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Clinical Program for Cerebrovascular Disorders Presented by Clara Raquel Epstein, MD, Fellow Aneurysms ~ Factor VIII Deficiency Neurosurgical/Neurological.

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Presentation on theme: "Clinical Program for Cerebrovascular Disorders Presented by Clara Raquel Epstein, MD, Fellow Aneurysms ~ Factor VIII Deficiency Neurosurgical/Neurological."— Presentation transcript:

1 Clinical Program for Cerebrovascular Disorders Presented by Clara Raquel Epstein, MD, Fellow Aneurysms ~ Factor VIII Deficiency Neurosurgical/Neurological Management and Intervention

2 Introduction

3 Aneurysm Incidence and Location Epidemiology Ratio of ruptured:unruptured (incidental) is 5:3 to 5:6 Ratio of autopsy prevalence is 0.2 – 7.9% Only 2% present in childhood

4 Aneurysm Incidence and Location Giant Aneurysms >2.5 cm (= 1 inch) diameter Two types – saccular and fusiform Comprise 3-5% of intracranial aneurysms Peak age of presentation years Female:Male Ratio = 3:1

5 Aneurysm Incidence and Location Giant Aneurysm Evaluation – Definitively via operative visualization Angiogram – underestimates the size secondary to thrombosed regions of the aneurysm that do not fill with contrast CT Scan – significant edema seen surrounding the aneurysm due to increased vascularity secondary to inflammatory reaction to the aneurysm MRI Scan – Turbulence within leads to complicated signal on T1 image. Pulsation artifact (linear distortion radiation thru aneurysm) on MRI helps differentiate giant aneurysms from solid or cystic lesions

6 Aneurysm Incidence and Location Location 90-95% in Carotid system ACoA (single most common): 30% Pcomm: 25% MCA: 20% 5-15% in Posterior Circulation (Vertebro-basilar) 10% on Basilar Artery:Basilar bifurcation/tip, followed by BA-SCA 5% on Vertebral artery, VA-PICA junction is most common 20-30% of Aneurysm patients have multiple aneurysms

7 Aneurysm Incidence and Location Etiology Congenital predisposition (arterial wall defect) “atherosclerotic” or hypertensive:presumed etiology of most saccular aneurysms Embolic (atrial myxoma) Infectious (mycotic) Traumatic Other

8 Aneurysm Incidence and Location Presentation Rupture – most frequently SAH Intracerebral hemorrhage in 20-40% (especially when distal to the Circle of Willis) Intraventricular hemorrhage in 15-20% (especially with PICA) Subdural blood in 2-5% Mass Effect Giant aneurysms Compression of neural structures (non pupil sparing 3 rd nerve palsy with enlarging PCOM aneurysm) Small Infarcts due to distal embolization Seizures Incidentally found

9 Conditions Associated with Aneurysms Polycystic kidney disease Fibromuscular dysplasia (FMD) Arteriovenous Malformations (AVM) including Moyamoya disease Connective Tissue Disorders – Ehlers-Danlos type IV (deficient collagen type III), Marfan’s syndrome, pseudoxanthoma elasticum Multiple other family members with intracranial aneurysms Coarctation of the Aorta Osler-Weber-Rendu Syndrome

10 Treatment Options for Aneurysms Non-Surgical Treatment Medical Management – control hypertension continue calcium-channel blockers stool softeners bed rest

11 Treatment Options for Aneurysms Surgical Treatment Clipping – across the neck of the aneurysm to exclude the aneurysm from the circulation Wrapping – with cotton or muslin, muscle, plastic resin or other polymer Trapping – distal and proximal arterial interruption by direct surgical means (ligation or occlusion with a clip), placement of a detachable balloon, or EC-IC bypass

12 Treatment Options for Aneurysms Proximal Ligation (Hunterian ligation) - especially with Giant aneurysms Thrombosing Aneurysm – with coils of wire placed either during open surgery or via endovascular techniques Intra-aneurysmal Placement of Detachable Balloon by interventional neuroradiologist – disadvantages include possible subsequent aneurysm growth, hemorrhage during balloon inflation, and embolization of thrombus

13 Presentation n A 61 year old Peruvian male with a history of hypertension, type II diabetes, hypothyroidism and a recent 30 pound weight loss, investigated with upper and lower endoscopies which were negative, presented to St. Joseph’s hospital in New Jersey, with complaints of headache, nausea and vomiting, and double vision with upward gaze. The patient was also found to have upon further investigation a factor VIII deficiency reflected by an elevated PTT. In July, 1999, an MRI was obtained which demonstrated a giant L ICA cerebral aneurysm (figure 1).

14 Hospital Course The patient was transferred to Mt. Sinai Hospital, initially assessed in the ER, and subsequently admitted to the NSICU for further management and pre-operative evaluation for surgical correction. On admission the patient presented with a left third nerve palsy, decreased sensory in the V2 and V3 distribution, diplopia with upward gaze, and was otherwise neurologically intact. Hematology was consulted and the pre-operative treatment plan included correction with Recombinant Factor VIII replacement and close monitoring of levels with a goal of raising the Factor VIII to 60% (previously reported as low as 15%).

15 Diagnostic Procedures

16 Surgical Procedure On the second hospital day, the patient was deemed stable for intraoperative intervention. A left ICA occlusion via proximal clipping, with an ECA-MCA bypass with saphenous vein grafts from the right leg were performed by Joshua Bederson, MD. Intraoperative neurophysiological monitoring of the nervous system was concurrently performed by Isabelle Germano, MD using continuous recording of somatosensory evoked potentials. Of note was that the patient did require large amounts of Factor VIII in order to control bleeding parameters intraoperatively.

17 Postoperative Course The patient tolerated the surgical procedure well. Postoperative recovery included close hematologic monitoring and continued therapy, including FFP, Vitamin K and PRBC replacement as well as continued recombinant Factor VIII replacement throughout the remainder of the hospital course. The patient postoperatively did not have obvious bleeding problems. On POD #2, the patient was noted to have hyponatremia with slight deterioration of mental status presumably related to this. After correction, improvement was evident.

18 Postoperative Course On POD # 6 a follow-up MRI/MRA was obtained which demonstrated a patent MCA to ECA bypass with some residual aneurysm filling, in addition to a hyperemic temporal area suggesting an ischemic region. Neurology was consulted to evaluate the patient in light of this new finding. At that time, the patient’s neurologic condition remained unchanged with the exception of a mild right upper extremity weakness and slight pronator drift noted.

19 The remainder of the postoperative recovery was unremarkable and the patient was deemed stable for transfer back to St. Joseph’s for further postoperative rehabilitation on the 8 th postoperative day. A follow-up MRI has been recommended at two weeks postoperatively for further evaluation. Postoperative Course

20 Discussion SAH Estimated Annual rate of aneurysmal SAH in North America is 10-28/100,000, or 28,000 aneurysmal ruptures per year 10% Die prior to receiving medical attention Rebleeding is the major cause of morbidity and mortality: risk is 38% 8% Die from progressive deterioration from the original bleed Of those receiving neurosurgical intervention, vasospasm kills 7% and causes severe deficit in another 7% 1/3 of the patients will have “good” results

21 Discussion Peak age for aneurysmal SAH is years, 20% between years 30% occur during sleep 50% of patients with aneurysms have warning symptoms, usually 6-20 days prior Headache is lateralized in 30%, most to side of aneurysm

22 Discussion SAH is complicated by: intracerebral hemorrhage in 20-40% Intraventricular hemorrhage in 15-35% Subdural blood in 2-5% SAH is seen more frequently in Spring and Fall

23 Discussion Risk Factors for SAH Hypertension Cigarette Smoking Oral Contraceptives, Pregnancy and Parturition Alcohol Consumption Diurnal Variations in Blood Pressure Increased Risk with Lumbar Puncture &/or Cerebral Angio Increased Risk with Age Cocaine Abuse

24 Discussion SAH Clinical Features Sudden Onset of Severe H/A Vomiting Syncope (Apoplexy) If LOC, patient may recover consciousness Focal Cranial Nerve Deficits (Especially 3 rd Nerve causing Diplopia) Low Back Pain may develop via lumbar nerve root irritation from dependant blood

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