Sept 2005 Mr. T s T s Headache Paul Gigante,, Harvard Medical School Year IV
Mr. T s T s Presentation 45 year-old welder complains of sudden severe headache and witnessed seizure with loss of consciousness at work History of an assault, which was a closed fist punch to the face a week prior to admission 2
Mr. T s T s Presentation On PE: Hypertensive to 150s to160s, Afebrile Lethargic, with garbled speech A + Ox2, following commands inconsistently PERLL, no seizure activity noted Labs: Hct 42, WBC 18,000, coags WNL 3
DDx? What Study? CT Head 4
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DDx? What next? Angiogram
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Right ICA Angio AP View PACS, BIDMC27
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Right ICA Angio Lateral View PACS, BIDMC30
What do you think they did?
S/P Coiling PACS, BIDMC32
S/P Coiling PACS, BIDMC33
A Week Later PACS, BIDMC34
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Intracranial Hemorrhage Review Epidural Biconvex, does not cross sutures except when fracture present, may cross falx and tent Subdural Crescent, crosses sutures, not dural attachments ICH Anywhere in parenchyma Subarachnoid 36
Epidural Hematoma 37 http://brighamrad.harvard.edu/cases/bwh/hcache/100/full.html
Subdural Hematoma PACS, BIDMC 38
Subarachnoid Hemorrhage Usual presentation: worst headache of life, trauma What study? Where and what are we looking for? CT look for hyperdensity in sulci, interhemispheric and sylvian fissures, and cisterns 39
Anatomy Review Sulcus Interhemispheric fissure PACS, BIDMC 40
Anatomy Review 4 th Ventricle Mastoid Sinus PACS, BIDMC 41
Anatomy Review Interhemispheric Cistern Suprasellar Cistern Interpeduncular Cistern Ambient Cistern Quadrigeminal Cistern PACS, BIDMC 42
Anatomy Review Sylvian Fissure Sylvian Fissure PACS, BIDMC 43
Subarachnoid Hemorrhage Once you ve found the hemorrhage and location, using the history, narrow DDx 1. Nonaneurysmal SAH 2. Pseudo SAH 3. Nonaneurysmal Perimesencephalic SAH 4. Aneurysmal SAH 44
1. Nonaneurysmal SAH Trauma is #1 cause of SAH! Not aneurysm, as many believe 1 Vascular malformation Neoplasm 1 Rinkel: Stroke 1993 45
Traumatic SAH Look for the star http://akimichi.homeunix.net/~emile/aki/medical/image/subarachnoid-hemorrhage-ct-1.jpeg 46
Pneumococcal Meningitis 2 2 Lloyd: Med J Aus 2003 Chased SAH, vasospasm After 1 day did LP: 1510 WBCs (all PMNs) ) and 160 RBCs SAH appearance 2/2 high protein, exudate. FLAIR also has high CSF signal in meningitis 47
Cerebral Edema Loss of cisterns Loss of gray-white differentiation Diffuse hypodensity CSF appears more bright http://merck.micromedex.com/index.asp?page=bpm_viewall&article_id=bpm01ne01&show_banner=no 48
2. Pseudo SAH Low density brain Cerebral edema High density/flair intensity CSF meningitis high O2 tension contrast administration 49
3. Nonaneurysmal Perimesencephalic SAH Clinically benign entity SAH confined to perimesencephalic, prepontine cisterns Likely caused by ruptured perimesencephalic/prepontine vein 3 3 Matsumaru: J Neurosurg 2003 50
Interpeduncular Cistern 51 PACS, BIDMC
4. Aneurysmal SAH: Epi Aneurysms account for 85% of non-traumatic SAH 4 Smoking, family hx increases risk Peak age: 40-60, F>M Concern: SAH causes vasospasm 20-30% incidence in aneurysmal SAH 5 3-14 days 4 Osborn: 2004 5 Kassell: Stroke 1985 52
Aneurysmal SAH 95% positive CT in first 24hr, <50% by 1 week Multislice CTA 90-95% 95% sensitive for aneurysm >2mm 6 MRA 85-95% sensitive 7 Conventional Angio considered gold standard 6 Schwartz: Radiology 1994 7 Huston: Am J Neurorad 1994 53
Aneurysmal SAH Hunt and Hess grade prognostic Fisher score risk of vasospasm 8 8 Greenberg: Handbook of Neurosurgery 2000 54
Aneurysmal SAH: Location Rebleed risk is increased compared to initial bleed risk. So if you see 2 aneurysms, how can you figure out which bled, and which to clip/coil? SAH location may help: Interhemispheric SAH suggests AcoA Sylvian suggests MCA 55
MCA emerges from sylvian fissure 56
AcoA lives near interhemispheric 57
Saccular Types of Aneurysms Round outpouching that lacks internal elastic lamina Inherited susceptibility and acquired mechanical stress 90-95% 95% in circle of willis (AcoA>PcoA) 10% posterior circulation Most often at vessel bifurcations! May have apical tit 20% multiple 9 9 Wiebers: Lancet 2003 58
Types of Aneurysms Be mindful of radiographic DDx if you think you see a saccular aneurysm: Vessel loop Infundibulum of PComm 59
Saccular Aneurysm http://members.fortunecity.com/danilhammoudimd/neuro1/11ab5bc0.gif 60
Types of Aneurysms Pseudoaneurysm Focal arterial dilatation not contained by layers of normal arterial wall Most commonly from trauma Cavitated clot communicates with vessel 10 10 Nomura: J Neurosurg 2000 61
Types of Aneurysms Fusiform aneurysm Ectatic vessel and focal aneurysmal outpouching More often found in vertebrobasilar circulation Usually large Elderly patients with atherosclerosis 11 11 Nakatomi: Stroke 2000 62
Left PCA Fusiform Aneurysm www.esnr.com/images/ case_studies/mejia_fig_2.jpg 63
Treatment: Coil vs Clip vs none Treatment choices rest largely on weighing risk of bleed versus procedural risk 64
Acknowledgements Pamela Lepkowski Larry Barbaras,, webmaster 65
References Greenberg MS. Handbook of Neurosurgery.. 5 th Ed. New York: Thieme Medical Publishers, 2000. Huston J 3 rd, Nichols DA, Luetmer PH et al. Blinded prospective evaluation of sensitivity of MR angiography a to known intracranial aneurysms: importance of aneurysm size. Am J Neuroradiol 15(9):1607-14, 14, 1994. Lloyd K Morgan. Pneumococcal meningitis masquerading as subarachnoid haemorrhage Med J Aust.. 179 (10): 559-560, 2003. Kassell NF; Sasaki T; Colohan AR; Nazar G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke.. 16(4):562-72, 1985. Matsumaru Y et al. Significance of a small bulge on the basilar artery in patients with perimesencephalic nonaneurysmal subarachnoid hemorrhage. Report of two cases. J Neurosurg.. 98(2):426-9, 9, 2003. Nakatomi H et al. Clinicopathological study of intracranial fusiform and dolichoectatic aneurysms. Stroke.. 31:896-900, 2000. Nomura M et al. Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site. J Neurosurg. 93(6):998-1002, 2000. Osborn AG et al. Diagnostic Imaging Brain. First Ed. Manitoba, Canada: Amirsys,, 2004. Rinkel GJ, Van Gijn J, Wijdicks EF. Subarachnoid hemorrhage without detectable aneurysm. A review ew of the causes. Stroke.. 24(9):1403-9, 9, 1993 Schwartz RB, Tice HM, Hooten SM, et al. Evaluation of cerebral aneurysms with helical CT: correlation with conventional angiography and MR angiography. Radiology.. 192(3):717-22, 22, 1994. Wiebers DO et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet.. 362 (9378): 103-110, 110, 2003. 66