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TREATMENT OF INTRACRANIAL ANEURYSMS. Introduction Incidence of aneurysm difficult to estimate Incidence of aneurysm difficult to estimate Prevalence 0.2-7.9.

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Presentation on theme: "TREATMENT OF INTRACRANIAL ANEURYSMS. Introduction Incidence of aneurysm difficult to estimate Incidence of aneurysm difficult to estimate Prevalence 0.2-7.9."— Presentation transcript:

1 TREATMENT OF INTRACRANIAL ANEURYSMS

2 Introduction Incidence of aneurysm difficult to estimate Incidence of aneurysm difficult to estimate Prevalence % Prevalence % Half the aneurysms ruptures Half the aneurysms ruptures 2% present during childhood 2% present during childhood

3 Etiology Congenital Congenital Atherosclerotic/ hypertensive Atherosclerotic/ hypertensive Embolic Embolic Infectious Infectious Traumatic Traumatic Associated with other conditions Associated with other conditions

4 Presentation Major rupture Major rupture SAH SAH IVH IVH Subdural blood Subdural blood Mass effect Mass effect Cranial neuropathy Cranial neuropathy Endocrine disturbance Endocrine disturbance

5 Presentation Minor hemorrhage/sentinel hemorrhage Minor hemorrhage/sentinel hemorrhage Small infarcts Small infarcts Seizures Seizures Headache Headache Incidentally discovered Incidentally discovered

6 Factors deciding treatment Mode of presentation Mode of presentation Ruptured aneurysm Ruptured aneurysm Un ruptured aneurysm Un ruptured aneurysm Patients related factors Patients related factors General condition General condition Medical co morbidities Medical co morbidities Aneurysm related factors Aneurysm related factors Location, anatomy, size Location, anatomy, size Availability of expertise Availability of expertise Surgical Surgical endovascular endovascular

7 Un-ruptured aneurysms: Why to treat these aneurysms: 1. Risk of SAH is % each year. 2. Around 50 % of these ruptures are fatal 3. Increase in size >1 cm increases the risk 11 fold (ISUIA trial. N Engl J Med 1998;339: )

8 Risks factors for SAH Increased aneurysm size on serial imaging Increased aneurysm size on serial imaging Posterior circulation aneurysms Posterior circulation aneurysms Previous SAH from another aneurysm Previous SAH from another aneurysm Symptomatic aneurysms Symptomatic aneurysms Females Females Cigarette smoking Cigarette smoking Binge alcohol drinking Binge alcohol drinking

9 Which un ruptured aneurysm to be treated? Symptomatic aneurysm Symptomatic aneurysm SAH from another aneurysm SAH from another aneurysm Aneurysm > 10 mm Aneurysm > 10 mm Aneurysm between 6-9 mm in middle and young age group Aneurysm between 6-9 mm in middle and young age group If any aneurysm increases on serial angiograms If any aneurysm increases on serial angiograms

10 Efficacy and risk factors of surgery More than 90% complete occlusion rate More than 90% complete occlusion rate Mortality 0-3% in various series Mortality 0-3% in various series Morbidity 2-11% quoted in large studies Morbidity 2-11% quoted in large studies Risk of surgery exceeds the 7.5 year risk of bleed in those aneurysm which are <10mm Risk of surgery exceeds the 7.5 year risk of bleed in those aneurysm which are <10mm

11 Factors affecting surgical outcome Aneurysm related factors Aneurysm related factors Aneurysm size (>2.5). Aneurysm size (>2.5). Location (A comm, ICA bifurcation). Location (A comm, ICA bifurcation). Orientation Orientation Patient related factors Patient related factors Age Age Ischemic cerebrovascular diseases Ischemic cerebrovascular diseases Diabetes mellitus Diabetes mellitus

12 RUPTURED ANEURYSMS Sixty percent of patients either die or disabled. Sixty percent of patients either die or disabled % rebleed in 30 days % rebleed in 30 days. 4% rebleed rate on day 1. 4% rebleed rate on day 1. more than 70% who rebleed, die. more than 70% who rebleed, die. Aneurysm occlusion either surgical or endovascular is the only answer. Aneurysm occlusion either surgical or endovascular is the only answer.

13 Treatment Resuscitation after SAH Resuscitation after SAH General medical treatment General medical treatment Bed rest, analgesia, catheterization, stool softeners Bed rest, analgesia, catheterization, stool softeners Antiepileptic, steroids, CCB, antiemetics, sedation Antiepileptic, steroids, CCB, antiemetics, sedation Management of fluids and electrolyte imbalance Management of fluids and electrolyte imbalance Definitive management Definitive management

14 Options for definitive treatment Surgery. Surgery. Simple Clipping Simple Clipping Wrapping Wrapping Parent vessel occlusion Parent vessel occlusion Revascularization procedures Revascularization procedures Endovascular methods. Endovascular methods. Destructive procedures Destructive procedures Reconstructive procedures Reconstructive procedures Endoscopy Endoscopy Conservative Conservative

15 The ideal treatment for aneurysms with good grade SAH ( gr 1 and gr 2) is surgical clipping. The ideal treatment for aneurysms with good grade SAH ( gr 1 and gr 2) is surgical clipping. However depending on the availability of expertise endovascular methods can be equally good. However depending on the availability of expertise endovascular methods can be equally good.

16 Exclusive Indications for surgery SAH with intracerebral hematoma SAH with intracerebral hematoma Presence of hydrocephalus Presence of hydrocephalus Signs of raised IC Signs of raised IC Other conditions in which endovascular treatment is contraindicated Other conditions in which endovascular treatment is contraindicated

17 Timing of surgery: Anterior circulation: early surgery has good results compared to late Anterior circulation: early surgery has good results compared to late Posterior circulations: Posterior circulations: Easy aneurysms: early surgery Easy aneurysms: early surgery Difficult aneurysms : after two weeks Difficult aneurysms : after two weeks (Haley EC jr et al the international cooperative study on the timing of aneurysm surgery; the north American experience. Stroke 23: ;1992)

18 Early surgery Virtually eliminates re-bleed Virtually eliminates re-bleed Facilitates treatment of vasospasm Facilitates treatment of vasospasm Allows removal of vasospasmogenic material Allows removal of vasospasmogenic material Though operative mortality higher, but overall outcome is better Though operative mortality higher, but overall outcome is better Factors favoring early surgery: Factors favoring early surgery: Good medical condition of patient Good medical condition of patient Good neurologic condition Good neurologic condition Large clot, blood Large clot, blood Early rebleed, multiple episodes Early rebleed, multiple episodes Imminent rebleed signs Imminent rebleed signs

19 Disadvantages Inflammation and brain edema causes more difficult and traumatic retraction Inflammation and brain edema causes more difficult and traumatic retraction Acute clot makes dissection difficult Acute clot makes dissection difficult Risk of intraoperative rupture is high Risk of intraoperative rupture is high Vessel injury may aggravate vasospasm Vessel injury may aggravate vasospasm Factors favoring late surgery: Factors favoring late surgery: Poor medical neurological condition Poor medical neurological condition Difficult aneurysms Difficult aneurysms Significant edema on CT Significant edema on CT Active vasospasm Active vasospasm

20 Goals of aneurysm treatment Complete, permanent and safe occlusion of aneurysm. Complete, permanent and safe occlusion of aneurysm. Less morbidity and mortality. Less morbidity and mortality. Good quality of life. Good quality of life.

21 Technical considerations of aneurysm surgery Intraoperative objectives prevent rupture prevent rupture Further enlargement Further enlargement Preserve normal vessels Preserve normal vessels Minimize injury to the brain Minimize injury to the brain

22 Technical considerations of aneurysm surgery Clip too low- may occlude parent vessel Clip too low- may occlude parent vessel Distal placement- aneurysmal rest Distal placement- aneurysmal rest Aneurysmal rest expand in future and may rebleed Aneurysmal rest expand in future and may rebleed Surgical exposure: Surgical exposure: avoid retraction avoid retraction Brain relaxation- hyperventilation, CSF drainage, lumbar spinal drainage, cisternal drainage Brain relaxation- hyperventilation, CSF drainage, lumbar spinal drainage, cisternal drainage drugs drugs

23 Technical considerations of aneurysm surgery Cerebral protection: Cerebral protection: Drugs that mitigate toxic effects of ischemia- CCB, barbiturates, mannitol Drugs that mitigate toxic effects of ischemia- CCB, barbiturates, mannitol Reduce electrical activity- barbiturates, etomidate, isoflurane Reduce electrical activity- barbiturates, etomidate, isoflurane By reducing maintenance energy- mild hypothermia (upto 33deg), mod hypothermia ( ), deep hypothermia ( upto 18 deg), profound hypothermia (upto 10 deg) By reducing maintenance energy- mild hypothermia (upto 33deg), mod hypothermia ( ), deep hypothermia ( upto 18 deg), profound hypothermia (upto 10 deg)

24 Technical considerations of aneurysm surgery Intra operative aneurysm rupture % in most series Intra operative aneurysm rupture % in most series Morbidity and mortality approach % Morbidity and mortality approach % When can rupture occur: When can rupture occur: Initial exposure- reduce Bp, place temporary clip if possible, lobectomy if necessary for exposure Initial exposure- reduce Bp, place temporary clip if possible, lobectomy if necessary for exposure Dissection of aneurysm- blunt or sharp tears- tamponade, temporary clip,. If extends to parent vessel micro sutures may be taken Dissection of aneurysm- blunt or sharp tears- tamponade, temporary clip,. If extends to parent vessel micro sutures may be taken Clip application- reapply clip or a second clip Clip application- reapply clip or a second clip

25 Wrapping Generally never the goal of treatment Generally never the goal of treatment Indications Indications On exposure aneurysm can not be clipped On exposure aneurysm can not be clipped Intraoperative ruptured aneurysm Intraoperative ruptured aneurysm Substances used for wrapping Substances used for wrapping Muscle, muslin Muscle, muslin Plastic resin or polymer, Plastic resin or polymer, Artificial glue and muscle, fascia or teflon Artificial glue and muscle, fascia or teflon

26 Parent vessel ligation: Indications: Indications: Large surgically difficult aneurysms Large surgically difficult aneurysms Recurred after coiling Recurred after coiling Other unclipable aneurysms Other unclipable aneurysms Prerequisite: Prerequisite: Good collateral circulation on balloon occlusion test or cross compression test Good collateral circulation on balloon occlusion test or cross compression test

27 Methods of parent vessel ligation Direct neck vessel ligation Direct neck vessel ligation Gradual occlusion Gradual occlusion Silverstone clamp Silverstone clamp

28 Revascularization procedures Indications: Indications: All those patients planned for ligation of parent vessel ligation but poor collateral circulation All those patients planned for ligation of parent vessel ligation but poor collateral circulation

29 Outcome Results: Results: Good outcome in 80% of anterior circulation and 44% of posterior circulation Good outcome in 80% of anterior circulation and 44% of posterior circulation Graft patency rate of 86% at 18 mnths Graft patency rate of 86% at 18 mnths Complications Complications Acute graft occlusion Acute graft occlusion Aneurysm rupture due to hemodynamic changes Aneurysm rupture due to hemodynamic changes Ischemic deficits Ischemic deficits

30 Endovascular methods Exclusive Indications: Exclusive Indications: Poor grade SAH Poor grade SAH Medical illness Medical illness Surgically difficult aneurysms like proximal ICA and basilar tops giant aneurysm Surgically difficult aneurysms like proximal ICA and basilar tops giant aneurysm patients choice patients choice

31 Endovascular methods Destructive procedures Destructive procedures Balloon occlusion of parent vessel Balloon occlusion of parent vessel Reconstructive procedures Reconstructive procedures GDC technology GDC technology Balloon remolding technique Balloon remolding technique Stent coil technique Stent coil technique

32 Balloon occlusion Generally used for proximal ICA and vertebrobasilar aneurysms Generally used for proximal ICA and vertebrobasilar aneurysms Advantages Advantages Mass effect resolves Mass effect resolves Cranial neuropathies are known to improve Cranial neuropathies are known to improve Disadvantages: Disadvantages: Recanalize, regrowth or rupture Recanalize, regrowth or rupture Ischemic symptoms Ischemic symptoms Formation of de-novo aneurysms Formation of de-novo aneurysms

33 GDC coils Platinum spiral coils with circular memory Platinum spiral coils with circular memory Fit snugly in the aneurysm and induce thrombosis Fit snugly in the aneurysm and induce thrombosis Disadvantages: Disadvantages: Incomplete obliteration Incomplete obliteration Recanalization Recanalization Prolapse of coil and distal migration Prolapse of coil and distal migration Parent artery thrombosis Parent artery thrombosis

34 Balloon remolding technique Introduced to overcome the problem of wide neck aneurysms Introduced to overcome the problem of wide neck aneurysms Balloon is inflated in parent vessel against the neck and then coils are put in sac Balloon is inflated in parent vessel against the neck and then coils are put in sac

35 Stent-coil technique Used in complex wide neck aneurysms Used in complex wide neck aneurysms Increases the density of coil packing Increases the density of coil packing

36 Limiting factors Dome to neck ratio < 2 Dome to neck ratio < 2 Neck width > 4 mm Neck width > 4 mm Inadequate endovascular access Inadequate endovascular access Unstable intraluminal thrombus Unstable intraluminal thrombus Arterial branch incorporated in neck Arterial branch incorporated in neck Middle cerebral artery aneurysms Middle cerebral artery aneurysms

37 ISAT trial ( lancet 2005;360: ) Randomized study of 2143 patients ruptured intracranial aneurysms Randomized study of 2143 patients ruptured intracranial aneurysms Mortality or disability was 30.6 Vs 23.7 in surgical and endovascular gp at one year (p=0.0019) Mortality or disability was 30.6 Vs 23.7 in surgical and endovascular gp at one year (p=0.0019) Relative and absolute risk reduction in dependency or death is 6.9 vs 22.6% in surgical and endovascular group. Relative and absolute risk reduction in dependency or death is 6.9 vs 22.6% in surgical and endovascular group. Risk of rebleed was higher in endovascular group at one year Risk of rebleed was higher in endovascular group at one year

38 Criticisms on ISAT trial Selection biases Selection biases premature analysis premature analysis Only 22.4 % were randomized Only 22.4 % were randomized Outcome assessment Outcome assessment MRs scale is used for assessment MRs scale is used for assessment Lack of angiographic data after surgery Lack of angiographic data after surgery Lack of long term follow up Lack of long term follow up Surgical outcome Surgical outcome Post procedural rebleed and outcome Post procedural rebleed and outcome

39 Endoscopy Endoscope (fiberscope) to assist the microsurgical clipping of cerebral aneurysm- first reported by Fischer and Mustafa in 1994 Endoscope (fiberscope) to assist the microsurgical clipping of cerebral aneurysm- first reported by Fischer and Mustafa in 1994 Rigid endoscope increasingly used during aneurysm surgery in which structures around the aneurysm can be detected with high quality imaging Rigid endoscope increasingly used during aneurysm surgery in which structures around the aneurysm can be detected with high quality imaging Endoscope - supportive role in planning surgical manoeuvres and verifying whether clipping has been performed correctly Endoscope - supportive role in planning surgical manoeuvres and verifying whether clipping has been performed correctly

40 Endoscopy Aneurysms of anterior circulation- particularly useful in those of the internal carotid and the anterior communicating arteries Aneurysms of anterior circulation- particularly useful in those of the internal carotid and the anterior communicating arteries In many cases of these aneurysms the posterior communicating artery, choroidal artery or one of the distal cerebral arteries is hidden behind the aneurysm dome In many cases of these aneurysms the posterior communicating artery, choroidal artery or one of the distal cerebral arteries is hidden behind the aneurysm dome

41 Endoscopy Dome retraction is often required in order to see vascular structures with the microscope Dome retraction is often required in order to see vascular structures with the microscope Endoscope with a 30 degrees view angle Endoscope with a 30 degrees view angle Concealed areas are identified without retraction, =prevents the possibility of the aneurysm being ruptured/ reduces the use of temporary clipping Concealed areas are identified without retraction, =prevents the possibility of the aneurysm being ruptured/ reduces the use of temporary clipping From its early use as a supportive measure that is sometimes useful in surgery for "easy" aneurysms, the endoscope has now become almost indispensable for the "difficult" aneurysms, including the large and giant ones before and after clipping From its early use as a supportive measure that is sometimes useful in surgery for "easy" aneurysms, the endoscope has now become almost indispensable for the "difficult" aneurysms, including the large and giant ones before and after clipping

42 Special circumstances POOR GRADE SAH POOR GRADE SAH Rapid resuscitation Rapid resuscitation Intracranial pressure monitoring Intracranial pressure monitoring Early aneurysm occlusion Early aneurysm occlusion Prophylaxis against delayed ischemia Prophylaxis against delayed ischemia

43 Advanced age Surgically treated patients do better than conservatively managed Surgically treated patients do better than conservatively managed Treatment of unruptured aneurysm is beneficial if life expectancy is more than 13 years Treatment of unruptured aneurysm is beneficial if life expectancy is more than 13 years Treatment should not be denied only on the basis of age Treatment should not be denied only on the basis of age

44 PREGNANCY Investigated and treated as same. Investigated and treated as same. Pregnancy can be continued Pregnancy can be continued Temporary clips than hypotension during surgery Temporary clips than hypotension during surgery Mannitol and hyperventilation to be curtailed Mannitol and hyperventilation to be curtailed LSCS is preferred in unruptured cases LSCS is preferred in unruptured cases Craniotomy and LSCS performed together Craniotomy and LSCS performed together Anticonvulsants and CCB to be avoided. Anticonvulsants and CCB to be avoided.

45 Infective aneurysms Staph aureus is most common cause Staph aureus is most common cause Course of IV antibiotics for 4-6 wks. Course of IV antibiotics for 4-6 wks. Surgical excision of aneurysm followed by bypass, anastomosis, or ligation of vessel. Surgical excision of aneurysm followed by bypass, anastomosis, or ligation of vessel.

46 Giant aneurysms Aneurysms more than 25 mm Aneurysms more than 25 mm Mortality quoted from 5-25% Mortality quoted from 5-25% Good or excellent outcome in 70-80% Good or excellent outcome in 70-80%

47 Treatment options Clipping ( multiple clipping, fenestrated clips) Clipping ( multiple clipping, fenestrated clips) Parent vessel ligation Parent vessel ligation Revascularization with or without trapping Revascularization with or without trapping Endovascular occlusion Endovascular occlusion Aneurysmectomy Aneurysmectomy Aneurysmorrhapy Aneurysmorrhapy

48 Thank you


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