Paul Gigante HMS IV Gillian Lieberman, MD. Sept Mr. T s T s Headache. Paul Gigante,, Harvard Medical School Year IV Gillian Lieberman, MD

Transcription

1 Sept 2005 Mr. T s T s Headache Paul Gigante,, Harvard Medical School Year IV

2 Mr. T s T s Presentation 45 year-old welder complains of sudden severe headache and witnessed seizure with loss of consciousness at work History of an assault, which was a closed fist punch to the face a week prior to admission 2

3 Mr. T s T s Presentation On PE: Hypertensive to 150s to160s, Afebrile Lethargic, with garbled speech A + Ox2, following commands inconsistently PERLL, no seizure activity noted Labs: Hct 42, WBC 18,000, coags WNL 3

4 DDx? What Study? CT Head 4

5 PACS, BIDMC 5

6 PACS, BIDMC 6

7 PACS, BIDMC 7

8 PACS, BIDMC 8

9 PACS, BIDMC 9

10 PACS, BIDMC10

11 PACS, BIDMC11

12 PACS, BIDMC12

13 PACS, BIDMC13

14 PACS, BIDMC14

15 PACS, BIDMC15

16 PACS, BIDMC16

17 PACS, BIDMC17

18 PACS, BIDMC18

19 PACS, BIDMC19

20 PACS, BIDMC20

21 PACS, BIDMC21

22 PACS, BIDMC22

23 PACS, BIDMC23

24 DDx? What next? Angiogram

25 PACS, BIDMC25

26 PACS, BIDMC26

27 Right ICA Angio AP View PACS, BIDMC27

28 PACS, BIDMC28

29 PACS, BIDMC29

30 Right ICA Angio Lateral View PACS, BIDMC30

31 What do you think they did?

32 S/P Coiling PACS, BIDMC32

33 S/P Coiling PACS, BIDMC33

34 A Week Later PACS, BIDMC34

35 A Week Later PACS, BIDMC35

36 Intracranial Hemorrhage Review Epidural Biconvex, does not cross sutures except when fracture present, may cross falx and tent Subdural Crescent, crosses sutures, not dural attachments ICH Anywhere in parenchyma Subarachnoid 36

37 Epidural Hematoma 37

38 Subdural Hematoma PACS, BIDMC 38

39 Subarachnoid Hemorrhage Usual presentation: worst headache of life, trauma What study? Where and what are we looking for? CT look for hyperdensity in sulci, interhemispheric and sylvian fissures, and cisterns 39

40 Anatomy Review Sulcus Interhemispheric fissure PACS, BIDMC 40

41 Anatomy Review 4 th Ventricle Mastoid Sinus PACS, BIDMC 41

42 Anatomy Review Interhemispheric Cistern Suprasellar Cistern Interpeduncular Cistern Ambient Cistern Quadrigeminal Cistern PACS, BIDMC 42

43 Anatomy Review Sylvian Fissure Sylvian Fissure PACS, BIDMC 43

44 Subarachnoid Hemorrhage Once you ve found the hemorrhage and location, using the history, narrow DDx 1. Nonaneurysmal SAH 2. Pseudo SAH 3. Nonaneurysmal Perimesencephalic SAH 4. Aneurysmal SAH 44

45 1. Nonaneurysmal SAH Trauma is #1 cause of SAH! Not aneurysm, as many believe 1 Vascular malformation Neoplasm 1 Rinkel: Stroke

46 Traumatic SAH Look for the star 46

47 Pneumococcal Meningitis 2 2 Lloyd: Med J Aus 2003 Chased SAH, vasospasm After 1 day did LP: 1510 WBCs (all PMNs) ) and 160 RBCs SAH appearance 2/2 high protein, exudate. FLAIR also has high CSF signal in meningitis 47

48 Cerebral Edema Loss of cisterns Loss of gray-white differentiation Diffuse hypodensity CSF appears more bright 48

49 2. Pseudo SAH Low density brain Cerebral edema High density/flair intensity CSF meningitis high O2 tension contrast administration 49

50 3. Nonaneurysmal Perimesencephalic SAH Clinically benign entity SAH confined to perimesencephalic, prepontine cisterns Likely caused by ruptured perimesencephalic/prepontine vein 3 3 Matsumaru: J Neurosurg

51 Interpeduncular Cistern 51 PACS, BIDMC

52 4. Aneurysmal SAH: Epi Aneurysms account for 85% of non-traumatic SAH 4 Smoking, family hx increases risk Peak age: 40-60, F>M Concern: SAH causes vasospasm 20-30% incidence in aneurysmal SAH days 4 Osborn: Kassell: Stroke

53 Aneurysmal SAH 95% positive CT in first 24hr, <50% by 1 week Multislice CTA 90-95% 95% sensitive for aneurysm >2mm 6 MRA 85-95% sensitive 7 Conventional Angio considered gold standard 6 Schwartz: Radiology Huston: Am J Neurorad

54 Aneurysmal SAH Hunt and Hess grade prognostic Fisher score risk of vasospasm 8 8 Greenberg: Handbook of Neurosurgery

55 Aneurysmal SAH: Location Rebleed risk is increased compared to initial bleed risk. So if you see 2 aneurysms, how can you figure out which bled, and which to clip/coil? SAH location may help: Interhemispheric SAH suggests AcoA Sylvian suggests MCA 55

56 MCA emerges from sylvian fissure 56

57 AcoA lives near interhemispheric 57

58 Saccular Types of Aneurysms Round outpouching that lacks internal elastic lamina Inherited susceptibility and acquired mechanical stress 90-95% 95% in circle of willis (AcoA>PcoA) 10% posterior circulation Most often at vessel bifurcations! May have apical tit 20% multiple 9 9 Wiebers: Lancet

59 Types of Aneurysms Be mindful of radiographic DDx if you think you see a saccular aneurysm: Vessel loop Infundibulum of PComm 59

60 Saccular Aneurysm 60

61 Types of Aneurysms Pseudoaneurysm Focal arterial dilatation not contained by layers of normal arterial wall Most commonly from trauma Cavitated clot communicates with vessel Nomura: J Neurosurg

62 Types of Aneurysms Fusiform aneurysm Ectatic vessel and focal aneurysmal outpouching More often found in vertebrobasilar circulation Usually large Elderly patients with atherosclerosis Nakatomi: Stroke

63 Left PCA Fusiform Aneurysm case_studies/mejia_fig_2.jpg 63

64 Treatment: Coil vs Clip vs none Treatment choices rest largely on weighing risk of bleed versus procedural risk 64

65 Acknowledgements Pamela Lepkowski Larry Barbaras,, webmaster 65

66 References Greenberg MS. Handbook of Neurosurgery.. 5 th Ed. New York: Thieme Medical Publishers, Huston J 3 rd, Nichols DA, Luetmer PH et al. Blinded prospective evaluation of sensitivity of MR angiography a to known intracranial aneurysms: importance of aneurysm size. Am J Neuroradiol 15(9): , 14, Lloyd K Morgan. Pneumococcal meningitis masquerading as subarachnoid haemorrhage Med J Aust (10): , Kassell NF; Sasaki T; Colohan AR; Nazar G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke.. 16(4):562-72, Matsumaru Y et al. Significance of a small bulge on the basilar artery in patients with perimesencephalic nonaneurysmal subarachnoid hemorrhage. Report of two cases. J Neurosurg.. 98(2):426-9, 9, Nakatomi H et al. Clinicopathological study of intracranial fusiform and dolichoectatic aneurysms. Stroke.. 31: , Nomura M et al. Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site. J Neurosurg. 93(6): , Osborn AG et al. Diagnostic Imaging Brain. First Ed. Manitoba, Canada: Amirsys,, Rinkel GJ, Van Gijn J, Wijdicks EF. Subarachnoid hemorrhage without detectable aneurysm. A review ew of the causes. Stroke.. 24(9):1403-9, 9, 1993 Schwartz RB, Tice HM, Hooten SM, et al. Evaluation of cerebral aneurysms with helical CT: correlation with conventional angiography and MR angiography. Radiology.. 192(3):717-22, 22, Wiebers DO et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet (9378): , 110,