Neurosurgical decision making in structural lesions causing stroke. Dr Rakesh Ranjan MS, MCh, Dip NB (Neurosurgery)

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1 Neurosurgical decision making in structural lesions causing stroke Dr Rakesh Ranjan MS, MCh, Dip NB (Neurosurgery)

2 Subarachnoid Hemorrhage Every year, an estimated 30,000 people in the United States experience a ruptured cerebral aneurysm and as many as 6 percent may have an unruptured aneurysm.

3 A 64 year old lady presents with sudden onset severe headache.

4 International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Andrew J Molyneux, Richard S C Kerr, Ly-Mee Yu, Mike Clarke, Mary Sneade, Julia A Yarnold, Peter Sandercock, for the International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group

5 Endovascular procedure Completed 1014 (92 6%) Failed to catheterise target aneurysm 29 (2 6%) Aneurysm catheterised but anatomy unsuitable 37 (3 4%) Not attempted 15 (1 4%) Total 1095 (100%) Neurosurgical procedure Clipped 977 (96 5%) Wrapped 13 (1 3%) Not completed (partial clipping or wrapping) 14 (1 4%) Not attempted 8 (0 8%) Total 1012 (100%) *The results relate to the first procedure done, not the random treatment assignment. Table 1: Technical outcome of first procedure *

6 Conclusion In patients with ruptured intracranial aneurysms suitable for both treatments, endovascular coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after endovascular coiling than after neurosurgical clipping.

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8 Aneurysm difficult to coil Wide necked (aspect ratio) MCA aneurysms Giant aneurysm

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10 Intra op images

11 Post op images

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14 Intraop images

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16 Arteriovenous malformation Arteriovenous malformations (AVMs) are present in about 1 percent of the general population. The risk of hemorrhage from an AVM is 4 percent per year with a 15 percent chance of stroke or death with each hemorrhage

17 Spetzler & Martin Grading Size of AVM Small (<3 cm) 1 Medium (3-6 cm) 2 Large (>6 cm) 3 Location Noneloquent site 0 Eloquent site* 1 Venous drainage Superficial 0 Deep 1

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19 Treatment options Surgery Embolization Radiosurgery

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21 24 year old lady with bleed and seizures

22 CT angio and DSA (cerebral)

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25 Cavernoma Bleed Seizures

26 Treatment decisions Poorly controlled seizures Intracerebral bleed Neurological deficit

27 Dural AV Fistula Venous malformation Vein of Galen malformation Moya Moya disease

28 Malignant cerebral infarction ICP monitoring Decompressive craniotomy

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31 Ultra early surgery in MCA infract decomprssive surgery in posterior circulation infact

32 Revascularization therapy Carotid endartectomy Stent Bypass techniques

33 Hazard Ratio for CAS Versus CEA in 1321 Symptomatic Patients by Treatment Group Periprocedural HR (95% CI) 4-Year Study Period HR (95% CI) MI 0.45 ( ) Any periprocedural stroke or postprocedural ipsilateral stroke 1.74 ( ) 1.29 ( ) Any periprocedural stroke, death, or postprocedural ipsilateral stroke 1.89 ( ) 1.37 ( ) Any periprocedural stroke, MI, death, or postprocedural ipsilateral stroke 1.26 ( ) 1.08 ( )

34 For patients with recent TIA or ischemic stroke within the past 6 months and ipsilateral severe (70% to 99%) carotid artery stenosis, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6% (Class I; Level of Evidence A).

35 Thank you Thank you