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Treatment of Intracranial Aneurysms PowerPoint Presentation

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Description : Check out this medical presentation on Aneurysm, which is titled "Treatment of Intracranial Aneurysms", to know about intracranial aneurysm (brain aneurysm), a cerebrovascular disorder in which weakness in the wall of a cerebral artery or vein causes a localized dilation or ballooning of the blood vessel.

Tags : Aneurysm, Treatment, Intracranial Aneurysms, brain aneurysm, cerebrovascular disorder, cerebral artery, vein, blood vessel

Published on : May 25, 2021 | Views : 1497 | Downloads : 0

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Slide 1-

TREATMENT OF INTRACRANIAL ANEURYSMS
Slide 2-

Introduction Incidence of aneurysm difficult to estimate Prevalence 0.2-7.9 % Half the aneurysms ruptures 2% present during childhood
Slide 3-

Etiology Congenital Atherosclerotic/ hypertensive Embolic Infectious Traumatic Associated with other conditions
Slide 4-

Presentation Major rupture SAH IVH Subdural blood Mass effect Cranial neuropathy Endocrine disturbance
Slide 5-

Presentation Minor hemorrhage/sentinel hemorrhage Small infarcts Seizures Headache Incidentally discovered
Slide 6-

Factors deciding treatment Mode of presentation Ruptured aneurysm Un ruptured aneurysm Patients related factors General condition Medical co morbidities Aneurysm related factors Location, anatomy, size Availability of expertise Surgical endovascular
Slide 7-

Un-ruptured aneurysms: Why to treat these aneurysms: Risk of SAH is 0.05-6 % each year. Around 50 % of these ruptures are fatal Increase in size >1 cm increases the risk 11 fold (ISUIA trial. N Engl J Med 1998;339:1725-33)
Slide 8-

Risks factors for SAH Increased aneurysm size on serial imaging Posterior circulation aneurysms Previous SAH from another aneurysm Symptomatic aneurysms Females Cigarette smoking Binge alcohol drinking
Slide 9-

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

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

Factors affecting surgical outcome Aneurysm related factors Aneurysm size (>2.5). Location (A comm, ICA bifurcation). Orientation Patient related factors Age Ischemic cerebrovascular diseases Diabetes mellitus
Slide 12-

RUPTURED ANEURYSMS Sixty percent of patients either die or disabled. 20-30% rebleed in 30 days. 4% rebleed rate on day 1. more than 70% who rebleed, die. Aneurysm occlusion either surgical or endovascular is the only answer.
Slide 13-

Treatment Resuscitation after SAH General medical treatment Bed rest, analgesia, catheterization, stool softeners Antiepileptic, steroids, CCB, antiemetics, sedation Management of fluids and electrolyte imbalance Definitive management
Slide 14-

Options for definitive treatment Surgery. Simple Clipping Wrapping Parent vessel occlusion Revascularization procedures Endovascular methods. Destructive procedures Reconstructive procedures Endoscopy Conservative
Slide 15-

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.
Slide 16-

Exclusive Indications for surgery SAH with intracerebral hematoma Presence of hydrocephalus Signs of raised IC Other conditions in which endovascular treatment is contraindicated
Slide 17-

Timing of surgery: Anterior circulation: early surgery has good results compared to late Posterior circulations: Easy aneurysms: early surgery 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 23:205-214;1992)
Slide 18-

Early surgery Virtually eliminates re-bleed Facilitates treatment of vasospasm Allows removal of vasospasmogenic material Though operative mortality higher, but overall outcome is better Factors favoring early surgery: Good medical condition of patient Good neurologic condition Large clot, blood Early rebleed, multiple episodes Imminent rebleed signs
Slide 19-

Disadvantages Inflammation and brain edema causes more difficult and traumatic retraction Acute clot makes dissection difficult Risk of intraoperative rupture is high Vessel injury may aggravate vasospasm Factors favoring late surgery: Poor medical neurological condition Difficult aneurysms Significant edema on CT Active vasospasm
Slide 20-

Goals of aneurysm treatment Complete, permanent and safe occlusion of aneurysm. Less morbidity and mortality. Good quality of life.
Slide 21-

Technical considerations of aneurysm surgery Intraoperative objectives prevent rupture Further enlargement Preserve normal vessels Minimize injury to the brain
Slide 22-

Technical considerations of aneurysm surgery Clip too low- may occlude parent vessel Distal placement- aneurysmal rest Aneurysmal rest expand in future and may rebleed Surgical exposure: avoid retraction Brain relaxation- hyperventilation, CSF drainage, lumbar spinal drainage, cisternal drainage drugs
Slide 23-

Technical considerations of aneurysm surgery Cerebral protection: Drugs that mitigate toxic effects of ischemia- CCB, barbiturates, mannitol Reduce electrical activity- barbiturates, etomidate, isoflurane By reducing maintenance energy- mild hypothermia (upto 33deg), mod hypothermia (32.5- 33), deep hypothermia ( upto 18 deg), profound hypothermia (upto 10 deg)
Slide 24-

Technical considerations of aneurysm surgery Intra operative aneurysm rupture- 18- 40% in most series Morbidity and mortality approach 30- 35% When can rupture occur: 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 Clip application- reapply clip or a second clip
Slide 25-

Wrapping Generally never the goal of treatment Indications On exposure aneurysm can not be clipped Intraoperative ruptured aneurysm Substances used for wrapping Muscle, muslin Plastic resin or polymer, Artificial glue and muscle, fascia or teflon
Slide 26-

Parent vessel ligation: Indications: Large surgically difficult aneurysms Recurred after coiling Other unclipable aneurysms Prerequisite: Good collateral circulation on balloon occlusion test or cross compression test
Slide 27-

Methods of parent vessel ligation Direct neck vessel ligation Gradual occlusion Silverstone clamp
Slide 28-

Revascularization procedures Indications: All those patients planned for ligation of parent vessel ligation but poor collateral circulation
Slide 29-

Outcome Results: Good outcome in 80% of anterior circulation and 44% of posterior circulation Graft patency rate of 86% at 18 mnths Complications Acute graft occlusion Aneurysm rupture due to hemodynamic changes Ischemic deficits
Slide 30-

Endovascular methods Exclusive Indications: Poor grade SAH Medical illness Surgically difficult aneurysms like proximal ICA and basilar tops giant aneurysm patients choice
Slide 31-

Endovascular methods Destructive procedures Balloon occlusion of parent vessel Reconstructive procedures GDC technology Balloon remolding technique Stent coil technique
Slide 32-

Balloon occlusion Generally used for proximal ICA and vertebrobasilar aneurysms Advantages Mass effect resolves Cranial neuropathies are known to improve Disadvantages: Recanalize, regrowth or rupture Ischemic symptoms Formation of de-novo aneurysms
Slide 33-

GDC coils Platinum spiral coils with circular memory Fit snugly in the aneurysm and induce thrombosis Disadvantages: Incomplete obliteration Recanalization Prolapse of coil and distal migration Parent artery thrombosis
Slide 34-

Balloon remolding technique 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
Slide 35-

Stent-coil technique Used in complex wide neck aneurysms Increases the density of coil packing
Slide 36-

Limiting factors Dome to neck ratio < 2 Neck width > 4 mm Inadequate endovascular access Unstable intraluminal thrombus Arterial branch incorporated in neck Middle cerebral artery aneurysms
Slide 37-

ISAT trial (lancet 2005;360:1267-75) 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) 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
Slide 38-

Criticisms on ISAT trial Selection biases premature analysis Only 22.4 % were randomized Outcome assessment MRs scale is used for assessment Lack of angiographic data after surgery Lack of long term follow up Surgical outcome Post procedural rebleed and outcome
Slide 39-

Endoscopy 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 Endoscope - supportive role in planning surgical manoeuvres and verifying whether clipping has been performed correctly
Slide 40-

Endoscopy 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
Slide 41-

Endoscopy Dome retraction is often required in order to see vascular structures with the microscope 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 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
Slide 42-

Special circumstances POOR GRADE SAH Rapid resuscitation Intracranial pressure monitoring Early aneurysm occlusion Prophylaxis against delayed ischemia
Slide 43-

Advanced age Surgically treated patients do better than conservatively managed 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
Slide 44-

PREGNANCY Investigated and treated as same. Pregnancy can be continued Temporary clips than hypotension during surgery Mannitol and hyperventilation to be curtailed LSCS is preferred in unruptured cases Craniotomy and LSCS performed together Anticonvulsants and CCB to be avoided.
Slide 45-

Infective aneurysms Staph aureus is most common cause Course of IV antibiotics for 4-6 wks. Surgical excision of aneurysm followed by bypass, anastomosis, or ligation of vessel.
Slide 46-

Giant aneurysms Aneurysms more than 25 mm Mortality quoted from 5-25% Good or excellent outcome in 70-80%
Slide 47-

Treatment options Clipping ( multiple clipping, fenestrated clips) Parent vessel ligation Revascularization with or without trapping Endovascular occlusion Aneurysmectomy Aneurysmorrhapy
Slide 48-

Thank you