ENDOVASCULAR TREATMENT OF CEREBRAL ANEURYSMS AND MANAGEMENT OF RUPTURED ANEURYSM. Vikram Jadhav MD, PhD. 04/12/2018 CentraCare Health St.

Transcription

1 ENDOVASCULAR TREATMENT OF CEREBRAL ANEURYSMS AND MANAGEMENT OF RUPTURED ANEURYSM Vikram Jadhav MD, PhD 04/12/2018 CentraCare Health St. Cloud, MN OBJECTIVES Understand epidemiology and risk factors for cerebral aneurysm Learn the historical development of endovascular treatment for cerebral aneurysm Know the different endovascular therapies for cerebral aneurysm Understand management of ruptured aneurysm focusing on SAH 1

2 A cerebral or intracranial aneurysm is an abnormal focal dilation of an artery in the brain that results from a weakening of the inner muscular layer (the intima) of a blood vessel wall. 2

3 MODIFIABLE Smoking Hypertension Heavy alcohol consumption Drugs cocaine OCP Atherosclerosis NON MODIFIABLE Age Female Sex Genetics / Familial Collagen Vascular Diseases Arteriovenous Malformations RISK OF RUPTURE Size of aneurysm and rate of increase in size Posterior Circulation Symptomatic Aneurysm Prior history of bleeding Daughter Sac in Aneurysm Familial History of SAH History of Autosomal Dominant Polycystic Kidney Disease UNRUPTURED LEAKING RUPTURED Asymptomatic Peripheral vision compromise Balance and co ordination Speech issues Headache Thunderclap headache Nausea and Vomiting Diplopia Stiff Neck Photosensitivity Confusion and Seizures Loss of Consciousness 3

4 4

5 ANEURYSM TREATMENTS CONSERVATIVE MANAGEMENT Risk factors Serial Imaging SURGICAL CLIPPING ENDOVASCULAR APPROACHES Knowledge of aneurysms dates back to 14th century BC. But, no effort to treat till 19th century AD 1864: CH Moore, Middlesex London performed autopsy on sailor with findings of fibrin embedded bullet in ascending aorta. Thereafter, used 26 yards of coil to treat thoracic aorta aneurysm. Iron wires, gold plated watch springs, direct electric current had poor outcomes. 5

6 1895: Wilhelm Roentgen discovered X Rays : Egas Moniz performs first cerebral angiography. Artico et al., Front Neuroanat

7 1959: Luessenhop and Spence first embolization of cranial AVM, published in J Am Med Assoc in 1960 Teitelbaum et al., Neurosurgery,

8 March 6, 1990: Use of GDC for treatment of carotid cavernous fistula Jan 1991: GDC used in humans for aneurysm coiling Sept 1995: FDA approval for GDC coils COIL TYPES 8

9 Pierot et al., AJNR

10 STENTS AND FLOW DIVERTERS Kojima et al., Asian J of Neurosurg,

11 11

12 ONYX EMBOLIZATION OF ANEURYSM Kurdi et al., Case Rep in Vasc Med, 2013 WEB System (Terumo) CONTOUR Flow Diversion (Cerus Endovascular) 12

13 Basilar Tip Aneurysm Acomm Aneurysm MCA Bifurcation Aneurysm Pierot et al., EJMINT 2014 PULSERIDER Tateshima et al., BMJ,

14 BARREL STENT MEDINA MANAGEMENT OF RUPTURED ANEURYSM PLAN TREATMENT CLIPPING OR ENDOVASCULAR Rerupture rate 4% 24 hrs, 20% 2 weeks, 50% 6 months, then 3% annual risk ABCV of SAH Intubation for GCS < 8 or if unable to protect airway If mechanical ventilation, pco SBP control with antihypertensives Assess for hydrocephalus, EVD if needed Follow up CT head / imaging ICU admission with Neuro focus 14

15 fisher grading scale for sah/ Acute Hydrocephalus After SAH 15

16 ICU Level Management After Securing Aneurysm Vital signs and Neuro Checks Triple H therapy: hypertension, hypervolemia, hemodilution If concern for severe malignant edema, hypertonic solutions and if needed decompressive craniectomy ICP management Daily TCDs; CTA and CTP as adjunct for vasospasm Labs, ECHO, EKG, CXR Follow up imaging Daily Nimodipine (level 1), Statin (level 2), magnesium sulfate (level 2), DVT prophylaxis (level 2) Seizure prophylaxis Treatment for other comorbidities, infections, etc 16

17 Questions? jordanfrancispatricksmith.wordpress.com 17