DISCLOSURE. Amar Siyar, RVT. No relevant financial relationship reported

Transcription

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2 DISCLOSURE Amar Siyar, RVT No relevant financial relationship reported

3 Ahmad Siyar Vascular Ultrasound Technology Diagnostic Ultrasound Program Bellevue College

4 SWEDISH Swedish Medical Center Cherry Hill

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6 UW Medicine Harborview Medical Center

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8 Clinical Instructor: Anne Moore Supervisor; Cerebrovascular Lab Harborview Medical Center

9 Contents o Brain aneurysm statistics and facts o Signs and symptoms o Risk factors o Treatment o Types of grafts o Equipment and transducers o Challenges to imaging o Case study (ECA-ICA Bypass Graft) o Study findings o References

10 Brain Aneurysm Statistics and Facts in the US o 6 million people have unruptured brain aneurysm, 1 in 50. o o o 30 Thousand people suffer a brain aneurysm rupture every year. 66% of survivors suffer permanent neurological deficit. 15% die before reaching the hospital o Most prevalent in people ages o Larger than 1 inch are giant aneurysms difficult to treat.

11 Warning Signs/Symptoms Unruptured brain aneurysms are typically completely asymptomatic. These aneurysms are typically small in size, usually less than one half inch in diameter. However, large unruptured aneurysms can occasionally press on the brain or the nerves stemming out of the brain and may result in various neurological symptoms.

12 Unruptured brain aneurysms o Localized Headache o Dilated pupils o Blurred or double vision o Pain above and behind eye o Weakness and numbness o Difficulty speaking

13 Ruptured brain aneurysms o Sudden severe headache, the worst headache of your life o Sudden blurred or double vision o Sudden pain above/behind the eye or difficulty seeing o Sudden change in mental status/awareness o Sudden trouble walking or dizziness o Sudden weakness and numbness o Sensitivity to light (photophobia) o Loss of consciousness o Nausea/Vomiting o Stiff Neck o Seizure o Drooping eyelid

14 Risk factors for brain aneurysm Smoking and drug use Hypertension Congenital artery wall abnormalities Family history of brain aneurysms Age over 40 Gender, women compared with men at a ratio of 3:2 Disorders such as Ehlers-Danlos Syndrome, Polycystic Kidney Disease, Marfan Syndrome, and Fibromuscular Dysplasia(FMD) Presence of an arteriovenous malformation (AVM) Infection Tumors Traumatic head injury African-Americans and Hispanics at twice the rate of rupture of whites

15 Treatment of brain aneurysm To relieve symptoms and to prevent any subsequent strokes vascular surgeons and neurosurgeons try: 1. Improving collateral sources of flow: a. endarterectomy b. angioplasty c. stenting 2. Direct intervention: a. traditional procedures b. minimally invasive procedures.

16 1. Improving collateral sources of flow: o Patients with complete carotid occlusion can be asymptomatic due to adequate collateral system. o However, patients with recent ischemic symptoms are at high risk for subsequent stroke because of hemodynamic impairment due to poor collateral flow.

17 2. Direct Intervention: Traditional Huntarian ligation Clipping Aneurysmorrhaphy Wrapping ECA-ICA bypass Endovascular Coiling Stent-assisted coiling Pipeline stents Flow diversion stents

18 A- Traditional Huntarian ligation Clipping Wrapping

19 B- Endovascular Flow diversion stent Coiling

20 B- Endovascular Pipeline stent Stent-assisted coiling

21 B- Endovascular Web device

22 Extracranial to intracranial arterial bypass o Extracranial-intracranial (EC-IC) bypass surgery is being increasingly used in the surgical management of cerebrovascular diseases, especially for the treatment of complex aneurysms not amenable to clipping and occlusive cerebrovascular disease. o For this purpose either synthetic or autogenous grafts are used as conduit.

23 Types of grafts Direct extracranial to intracranial arterial bypass of the ipsilateral external carotid artery is performed either by: A. Superficial temporal artery (STA) bypass; B. Radial artery (RAD) bypass graft; C. Saphenous vein (SAPH) bypass graft; or D. Anterior tibial artery (ATA) graft. connecting external carotid artery (ECA) to one of the middle cerebral artery (MCA) branches.

24 Graft anatomy MCA - M2 Dist. Anastomosis Aneurysm Radial artery graft Prox. Anastomosis Prox. ECA

25 Bypass Map Distal MCA RAD Graft Proximal MCA

26 Philips iu22

27 Transducers o Broadband S5-1 sector array transducer o Hockey Stick L 15-7io Linear array transducer o L 9-3 Linear array transducer

28 Challenges to Imagining o Penetration of bone layer in order to image cerebral bed. o Patients limited maneuverability. o Intensive care equipment such as Intracranial pressure monitors and drains. o Patient cooperation. o Immediate post-op staples and bandages.

29 Case study o Immediate Post-Op duplex study o Exam performed in October, 2017 o Duration of the exam minutes o Inpatient setting o Patient non-intubated and awake o Vessels studied CCA, ECA, RAD graft, MCA, ACA, PCA

30 Patient history o Hypertension. o Cerebrovascular accident. o Gastroesophageal Reflux Disease. o 50-year previous smoker. o Chronic Obstructive Pulmonary Disease. o No family history of aneurysm.

31 History of present illness A 67-year old male patient was admitted early September Patient previously had a R MCA aneurysm rupture during attempted clipping in January 2017, causing hemorrhagic stroke with significant deficit followed by decompressive hemicraniectomy. The significant deficit caused multiple large left MCA territory infarct.

32 Pre-Op Angio

33 Operative plan o Palmar arch is assessed for patency. o Rad graft diameter is assessed. o The predetermined 22 cm segment of radial artery is harvested. o Proximal RAD graft is end to side anastomosed to the ECA. o Distal end of the graft is end to end to anastomosed to MCA-M2.

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35 Post Op Angio

36 Left ECA

37 Proximal Anastomosis

38 Mid Graft - Volume Flow

39 Transcranial Distal Graft

40 Left MCA

41 Preliminary findings 1. Patent left ECA-MCA radial artery bypass graft with averaged mid-graft volume flow measuring 78mL/minute. 2. Low velocities with antegrade flow left MCA. 4. Elevated pulsatility indices throughout the bypass graft and in the left MCA, ACA, PCA. 5. Normal velocity in PCA-P2.

42 Follow up o Patient developed postoperative aspiration pneumonia and pseudomeningocele hydrocephalus which complicated the course of the treatment. o Patient responded well to the procedure and started the course of recovery. o Patient was then discharged to rehabilitation.

43 References J Korean Neurosurg Soc Roh SW1, Ahn JS, Sung HY, Jung YJ, Kwun BD, Kim CJ J Korean Neurosurg Soc /c55450exv99w1.htm

44 References Colin P. Derdeyn, Robert L. Grubb, Jr., W illiam J. Powers Skull Base Feb; 15(1): doi: /s PMCID: PMC Sung Woo Roh, Jae Sung Ahn, Han Yoo Sung, Young Jin Jung, Byung Duk Kwun, Chang Jin Kim J Korean Neurosurg Soc Sep; 50(3): Published online 2011 Sep 30. doi: /jkns PMCID: PMC Sep;50(3): doi: /jkns Epub 2011 Sep 30. PMID: Brain aneurysm foundation, warning signs and symptoms Zuccarello, MD, reviewed, Mayfield Certified health info, Mayfield Clinic Failure of EC-ICA BPG to reduce ischemic stroke 1985 Nov 7;313(19): PMID: Barnhart, Krislynn, Transcranial Doppler in Current Endovascular Neurosurgery, 2017, PowerPoint file.

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