4/10/2018. The Surgical Treatment of Cerebral Aneurysms. Aneurysm Locations. Aneurysmal Subarachnoid Hemorrhage. Jerone Kennedy, M.D.

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1 The Surgical Treatment of Cerebral Aneurysms Aneurysmal Subarachnoid Hemorrhage Jerone Kennedy, M.D. Medical Director, Vascular Neurosurgery CentraCare Health-Neurosciences St. Cloud Hospital Aneurysm Locations 1

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5 Cerebral Aneurysms Prevalence of unruptured in US: Age F/2M 1/50 people, or 6,000,000 Likelihood of rupture: <10mm = 0.05% per year >10mm = 1% per year >25mm = 6% first year, 45% within 7.5 years Incidence of rupture in US >15/100,000 people, or 30,000 Causes of Subarachnoid hemorrhage Trauma Spontaneous Aneurysm (75-80%) Angio negative SAH (7-10%) AVM (4-5%) Vasculitis 5

6 Subarachnoid Hemorrhage (SAH) and Intraventricular Hemorrhage (IVH) Cerebral Aneurysms: Factors Affecting Rate of Rupture Size: >7mm Location: Basilar apex, P-comm, A-comm Multiple (in 15%) Increasing age Family hx Smoking/Alcohol (15x!) Cocaine 6

7 Cerebral Aneurysms: Factors Affecting Rate of Rupture Genetic syndromes PKD Connective tissue disorders, eg. Ehlers-Danlos Female Symptomatic Ethnicity Previous rupture Aneurysmal SAH Pt evaluation S/sxs of SAH in conscious pts SAH Headache (1% of HA in ER) 80%: Classical: sudden onset, thunderclap, worse headache of my life! Other 20% Unusually severe headache for them Sentinel HA = major rebleed 2 8 weeks later Nausea/vomiting SAH General Management General Care -ER -ABCs Neuro exam CT Ventric for HCP? Crani for hematoma? Intubation if GCS < 8 Check for h/o: coarctation of aorta, PKD, FMD, SCD, cocaine 7

8 Hunt and Hess Fisher Grade Aneurysmal SAH: Clinical Grading Hunt and Hess WFNS Fisher Grade May be useful for Standardizing assessment Estimating prognosis Downsides: Inter/intraobserver variability Omits other important features 8

9 Aneurysmal SAH Clinical Grading The worse the exam The more the blood The worse the prognosis Aneurysmal SAH - Diagnosis CT Volume of blood, time after bleed, quality of scan > 97.5% sensitivity for SAH on day one CTA: Sensitivity 95% (for aneurysms >2.1mm) Specificity 83% MRA: Sensitivity 86% (for aneurysms > 3mm) Specificity 84% Lumbar puncture From Weir B. Headaches from aneurysms. Cephalalgia. 1994;14:

10 Aneurysmal SAH - Diagnosis MRI FLAIR, PD, DWI for acute SAH Gradient echo, FLAIR for subacute SAH If positive, can skip LP If negative, must still do LP Aneurysmal SAH - Diagnosis Catheter cerebral angiography Versus CTA Complex aneurysm Endovascular tx Other assoc d anomalies (AVM, DAVF) Benign perimesencephalic SAH? Spinal AVM/AVF Diffuse aneurysmal pattern SAH on CT, and negative CTA If negative, do delayed study = small aneurysm in 15% Ddx includes vasculitis Aneurysmal SAH - Diagnosis Catheter cerebral angiography Complications Neurological 1.3% 0.7% transient, 0.2% reversible, 0.5% permanent Aneurysm rupture» % during angio» 0.22% within 24 hours» 70% mortality» Causative?? Allergic: 1/50,000 1/1,000,000 die 10

11 Aneurysmal SAH - Diagnosis Cerebral catheter angiography 20 30% have multiple aneurysms: which ruptured? Focal SAH on CT Focal spasm on angio Largest most irregularly shaped most proximal Focal neuro signs Repeat angio shows change Most likely to rupture ( eg, a-comm) Aneurysmal SAH - Diagnosis Negative cerebral angio (10 30%) Consider MRI/MRA Repeat angio > 1 week later = aneurysm in 15% Thrombosis A-comm Benign perimesencephalic SAH Repeat angio? SAH General Management General care Admit to ICU SAH order set Adequate analgesia: pain can incr CMRO by 30% TCDs: watch for vasospasm Isotonic crystalloid/colloid IVF to maintain euvolemia CVP/PCWP, prn, to monitor volume status Nimodipine: Improves neuro outcomes. Give for 21 days Can cause HA, hypotension, intestinal pseudo-obstruction 11

12 SAH General Management General care Mgmt of BP Target BP (Stroke vs Rebleed vs CPP) Premorbid BP ICP Time after SAH» Aneurysm not yet secured: SBP < 130» Aneurysm secured: SBP < 160» DCI: SBP < 220 Cerebral Aneurysms: Surgical Decision- Making Factors favoring clipping Aneurysm location (eg, MCA) Large ICH Wide-neck; branches from neck Reasonably good grade clinically (HH 1-3) Large aneurysm size Younger pt Patient preference Cerebral Aneurysms: Surgical Decision- Making Which aneurysms should be treated? Ruptured 15% die pre-hospital; 40% die in hospital; 2/3 of survivors have significant neuropsych and cognitive deficits If not treated, 20% re-rupture within 2 weeks, 50% within 6 months, At one year: 3% rupture/yr 4% re-rupture day 1, then 1.5% per day for next 13 days 70% of patients who rebleed die 12

13 Cerebral Aneurysms: Surgical Decision- Making Factors favoring coiling Aneurysm location (eg, basilar apex) Narrow neck, amenable to coil or clip Poor clinical grade (HH 4,5) Active vasospasm Smaller aneurysm size Elderly pt Patient preference 13

14 Aneurysmal SAH Neuro Complications Rebleeding: > 75% die Peak risk: first 24 hours 75% of rebleeds occur within 3 days If clip/coil delayed: Amicar or tranexamic acid Hydrocephalus: 20% EVD Risk of rebleeding?, infection (10%), hematoma Place before endovasc interventions (antiplatelets) Chronic HCP: 10 21% of survivors Risk factors Age, F, poor H&H, thick SAH, IVH, post circ aneurysm, vasospasm, coiled aneurysm Aneurysmal SAH Neuro Complications Intraventricular hemorrhage (IVH) Independent risk factor for death, disability, vasospasm, acute/chronic HCP In > 50% of pts with large IVH: > 64% die Most likely to occur with a-comm or basilar apex aneurysm rupture Intracerebral hemorrhage Frontal or temporal Crani if clinically significant mass effect Clip aneurysm if possible 14

15 Aneurysmal SAH Neuro Complications Seizures ( 20%) Assoc d with ICH, HTN, MCA or Acomm aneurysms Incr BP may cause rebleed Sz within first week not a risk factor for late epilepsy AED first week (Keppra, not Dilantin) Late epilepsy (3 10%) 94% occur within 2 years Less likely in coiled pts Aneurysmal SAH Neuro Complications Symptomatic vasospasm (46%) Inflammatory reaction in blood vessel wall Develops between 3 14 days after SAH Best predictor is the amount of SAH on CT Trancranial doppler for screening/monitoring Mean velocity >120 cm/sec; MCA/ICA > 3 Initial tx is euvolemia and induced hypertension Cerebral angio for IA Verapamil or angioplasty Nimodipine improves functional outcome in survivors Vasospasm: MRI and Angiogram 15

16 Vasospasm, with angioplasty Aneurysmal SAH Medical complications Almost all suffer at least one med complication -40% life-threatening 25% deaths due to med complications Fever (Most common medical complication) Incr cerebral edema and ICP Worsens cerebral ischemia Alters LOC Maintain euthermia Aneurysmal SAH Medical Complications Anemia Optimum hgb unknown Transfuse if < 8 and no vasospasm Transfuse if < 10, with vasospasm Avoid hyperglycemia (gluc > 130) or hypoglycemia Heparin-induced thrombocytopenia Related to number of angios 16

17 Aneurysmal SAH Medical Complications Venous thromboembolism (20 50%) Sx DVT 2% of pts with SAH SCD SQ heparin or LMW heparin 24 hours after aneurysm tx Anticoag after one week vs IVC filter Aneurysmal SAH Medical Complications Fluids/electrolytes Acute Hyponatremia (14-40%) Cerebral Salt wasting (BNP/ANP): hypovolemic hyponatremia Assess volume with CVP or PCWP Replace volume and Na with NS/Hypertonic saline/salt tabs Fludrocortisone acetate (mineralocorticoid) Hypernatremia DI (a-comm aneurysm: Hypotonic fluids, DDAVP) Clinical outcome after Aneurysmal SAH Mortality has decr d 15% over the past 30 years 12% die before reaching the hospital 40% of those reaching the hospital die 31% of clipped pts dead or dependent at 1 yr 24% of coiled pts dead or dependent at 1 yr Poor outcome: age, neuro grade, extent of SAH on CT, preop hypertension, vasospasm, presence of IVH/ICH, location and size of aneurysm 17

18 SAH: Medical Issues Rebleeding Hydrocephalus (20%) Delayed Cerebral Ischemia (46%) aka: DCI or Vasospasm Seizures (20%) Medical complications Fever (most common) Anemia DVT (35%) Hyponatremia (30%) 18