Cerebral Aneurysms: Imaging and Treatment Options

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1 Cerebral Aneurysms: Imaging and Treatment Options Jussi Numminen, MD,PhD, neuroradiologist Helsinki University Central Hospital

2 Subarachnoidal Hemorrhage (SAH) Blood between arachnoid and the pia: Sulci and cisterns Trauma the most common cause Nontraumatic SAH Vasculature imaging mandatory (CTA, DSA) ~80%: Ruptured intracranial aneurysm ~20%: Nonaneurysmal Perimesencephalic SAH Convexal SAH Venous hemorrhage, trombosis Vasculitis Amyloid angiopathy Reversible Cerebral Vasoconstriction Syndrome (RCVS) AVM, davf Coagulopathy PRES etc

3 Aneurysmal Subaracnoid Hemorrhage Sudden onset severe headache (worst in my life) 9/ /year in Finland M/F 1:2, peak age years 3-5% of all strokes 1/3 fatal, 1/3 survive but disabling neurologic deficit, 1/3 survive Unfavorable outcome: Large amount of SAH Old age Parenchymal hematoma + intraventricular hematoma

4 Aneurysmal Subarachnoid Hemorrhage Without treatment rebleeding rate 20% within first two weeks Vasospasm (2/3, 1/3 symptomatic) Critical period within three first weeks Late ischemia and morbidity Treatment: Nimodipine + hypertension Hydrocephalus Early (ventriculostomy) Late (Shunt)

5 SAH: Imaging + Diagnosis CT SAH distribution, ICH, IVH, hydrocephalus, late ischemia Pseudo SAH: severe cerebral oedema MR: Hyperacute blood is isointense on T1, bright on T2 : difficult to identify The best is FLAIR and SWI FLAIR subarachnoid hyperintesity can be artefact, meningitis, meningeal metastases, STROKE (slow flow and collaterals), MoyaMoya, RCVS

6 Perimesencephalic SAH Headache SAH around pons and midbrain (mesencephalon) and posterior supracellar cistern CTA and DSA normal CTA control after one week Venous bleeding? Perforator rupture? Most cases clinically benign, rebleeding rare (<1%)

7 SAV, CTA negative

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9 Intracranial Aneurysms True Saccular Aneurysm One side of artery focally dilated, have true wall but internal elastic lamina and media may be missing Vessel bifurcations Pseudoaneurysm No true arterial wall, cavity within a hematoma clot Dissection, trauma, infection, neoplasm, iatrogenic Anywhere in vasculature Blood Blister-like Aneurysm Small broad based dilation of arterial wall Covered only by fragile thin fibrous tissue Typically on dorsal supraclinoid ICA Fusiform Aneurysm Whole artery focally dilated Atherosclerosis

10 Intracranial Ruptured Aneurysms: Imaging CTA first option Fast and available in an acute setup 3D data-analysis with MIP or MPR reformats mandatory Excellent sensitivity and specificity Calcifications Artefacts due to previous coiling or clipping or finding needs verification -> DSA DSA golden standard 4-6 vessel selective injections with at least two projections (biplane) 3D rotational angiography Invasive Intervention MRA Suspected dissection: intramural hematoma

11 CTA Protocol in Helsinki Helical whole skull starting C1 350 mgi/ml, 70 ml, 5 ml/s SmartPrep window C3-4, no delay mm/0.312 mm slice reconstructions 22 mm/3 mm MIP, axial, coronal and sagittal reformats 3D analysis programs (GE, Vitrea)

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14 Intracranial Saccular Aneurysm Prevalence 2% (Finland), nonruptured and asymptomatic ~10 times more common than ruptured Acquired lesions Smoking, hypertension, alcohol Abnormal flow (AVM, abnormal anatomy), stress on vessel wall Increased risk Persistent trigeminal artery, fenestration Vasculopathy (Marfan, Ehlers-Danlos, fibromuscular dysplasia) Polycystic kidney disease Family history First order relative has SAH due to saccular aneurysm

15 Intracranial Saccular Aneurysm SAH: Intradural (supraclinoid) aneurysms Annual rupture rate 1-2% Differentiated from infundibular enlargements 90% in the anterior circulation (ICA, MCA, ACA) vessel bifurcations Acomm (~30%), Pcomm (~30%, III CN palsy ), MCA bifurcation (~20%) Oftalmic artery, Anterior choroidal artery, ICA bifurcation, M1 branch, Pericallosa bifurcation 10% in the posterior circulation (vertebral and basilar artery) Basilar tip, PCA-a.cerebelli superior, PICA Aneurysm of any size can rupture, larger one more probably Aneurysm size in relation to parent vessel may be important Aneurysm with secondary lobules may be more prone to rupture SAH distribution, parenchymal hematoma close to aneurysm Giant aneurysm, size >2,5 cm Compression symptoms Trombosis Tromboembolic event

16 SAH with a Ruptured Aneurysm:Treatment Treatment of a ruptured aneurysm is to prevent rebleeding Highest risk during first two weeks, treatment within 24 hours Spasm prevention with hypertension after aneurysm closure Observation Severely comatose Surgery Clipping Trapping Wrapping By-pass and vessel closure Endovascular treatment Coiling Stenting and coiling Flow diverters WEB ( intra aneurysmal flow diverter) Vessel occlusion In most centers endovascular > surgery In Helsinki treated patients: Endovascular 62%, Surgery 38% Posterior circulation ~100% endovascular, MCA ~100% surgery

17 Endovascular Treatment Suitable for any location, any size, and any form (broad base and narrow neck) Any device which remains in the parent vessel needs dual antiplatelet therapy Klopidogrel 75 mg 1 x 1 + ASA 100 mg 1 x 1 Stent: 3 months Flow diverter stent: 6 months Activity measurement (VerifyNow test) Endothelization later, maybe ASA for a longer period Acute ruptured aneurysm best treated with coiling or WEB No need for anticoagulation Ventriculostomy safe

18 Endovascular Treatment Follow up: 6 months DSA, 2 years MRA/DSA, 5 years MRA/DSA If residive or coil compaction Flow diverter Stent assisted coiling Recoiling Clipping Complications (~6%) Aneurysm rupture Dissection Tromboembolic Event

19 Endovascular treatment General anestesia Biplane Neuroangiosuite 3D rotational angiogram Triaxial-tetraxial system: Groin puncture, 8 Fr introduser to aorta 6-8 Fr Guiding catheter to ICA, 6 Fr to vertebral artery 5 Fr Distal acces catheter to intracranial ICA (Flow diverter, WEB) 1,7 Fr (~1,7/3 mm = 0,7 mm) Microcatheter to the aneurysm All continuously flushed with saline Heparine with ACT measurements

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22 Ruptured Acomm aneurysm Primary coiling and 6 months follow up

23 Aneurysm Coiling Platinum Coil sizes: 1 mm 24 mm diameter 1 cm 60 cm lengths Framing coil: spherical or complex shape Filling coil: helical Broad based: -Baloon assisted coiling -Comaneci assisted coiling -Stent assisted coiling -Pulse Rider bifurcation device assisted coiling

24 SAH 1981, Acomm aneurysm clipped SAH 2017, Acomm residive aneurysm and right MCA bifurcation aneurysm with lobulations

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26 Treatment 3 mm Acomm aneurysm ruptured: ICH at aneurysm site Stent Neuroform atlas 3 mm x 20 mm Intraprocedural heparin + ASA 500 mg IV + Plavix loading 300 mg when awake

27 Nonruptured 3 mm PCA-a.cerebelli superior aneurysm PulseRider bifurcation device and coiling 6 months follow up

28 56 y healthy male Sudden onset headache CT: Intraventricular hematoma CTA: MoyMoyA +small aneurysm in posterior choroidal artery branch

29 Treatment with glue and ONYX (Ethylene- Vinyl Alcohol Copolymer)

30 Aneurysm Treatment with WEB Intra-aneurysmal flow diverter Broad based aneurysms No anticoagulation needed: treatment of ruptured aneurysms

31 Ruptured basilar tip 5 mm x 7 mm aneurysm Treatment with WEB embolisation device

32 Aneurysm Treatment with Flow Diverter Dense mesh stent No need for coils Perforators remain open: flow demand Aneurysm tromboses: no flow Dual antiplatetlet therapy crucial Acute and late bleeding complications In acute setup dissecting aneurysms, blister aneurysm, pseudoaneurysms Later treatment of residives, large and giant aneurysms

33 30 y female collapsed during horse riding CT: SAH CTA: Distal pericallosal dissection/pseudoaneurysm

34 Treatment Flow diverter: Fred Jr Intraprocedural heparin, ASA 500 mg IV prior to stent placement, ReoPro bolus + infusion after stent, 600 mg klopidogrel to the nasogastric tube

35 5 days later Deterioration of clinical condition CTA: Vasospasm CT: Ischemia

36 70 y male Headache CT: SAH CTA: dissecting basilar trunk aneurysm Primary treatment with coiling

37 6 months follow up Residive Retreatment with a flow diverter: Surpass

38 60 y female Abducens paresis MRI and MRA reveals a large ICA intracavernous aneurysm

39 Treatment Flow diverter: Surpass 4 mm x 30 mm

40 Follow up 2 years

41 Points to remember Aneurysmal SAH is a severe disease Imaging is simple: CT There are good treatment options and the patient should be treated as soon as possible In spite of the treatment the course of the disease can be fatal Flow diverters are cool!