CEREBRAL ANEURYSM. Epidemiology. Number of Case per Year 12/15/2008. Wanarak Watcharasakailp M.D.

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1 Epidemiology CEREBRAL ANEURYSM Wanarak Watcharasakailp M.D. 5-10% of all stroke 6-7 /100,000 persons/yrs, 20/100,000 in Finland and Japan Female predominant Most in anterior circulation Female->ICA 36.8% Male -> Anterior Com.46% Number of Case per Year

Site of Aneurysm 45 40 35 30 25 20 15 10 5 0 A corn P corn MCA pericallosal PCA

- Prehospital mortality 10-15% - Sudden onset of worst headache [1/3] 76% - 20%

confusion,lethargy 30% Transient loss of conscious [30%] 37% Coma [17%]- 7% Meningism

2 Site of Aneurysm A corn P corn MCA pericallosal PCA Basilar tip CA vertelral mulitple Clinical Presentation Clinical Presentation(Con t) - Prehospital mortality 10-15% - Sudden onset of worst headache [1/3] 76% - 20% associate with exertional activities - Alteration of conscious [2/3] 25% confusion,lethargy 30% Transient loss of conscious [30%] 37% Coma [17%]- 7% Meningism 52% Focal neurological sign 21% Seizure 7-17% Warning leak 15-39% Subhyaloid hemorrhage,terson s syndrome 2

3 Imaging CT Brain 4-vessels angiogram CTA [30%] MRA [70%] 3

4 4

Suspect SAH -VE lumbar puncture CT brain +VE 4VV angiogram or CT angiogram or MRA positive->treatment negative Non aneurysmal pattern stop investigate Aneurysmal pattern repeat angiogram 1-4 wks

5 Suspect SAH -VE lumbar puncture CT brain +VE 4VV angiogram or CT angiogram or MRA positive->treatment negative Non aneurysmal pattern stop investigate Aneurysmal pattern repeat angiogram 1-4 wks Management of Rupture Aneurysm Without treatment 50% of aneurysmal SAH death Suspect SAH -> immediate evaluation, stabilizaton, refer to neurosurgical care Key ->aneurysm obliteration to prevent rebleeding and to prepare the stage for other management Management implication Treatment should be initiate early to minimizing the complication of ischemia Surgery best perform soon after rupture Euvolemia for improve CBF Cerebral protection decrease effect of ischemia 5

6 Clinical Grading Grade (WFNS) Outcomepredictor > Patient clinical status at admission Hunt&Hess,WFNS, Fischer grading Hunt and Hess Scale WF SGrade GCS* Score Motor Deficit Grade Clinical Findings 0 Nosubarachnoid hemorrhage I Asymptomatic or mild headache, mild nuchal rigidity II Moderate to severe headache, nuchal rigidity, No neurologic deficit except cranial nerve palsy III Drowsiness, confusion, or mild focal deficit IV Stupor or mild to moderate hemiparesis ; possible early decerebrate rigidity V Deep coma, decerebrate posturing, moribund 0 15 Absent and no subarachnoid hge 1 15 Absent Absent Present Present or absent Present or absent 6

7 Fischer Grade CT Scan Findings Preoperative Care 1 No blood detected 2 Diffuse thin layer of subarachnoid blood ( vertical layers > 1 mm thick ) 3 Localized clot or thick layer subarachnoid blood ( vertical layers > 1 mm thick ) 4 Intracerebral or intraventicular blood with diffuse or no subarachnoid blood Goal: stabilize patient for aneurysm obliteration and prevent the development of systemic complication or secondary insult ER ->ICU Good grade ->strict bed rest,neurologic assessment,iv fluid Poor grade -> ICPmonitor,ventilation,sedation Pharmacologic Treatment 1.BP control systolic BP > 180 mmhg Morphine for control pain Rapid acting IV agent : NTP,NTG,nicardipine 2.Seizure 10% Anticonvulsant Pharmacologic Treatment(Con t) 3.Nimodipine Improve outcome neuroprotectant.,pia collateral circulation 4.Steroid Controversy 7

8 Surgery or Endovascular? Trends in the treatment of cerebral aneurysm.[ ] - clipping : 11,000 13,000 - endovascular : 11,000 24,000 M. Zuccarello 8

9 9

10 10

Early surgery Good point Prevention of rebleeding Aggressive management of vasospasm - Tripple H - angioplasty Remove of subarachnoid clot - mechanical,thrombolytic Early surgery(con t)

11 Early surgery Good point Prevention of rebleeding Aggressive management of vasospasm - Tripple H - angioplasty Remove of subarachnoid clot - mechanical,thrombolytic Early surgery(con t) Decrease hospital stay Prevent of medical complication like pneumonia or DVT Prevent hydrocephalus Decrease psychosocial stress Early surgery(con t) Weak point Swollen brain Unstable patient 11

Endovascular Nonsurgical management Selected case ISAT Study Coiling versus clipping - relative risk reduction 24% in poor outcome - absolute risk reduction 7% -

12 Endovascular Nonsurgical management Selected case ISAT Study Coiling versus clipping - relative risk reduction 24% in poor outcome - absolute risk reduction 7% - except in age> 70,MCA aneurysm - timing : 7% absolute advantage > 1 year Problem - time to followed up - radiologic technics - secondary procedure after recurrent 12

13 Postoperative Care ICU care at least in period of maximum vasospasm (10 days) Critical care monitor Careful attention to cardiorespiratory function,volume status,icp,prevention of secondary insult and medical complication Vasospasm Hypotension Hypoxia Hyperglycemia all affect outcome and greatest impact in good grade patient Perioperative Management General care - Admitting Order monitoring :V/S, N/S, arterial catheter, CVP nursing care : bed rest, elevate head 30degree, foley s catheter, NG tube medication : Stool softener, Laxative, Analgesic, IV fluid[ 3 L/ day], sucralfate/ omeprazole, Sedative [ Lorazepam], anticonvulsant, Antihypertensive. 13

14 Complication specific to SAH Management of blood pressure - depend on : time, aneurysm clipped, premorbid BP. - Analgesia : morphine - Sedation : midazolam - Antihypertensive NTP, Nicardipine - Surgical : Rebleeding : Hydrocephalus : ICH, IVH Medical complication : Respiratory complication - Pulmonary edema [ neurogenic, cardiogenic, volume over load] - Pneumonia Cardiovascular complication - EKG abnormality : sympathetic hyperactivity -> arrhythmia :< 4% serious Fluid/ electrolytes - hyponatremia, hypernatremia, hypokalemia 14

15 Postoperative deterioration Multiple causes Neurogenic : rebleeding, hydrocephalus, vasospasm, ICH, cerebral edema Post operative : vascular occlusion, cerebral edema, contusion, infection Systemic: hyponatremia, hypoxia, hypotension, hypercarbia Cerebral vasospasm Angiographic/ symptomatic vasospasm Diagnosis - clinical : focal deficit[1/4],decrease level of conscious[1/4],both [1/2] - TCD - angiography - SPECT/ Xe CT Vasospasm prevention Predictor - total amount of subarachnoid blood - loss of consciousness at the time of hemorrhage - hypovolemia - hypotension Fluid management - preventing hypovolemia, anemia and antihypertensive - IV [ 3L/day], maintain highnormotensive[ mmhg], slight hypervolemia 15

16 Subarachnoid blood clot removal Calcium channel blockers - BRANT trial : nimodipine 60 mg q4 hr for 21 days - Cochrane review: relative risk reduction 18%, absolute risk reduction 5.1% Magnesium sulphate - 50% hypomagnesemia in poor outcome group. - phase 2 study Treatment of delayed cerebral ischemia - diagnosis is often defined poorly[20 pts] - lab /CT brain to exclude other causes - TCD/ angiogram : poor positive and negative predictive value. - Triple H,angioplasty and vasodilating drugs had not RCT to prove efficacy. Management of hydrocephalus [15%] - gradual reduction of consciousness. - 20% alert when detected, 50% spontaneous improvement. - lumbar drainage/ ventriculostomy. 16

17 Improve Overall Outcome Outcome - good outcome = 63% - poor outcome = 33.4% - death = 13% Early surgery Imaging technic Transcervical doppler ultrasound Hypervolemia Ca channel blocker Endovascular technic Identified secondary insult Aggressive monitoring&intensive care FUTURE 1. Aneurysm formation and rupture primary prevention - modified risk factor:smoking,atherosclerosis,ht 2. Systemic approach - brain attack organization - prehospital care,er,preoperative care,rehabilitation FUTURE(con t) 3. Specialized center successful treatment -> multidisciplinary team :neurosurgeon,neurologist neuroanesthesiologist,neurointensivist intensive care unit nurse 4. Physician education:early Dx warning leak 17

18 FUTURE(con t) 5. Appropriate use of endovascular and surgical technic 6. Academic evaluation - control randomized - guideline FUTURE(con t) 5. Prevention 5.1 Incidental unruptured aneurysm. - risk of clipping /coiling versus risk of bleeding - age,size,aneurysm,location,sex, country,comorbidity,family history. 5.2 Unruptured aneurysm in patients with SAH - coiling /clipping - high risk of rupture in subgroup analysis Screening - relative of SAH patients: twos or more affected first degree relative,ad polycystic kidneys disease, identical twins. - screening for new aneurysm: slightly increasedlife expectancy but reduced quality of life and increase cost. 18

19 Except women with first episode at very young age, multiple aneurysm. Time : every 5 years THE END QUESTION Perioperative and Intensive Care Unit of patient with SAH Medical complication of SAH Medical complication of SAH Volume and electrolyte hypovolemia and hyponatremia plasma volume decrease > 10% in 6 days normovolemia and hypervolemia hyperglycemia > 200 mg/dl (cerebral ischemia) 19

20 Cardiac Complication(50%) MI 0.7% Abnormal EKG -> MI Hypertension sedation -> morphine,sedation,paralysis not require treatment in all patient Pulmonary Complication aspirate pneumonia pulmonary edema PE,atelectasis and bronchospasm neurogenic pulmonary edema Thromboembolic Events DVT,PE gradual stretching, intermittent calf compression Fever and Infection around 30 % antipyretic -> increase cerebral ischemic injury Nutrition Support within 48 hrs GI Complication GI bleeding prophylactic therapy:h2 block,antacid,sucralfate Sedation and Analgesic pain,irritable and agitation -> increase risk of rupture good grade -> paracetamol,morphine poor grade -> short acting eg. Fentanyl, midazolam 20

21 eurologic Complication 1. Rebleeding major cause of mobidity and mortality 7-19% rebleeding in 30 days repeat CT Brain aneurysm occlusion 2. Seizure and Epilepsy initial seizure 4-25% early seizure 1.5-5% late seizure 3% systemic effect devastating to SAH patient low risk -> anticonvulsant for 1-2 wks high risk -> anticonvulsant for 1 yr 3. Cerebral edema and intracranial hypertension vasogenic edema -> breakdown of BBB cytotoxic edema -> hypoxia,cerebral ischemia interstitial edema -> hydrocephalus 24-30% develope IICP Management of IICP ABC assesment CT brain emergency surgical Non-surgical Hydrocephalus Maintain cerebral perfusion EVD ICH Head position -clot evacuation Mannitol/lasix - aneurysm clip (hyperventilation,dexamethasone 4. Hydrocephalus -communicating or obstruction ventriculostomy Benefit : control ICP,clinical improve monitor ICP blood remove Risk : rebleeding Infarction shunt dependent 21

22 Intensive Care Monitor 5.secondary cerebral insults hypotension hypoxia hyperglycemia fever electrolyte imbalance Protocol for intial management following subarachnoid hemorrhage Evaluation/stabilization Airway, breathing, circulation Intubate if poor grade Maintain normovolemic, normotensive Complete examination Assign GCS* Baseline complete blood count, electrolytes, clotting studies Correct eletrolyte disturbances Head computed tomography with infusion computed tomography Determine amount of subarachnoid hemorrhage Determine aneurysm location Eevaluate for intracranial hemorrhage, hydrocephalus Monitoring Oxgenation Pulse oximetry Arterial blood gases Hemodynamics Arterial catheter, blood pressure cuff Central venous catheter (good grade) Swan - Ganz catheter (poor grade or medical indications) Intracranial pressure Intracranial pressure monitor Vasospasm Baseline transcranial Doppler ultrasonographic evaluation Fluid balance Bladder catheterization Hourly intake and output 22

23 Cerebral perfusion Establish normovolemia if low vasospasm Consider hypervolemia if high vasospasm risk Do not lowe systemic blood presure < 180 mmhg Ensure pain control/secdation Acetaminophen + morphine + benzodiazepines Fentanyl (propofol if intubated ) if necessary Initiate seizure prophylaxis Fosphenytoin or phenytoin for 1-2 weeks unless high risk Begin deep vein thrombosis prophylaxis Pneummatic compression stockings + Subcutaneous heparin postoperatively + Low molecular weight heparin postoperatively Begin vasospasm prophylaxis Main normovolemia, normonatremia Nimodipine Hydrocephalus Ventriculostomy Ensure ABC s (airway, breathing, and circulation ) Surgical Emergent Head CT scan Intracerebral hemorrhage Clot evacuation Aneurysm clipping Nonsurgical Maintain cerebral perfusion Head positioning Mannitol / Furosemide (Lisix ) + Hyperventilation + Dexamethasone VASCULAR MALFORMATIO - AVM - CAVERNOUS MALFORMATION - CAPILLARY TELANGIECTASIA - VENOUS ANGIOMA Ateriovenous Malformation Abnormality connection between arteries and venous system that lack an intervening capillary bed Most lesion < 40 years Leading cause of non traumatic ICH in young people 23

24 Clinical presentation Hemorrhage ( ICH, IVH, SAH, Combine) mortality 10-29% annual risk 2-4% per year Seizure Focal neurologic deficit Headache IMAGING CT CT ANGIOGRAM MRI ANGIOGRAM 24

25 TREATMENT GRADING Spetzler Martins Scale Lesion size small < 3 cm 1 medium 3-6 cm 2 large > 6cm 3 25

RISK OF HEMORRHAGE Location noneloquent 0 eloquent 1 Venous drainage superficial 0 deep 1 Grade 1-5 Deep seated lesion Small size Single draining vein Deep

26 RISK OF HEMORRHAGE Location noneloquent 0 eloquent 1 Venous drainage superficial 0 deep 1 Grade 1-5 Deep seated lesion Small size Single draining vein Deep venous drainage Associate aneurysm TREATMENT OPTION OBSERVATION - Thalamic and basal ganglion > 6 cm - Intinnsic brainstem AVM > 2.5 cm - Elderly grade

aneurysm Inadequate Rtand prospective study MICROSURGERY -

27 EMBOLIZATION - Adjunct to microsurgery and radiosurgery - suggest in : grade 4-6 : critical brain rehgion : associate aneurysm Inadequate Rtand prospective study MICROSURGERY - Convexity AVM grade Cerebellar and pial AVM - Thalamic and basalglion AVM 27

obliterate rate 60-85% after 2 years Angiographic

28 CAVERNOUS MALFORMATION STERIOTACTIC RADIOSURGERY - Small, unrupture AVM indeep and crittical area - obliterate rate 60-85% after 2 years Angiographic occult Sinusoid, thin wall, dilated and single cell endothelial layer 28

29 clinical Headache Seizure Focal neurologic deficit Hemorrhage - annual risk 0.7% per year after hemorrhage 4.5% per year IMAGING CT MRI 29

30 TREATMENT Complete surgical excision Surgery - symptomatic lesion 30

31 Vasospasm Reversal Triple- H therapy Intra- aortic balloon Endovascular therapy Balloon angioplasty 31

Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage. Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA

Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA The traditional view: asah is a bad disease Pre-hospital mortality