Cerebrovascular Malformations in the Elderly Indications for Treatment

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1 Cerebrovascular Malformations in the Elderly Indications for Treatment Johanna T. Fifi, MD, FAHA, FSVIN Director of Endovascular Ischemic Stroke Assistant Professor of Neurology, Neurosurgery, and Radiology Mount Sinai Health System, New York, NY May 21 st, 2016

2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Consulting Fees/Honoraria Stock Shareholder/Equity Company Microvention, Penumbra Lazarus Effect, Cerebrotech

3 Introduction Cerebrovascular malformations such as arteriovenous malformations, fistulas, and aneurysms can present at any age However, most congenital malformations are discovered earlier in life In the elderly, certain types of malformations can present acutely or become symptomatic in an insidious manner which can lead to delays in diagnosis

4 Introduction Lesions can also be incidentally discovered upon work up for other conditions A main factor in terms of management is symptomatic versus non-symptomatic This can inform the risk of future morbidity or mortality The management of cerebrovascular diseases presenting or incidentally discovered in the geriatric population requires careful analysis of the risk benefit ratio of any proposed treatment

5 Outline Neurovascular diseases in the elderly Arteriovenous malformations Dural arteriovenous fistulas Spinal dural arteriovenous fistulas Cerebral aneurysms Case based approach

6 Case Presentation: ZC 65 year old man No significant past history 6 months of slowly progressive mild cognitive decline Family noticed personality change: increased aggression and short temper Reduced verbal output Less involvement in social activities New onset seizure at 2 am while travelling on overnight train

7 Presentation assessment Lethargic, decreased verbal output Oriented to person, place and time Intermittently obeying commands No focal sensorimotor deficit

8 Initial CT

9 Initial CT

10 MRI C+ T1 FLAIR

11 C+ T1 FLAIR

12 RIGHT EXTERNAL CAROTID ARTERY

13 RIGHT EXTERNAL CAROTID ARTERY

14 RIGHT EXTERNAL CAROTID ARTERY

15 RIGHT INTERNAL CAROTID ARTERY

16 RIGHT INTERNAL CAROTID ARTERY

17 RIGHT INTERNAL CAROTID ARTERY

18 Dural Arteriovenous Fistula Pathologic shunts between dural arteries and veins Occur outside the brain in the dura 10-15% of intracranial AVM Present in adulthood More common in women

19 Classification Borden Classification Type 1: Anterograde sinus flow and no cortical venous reflux Type 2: Retrograde sinus flow and cortical venous reflux Type 3: No flow inside the sinus and exclusive cortical venous reflux

20 Presentation Highly variable Symptoms depend on location Pulsatile tinnitus, Bruit, Headache Opthalmoplegia, Chemosis, Proptosis Papilledema, Intracranial hemorrhage Focal or Global Neurologic Deficit

21 Natural History Aggressive presentation Intracranial Hemorrhage, Focal Neurologic Deficit or Death Borden Type 1 2% Borden Type 2 39% Borden Type 3 79% Borden Type 2 & % / patient-year ICH Interventional Neuroradiology 1997; 3:

22 Etiology Idiopathic; Not completely understood Often occurs in patients with prior trauma, sinus thrombosis, hypercoagulable states, or infection Theory: collateral revascularization of occluded sinuses/veins

23 Radiographic Evaluation CT/CT Angiogram, MR/MR Angiogram Abnormal blood vessels, hemorrhage, white matter edema Cannot exclude DAVF Conventional Cerebral Angiography The Gold Standard Hallmark early filling of venous structures Accurate classification

24 Treatment Observation Medical Management Endovascular Transarterial Transvenous Liquid Embolic, Coils, Stents Surgery Exposure Ligation, Resection or Disconnection of DAVF Stereotactic Radiosurgery Gamma Knife Cyber Knife Novalis Combination Endovascular, Surgery, Radiosurgery

25 Post treatment

26 Pre and Post treatment

27 Case Presentation: CA 75 year old Haitian woman with no past medical history Presents with 2 years of progressive loss of balance, difficulty walking, bilateral lower extremity weakness, and muscle spasms.

28 Physical Examination Normal alertness and mentation Full strength, normal sensation and reflexes in the upper extremities Right lower extremity 3/5 in the hip flexor and knee extensors, 5/5 distally Left lower extremity 2/5 in all muscle groups Decreased sensation in the LLE to light touch No associated radicular pain Hyperreflexia in both lower extremities

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32 Spinal Vascular Malformations AV fistula (AVF): direct communication between artery & vein AV malformations (AVMs): multiple complex communications with a nidus Nidus: the core of an AVM that appears angiographically and anatomically as a conglomeration of vessels

33 Classification - 4 Types Type I: Dural AV Fistula Type II: Glomus AVMs Type III: Juvenile AVMs Type IV: Intradural AV Fistula

34 Type I (Dural AV Fistula) 60% of spinal AVF/AVM Single AV connection within the dura of the nerve root sheath Results in dilated arterialized venous plexus Impaired venous drainage

35 Clinical Presentation Type 1 Mean age: 50yr Men 4 times more common Majority: thoracic and thoracolumbar Symptoms: insidious back and leg pain, mild sensorimotor dysfunction (like spinal stenosis) Signs: mixed UMNL and LMNL and patchy sensory loss.

36 Natural History of Type 1 Inevitable progression of symptoms Episodes of acute worsening Foix-Alajouanine syndrome If untreated: wheelchair dependence within 6 mo to 3 years after symptom onset Preoperative neurologic status is the most important predictor of post-treatment outcomes Median time from symptom onset to diagnosis: 15 to 23 months.

37 Treatment Goal: total obliteration or excision of the abnormal shunt through embolization or surgery If only partially reduce the shunt or address proximal feeders only recurrence

38 General Considerations of Endovascular Treatment In most centers nowadays, endovascular embolization is the first line treatment Either primary or adjunctive role depending on the type of AVMs & expertise Type I: attempts of embolization, if failed surgery Surgery produces 98% fistula obliteration rate Endovascular embolization only possible when able to deliver embolic material to the fistula site and has a lower 40 to 66% obliteration rate

39 Case Presentation: CA 75 year old Haitian woman with no past medical history Presents with 2 years of progressive loss of balance, difficulty walking, bilateral lower extremity weakness, and muscle spasms.

40 Case Presentation: RA 89 year old man with history of asthma, hypertension, and high cholesterol Developed sudden, severe right sided head and neck pain while brushing his teeth. Over the next two days, the patient noted unsteady gait and blurry vision Symptoms did not resolve and he went to the emergency department and had imaging work up CT and MRI of the brain showed subtle subarachnoid blood

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48 Case Presentation: RA The patient did well following the procedure He recovered back to baseline Back at home

49 Cerebral Aneurysms: Background Incidence: From autopsy and angiography studies Estimated at 2-3.2% of the general population Higher incidence in First degree relative with SAH (RR 4.4) ADPKD (RR 4.0) Atherosclerotic disease (RR 2.3) Rinkel et al. Stroke. 1998

50 Cerebral Aneurysms: Background Incidence SAH: 30,000 per year in US 2% of US population (6,000,000) have aneurysms 0.5% rupture per year Estimation of rupture risk depends on many individual factors

51 Subarachnoid Hemorrhage Devastating Disease 15% die before reaching the hospital Further 15-20% die during next few months 4/7 who recover will have disabilities

52 Cerebral Aneurysms: Locations

53 Aneurysm Morphology Size, Daughter sac Technical risk of treatment

54 How do we decide who to treat?

55 Ruptured aneurysms Very easy decision High rate of re-rupture and death in the weeks following initial hemorrhage Treat to prevent re-rupture Don t treat if futility in care

56 The Data - Unruptured aneurysms International Study of Unruptured Intracranial Aneurysms 4060 total patients enrolled 1692 untreated patients with 2686 aneurysms 2368 treated (not randomized) Primary aim to determine natural history and treatment risk for cerebral aneurysms Not randomized!

57 The Data - ISUIA

58 Aneurysms with increased risk Previous SAH self and family Multiple aneurysms Symptomatic CN Palsy Multiple 3 rd nerve palsy series Mass effect Potentially ruptured Irregularity daughter sac Recent growth Serial imaging

59 UCAS DATA UCAS Unruptured Cerebral Aneurysm Study in Japan Over 5,000 patients enrolled Some treated Followed 3-8 years UCAS II 1,069 patients with UIA followed Followed for 3 years

60

61 Treatment Options Two basic strategies Surgical clip occlusion Endovascular embolization

62 Coil Embolization First Guglielmi detachable coils introduced in 1992 Gained FDA approval in 1995 Significant advancements in coil technology have given: More variability In diameter, length, stiffness More complex shapes Stretch resistance

63 Treatment: New technology All in clinical trials taking place at Mount Sinai

64 Who to treat? Must be weighed against treatment risk Generally <5% risk of treatment in UNRUPTURED cases Expected 5-10% complication if RUPTURED General anesthesia risk due to co-morbid conditions Patient comfort/anxiety and preference

65 Calculating Risk A note: ISUIA and others give us approximate 3-5-year risk No single trial gives us data further out Many clinicians will use an additive risk by 5-year increments

66 Life Expectancy Male Female Exact Death Number of Life Death Number of Life age probability a lives b expectancy probability a lives b expectancy , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Data from SSA 2011 period life table

67 Case Presentation: SP 83 year old woman who presented with SAH in 2007 Had coiling of a right posterior communicating artery aneurysm She has been followed since that time

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69 Case Presentation: SP Probability of rupture: Estimated at 15% over next three years no one knows for sure Patient has severe COPD SOB walking ½ block, 2-3 pillows After 2 minutes walking, SpO2 96%-90% FEV1/FVC 51%

70 The Future Neuroimaging to predict rupture Computational flow dynamics Imaging the wall

71 Conclusions Treatment of incidentally discovered neurovascular lesions must be carefully weighed against natural history data Advances in endovascular technology have made difficult lesions accessible with shorter, less invasive procedures Neurovascular conditions that present with potentially life threatening events can be safely treated in the elderly

72 72 Mount Sinai / Presentation Slide / December 5, 2012

73 Questions?

74 Contact Info Johanna Fifi Cell:

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