.
• Open arachnoid over carotid and optic cistern and drain CSF. Elevate temporal tip, coagulate any
bridging temporal tip veins that are present, and expose ICA. Follow the ICA distally, looking for
A1 (the exposure of which allows temporary clipping in the event of rupture).
• If the A1 take-off is too high, it may be hidden and would require excessive retraction to expose.
Options to increase exposure include
• 1. gyrus rectus resection: a 1 cm long gyrus rectus corticectomy is performed just medial to the
olfactory tract. Helps find the ipsilateral A1 and often ACoA and A2. This is also helpful for
downpointing aneurysms because it permits visualization of the contralateral A1 before exposing
the dome of the aneurysm (for proximal control). May lead to neuropsychiatric deficits. A subpial
resection is performed with preservation of the small arterial branch that is consistently located
here
• 2. fronto-temporal-orbital-zygoma removal
• 3. splitting the Sylvian fissure
• 4. ventricular drainage Once found, A1 is followed until the ipsilateral A2 is identified. Then the
contralateral A2 is identified and is followed proximally until the contralateral A1 is exposed. The
a-comm is usually encountered in the process.
• Critical branches to preserve: recurrent artery of Heubner; small ACoA perforators (may be
adherent to aneurysm dome). If the aneurysm cannot be clipped, it may be trapped by clipping
both ends of the ACoA only if each ACA fills from the carotid on its own side. Post clipping, some
authors recommend fenestrating the lamina terminalis in an effort to reduce the need for post-op
shunting.
32. • Anterior interhemispheric approach
• Involves minimal brain retraction. More suitable for an aneurysm
that points straight up, but even with this proximal control is poor.
• Position: supine with the neck extended ≈ 15°.
• A transverse skin incision is made in a skin crease in the lower
forehead. This describe using a 1.5 inch trephine craniotomy in the
midline just superior to the glabella. Alternatively, better advantage of
the dural opening may be possible with a more rectangular opening.
The dural flap is hinged on the superior sagittal sinus. The depth of
the aneurysm is ≈ 6 cm from the dura. Proximal control of the A1
branch of the ACA is difficult with this approach.
33. • Distal anterior cerebral artery aneurysms
• Aneurysms of the distal anterior cerebral artery (DACA) (i.e., the ACA distal to the
ACoA) are usually located at the origin of the frontopolar artery, or at the
bifurcation of the pericallosal and callosomarginal arteries at the genu of the
corpus callosum.
• Aneurysms located more distally are usually posttraumatic, infectious (mycotic),
or due to tumor embolus.
• DACA aneurysms are often associated with intracerebral hematoma or
interhemispheric subdural hematoma since the subarachnoid space is limited
here.
• Conservative treatment of DACA aneurysms is often associated with poor results.
Unruptured DACA aneurysms have a higher incidence of bleeding than
unruptured aneurysms in other locations. These aneurysms are fragile and
adherent to the brain, which predisposes to frequent premature intraoperative
rupture. Best treated with open microsurgical treatment
• On arteriography, if both ACAs fill from a single sided carotid injection, it may be
difficult to make the important determination as to which ACA feeds the
aneurysm. Multiple aneurysms are commonly associated with DACA aneurysms.
• Treatment. Aneurysms up to 1 cm from the ACoA may be approached through a
standard pterional craniotomy with partial gyrus rectus resection.
34.
35. • Aneurysms > 1 cm distal to the ACoA up to the genu of the corpus callosum, including those of
the pericallosal/callosomarginal bifurcation, may be approached surgically by a basal frontal
interhemispheric approach via a frontal craniotomy using a bicoronal skin incision.
• The patient is positioned supine with the neck slightly extended, positioned vertically or just a
few degrees to the left. A right sided craniotomy is preferred in most instances (exception:
aneurysm dome buried in the right cerebral hemisphere making retraction hazardous), but should
cross to the contralateral side by a couple centimeters. It must be taken all the way to the floor of
the frontal fossa to permit exposure of the anterior cerebral artery for proximal control. The
craniotomy extends ≈ 8 cm above the supraorbital ridge in order to provide way in
circumnavigating veins bridging to the superior sagittal sinus. The dural flap is based on the
superior sagittal sinus. If the sinus needs to be mobilized, it may be divided low anteriorly.
• ACA aneurysms distal to the genu of the corpus callosum may also be approached by an
interhemispheric approach using a unilateral skin incision.
• For these, the patient’s neck is not extended, and a parasagittal craniotomy is used that doesn’t
need to be as low on the frontal fossa. The cingulate gyri may be difficult to separate, and care
must be taken because excessive retraction may pull the cingulate gyrus off the dome of the
aneurysm and produce premature rupture.
• Ideally, A2 proximal to the aneurysm should be identified initially for proximal control and then
followed distally to the aneurysm. When this is not possible, dissection should follow distal ACA
branches proximally toward the aneurysm, taking care not to disturb the aneurysm. Often, a
portion of the cingulate gyrus may need to be removed and sometimes up to 1–2 cm of the
anterior corpus callosum may need to be divided
36. • Surgical complications: Prolonged retraction on the cingulate gyrus
may produce akinetic mutism that is usually temporary. The
pericallosal arteries are small in caliber and may be atherosclerotic,
which together increases the risk of occlusion of the parent artery
with the aneurysm.
37. • Middle cerebral artery (MCA) aneurysms
• The following considers MCA aneurysms of the M1-M2 junction
(referred to as “trifurcation” region, although this is not a true
trifurcation).
• Surgical treatment
• Approaches
• 1. transsylvian approach through a pterional craniotomy: this is the
most commonly used approach
• 2. superior temporal gyrus approach
• a) advantages: minimizes brain retraction, possible reduced
vasospasm from manipulation of proximal vessels
• b) disadvantages: proximal control difficult, slightly larger bone flap,
possible increased risk of seizures
38.
39. • Microsurgical dissection
• Dissect down Sylvian fissure with major vector of retraction on tip of
temporal lobe (less on frontal lobe than in ACoA aneurysm). Open
arachnoid and drain CSF. Elevate temporal tip, coagulate bridging
temporal tip veins, and expose the ICA for proximal control in the
event of rupture. Follow the ICA distally by splitting the Sylvian fissure
to expose the M1 (again, for proximal control).
• Although exposure for proximal control is helpful to have as a
contingency, one may be able to avoid temporary clipping of the MCA
in the event of intraoperative rupture by controlling bleeding with a
large suction, and subsequent clip placement (since the blood flow
through the MCA is not as voluminous as through the ICA, and the
surgical access to these aneurysms is usually fairly unrestricted).
• Critical branches to preserve: distal MCA branches, recurrent
perforators from the origin of the major MCA branches
40. • paraclinoid aneurysms
• Applied anatomy The carotid artery exits the cavernous sinus and enters the subarachnoid space
at the dural constriction known as the carotid ring (AKA clinoidal ring). Arising from ICA Between
the roof of cavernous sinus and origin of posterior communicating artery.
• Classified as: 1.dorsal 2. ventral 3. carotid cave 4. global type.
• The supraclinoid portion of the carotid artery may be divided into the following segments
• 1. ophthalmic segment: the largest portion of the supraclinoid ICA. Lies between the take-off of
the ophthalmic artery and the posterior communicating artery (PCoA) origin. The proximal
portion of this (including the origin of the ophthalmic artery) is often obscured by the anterior
clinoid process.
• Branches include: a) ophthalmic artery: usually originates from the supracavernous ICA just after
the ICA enters the subarachnoid space. Enters the optic canal positioned inferolateral to the optic
nerve
• b) superior hypophyseal artery: the largest of several perforators supplying the dura of the
cavernous sinus and the superior pituitary gland and stalk
• 2. communicating segment: from the PCoA origin to the origin of the anterior choroidal artery
(AChA)
• 3. choroidal segment: from AChA origin to the terminal bifurcation of the ICA
41.
42. • Ophthalmic segment aneurysms (OSAs) :
• 1. ophthalmic artery aneurysms
• 2. superior hypophyseal artery aneurysms:
• a) paraclinoid variant: usually does not produce visual symptoms
• b) suprasellar variant: when giant, may mimic pituitary tumor on CT Presentation (excluding
incidental discovery) Ophthalmic artery aneurysms Arise from the ICA just distal to the origin of
ophthalmic artery.
• They project dorsally or dorsomedially towards the lateral portion of the optic nerve.
• Presentation: 1. ≈ 45% present as SAH
• 2. ≈ 45% present as visual field defect:
• a) as the aneurysm enlarges it impinges on the lateral portion of the optic nerve → inferior
temporal fiber compression → ipsilateral monocular superior nasal quadrantanopsia
• b) continued enlargement → upward displacement of the nerve against the falciform ligament (or
fold) → superior temporal fiber compression → monocular inferior nasal quadrantanopsia
• c) in addition to near-complete loss of vision in the involved eye, compression of the optic nerve
near the chiasm may also produce a superior temporal quadrant defect in the contralateral eye
(junctional scotoma AKA “pie in the sky” defect) from injury to the anterior knee of Wilbrand
(nasal retinal fibers that course anteriorly for a short distance after they decussate in the
contralateral optic nerve15)
• 3. ≈ 10% present as both
43. • Superior hypophyseal artery aneurysms
• Originate in the small subarachnoid pocket medial to the ICA near the
lateral aspect of the sella.
• The direction of enlargement is dictated by the size of this pocket and the
height of the lateral sellar wall, resulting in two variants: paraclinoid &
suprasellar.
• Suprasellar variant may actually grow to a size large enough to compress
the pituitary stalk and cause hypopituitarism and “classic” chiasmal visual
symptoms (bilateral temporal hemianopsia).
• Angiographic considerations A notch can often be observed in the anterior,
superior, and medial aspects of giant ophthalmic artery aneurysms due to
the optic nerve.
• If additional views are needed to better demonstrate aneurysm. Try
oblique 25° away from injection side, center beam 3–4 cm above lateral
aspect of ipsilateral orbital rim, orient X-ray tube in Towne’s view. Try
submentovertex view.
44. • Surgical treatment
• Ophthalmic artery aneurysms If necessary, the ophthalmic artery may be sacrificed
without worsening of vision in the vast majority. Clipping a contralateral ophthalmic
artery aneurysm is not technically difficult, and is not uncommonly required as OSAs are
often multiple. The aneurysm arises from the superomedial aspect of the ICA just distal
to the ophthalmic artery origin, and projects superiorly. Cutting the falciform fold early
decompresses the nerve, and helps minimize worsening of visual deficit from surgical
manipulation.
• For unruptured aneurysms, drill off anterior clinoid via an extradural approach before
opening dura to approach neck; for ruptured aneurysms, this may not be as safe. In most
cases, a side-angled clip can be placed parallel to the parent artery along the neck of the
aneurysm.
• Superior hypophyseal artery aneurysms If necessary, the superior hypophyseal artery on
one side may be clipped without demonstrable deleterious effect (due to bilateral supply
to stalk and pituitary). Clipping a contralateral superior hypophyseal aneurysm is not
really feasible. With a usual pterional approach, the carotid artery is usually encountered
first, and with large aneurysms is usually bowed laterally towards the surgeon. Clinoidal
removal is usually required. The entire ICA wall may appear to be involved, and it may
necessitate temporary ICA clipping (with cerebral protection) to reconstitute the ICA
using encircling clips parallel to the parent vessel