grand rounds cranial aneurysm treatment advance seris
TRANSCRIPT
![Page 1: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/1.jpg)
Supervisior / VS Chen shiu-jau Presenter / R2 Chiang kuan-yu
![Page 2: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/2.jpg)
Introduction• Prevalence 1-5%• Incidence of rupture
– 1/10000
• Female:Male = 2: 1• Peek 55-60 years-old
• Etiology– Genetic– Sporadic– Hemodynamic
• Hypertension
Jonathan L, et al NEJM, 2006Jonathan L, et al NEJM, 2006
![Page 3: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/3.jpg)
Ruptured aneurysm• 30 days mortality rate: 45 %• Survival with 1/3 moderate or severe disability• Rebleeding
– 4 % in first hour– 20 % in 2 weeks
Jonathan L, et al NEJM, 2006Jonathan L, et al NEJM, 2006
![Page 4: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/4.jpg)
Introduction-Treatment
Craniotomy and clippingCraniotomy and clipping Endovascular coilingEndovascular coiling
![Page 5: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/5.jpg)
Hunt and Hess Classification
Grade 1 Asymptomatic or minimal headache with slight nuchal rigidity
Grade 2 Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
Grade 3 Drowsiness, confusion, or mild focal deficit
Grade 4 Stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity, and vegetative disturbances
Grade 5 Deep coma, decerebrate rigidity, moribund appearance
![Page 6: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/6.jpg)
![Page 7: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/7.jpg)
![Page 8: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/8.jpg)
Case 1
• 47 y/o male• History: HTN• Chief Complaint :
– Acute onset and persisted headache
![Page 9: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/9.jpg)
Physical examinationConsciousness: alert, E4V5M6Nausea or vomiting(+)
Hunt and Hess scale 1 WFNS grade 1
![Page 10: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/10.jpg)
Image study
Diffuse SAH
r/o A-Com aneurysm
![Page 11: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/11.jpg)
A 15.88x10.34x11.83mm aneurysm at A-com with 7.43mm base
![Page 12: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/12.jpg)
3D Reconstruction Cerebral Angiography3D Reconstruction Cerebral Angiography
![Page 13: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/13.jpg)
Operation
Left pterional approach aneurysm clipping
– Intraoperative ICG study [Video]
![Page 14: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/14.jpg)
![Page 15: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/15.jpg)
Residual neck : 2.91x1.57x3.67 mm
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
Residual neck : 2.91x1.57x3.67 mm
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
![Page 16: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/16.jpg)
Case 2
• 74 y/o male• History: BPH• Chief Complaint : –Persisted Headache with Dizziness
![Page 17: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/17.jpg)
Physical examinationConsciousness: alert, E4V5M6Neck stiffness(+)Nausea or vomiting(+)
Hunt and Hess scale 2 WFNS grade 1
![Page 18: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/18.jpg)
Image study
• Diffuse SAH
![Page 19: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/19.jpg)
![Page 20: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/20.jpg)
Ruptured saccular aneurysm 7.8x7.3x12.2mm at A-com. a.
![Page 21: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/21.jpg)
Operation
Right pterional approach clipping aneurysm
–Intra-operative sonography [Video]
![Page 22: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/22.jpg)
![Page 23: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/23.jpg)
Residual neck : Nil
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
Residual neck : Nil
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
![Page 24: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/24.jpg)
Our Experiences
From 2009 Jan to 2014 May
Mackay Memorial Hospital, Medical Center
Sample : 50 aneurysms (47 patients)4 unruptured
Craniotomy and aneurysm clipping
![Page 25: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/25.jpg)
Case Series: DemographyTable1 Patient’s demographic and selected characteristics
N %
Age 35-44 7 14.9
45-54 13 27.7
55-64 11 23.4
>65 15 31.9
![Page 26: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/26.jpg)
Case Series: Demography
Table1 Patient’s demographic and selected characteristics
N %Sex Female 31 66
Male 16 34
![Page 27: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/27.jpg)
Case Series: Demography
Table1 Patient’s demographic and selected characteristicsvariable N %
size mm< 5 22 44> 5 28 56
< 7 32 64> 7 18 36
![Page 28: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/28.jpg)
Case Series: DemographyTable1 Patient’s demographic and selected characteristics
N %LocationAnterior circulation Anterior communicating a. 21 44.7
L’t A2A3 Juction 1 2.1MCA bifurcation 6 12.8
Posterior circulation
Post. communicating a. 16 34.1
PICA 2 4.2
![Page 29: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/29.jpg)
ComplicationsComplications nParent artery stenosis 4 Pcom * 1, ACA *2, ICA *1
Residual neck 13 One received TAE
Vasospasm
Angiography 4
Transcranial Doppler 7
Hydrocephalus 21 16 received V-P shunt
Electrolyte imbalance 29 Sodium & Potassium
Perioperative Rebleeding 18
![Page 30: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/30.jpg)
Patient Outcome
GOS Patient Number
1 6
2 7
3 2
4 8
5 24
Age / Sex / Lesion size
Predictors
Complications
![Page 31: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/31.jpg)
Patient OutcomeVariable GOS Total
N=47N(%)
p
1-3n=15n(%)
4-5n=32n(%)
Age (years) 0.093≦54 5(10.6) 16(3.1) 17(2.1)55-64 2(4.3) 9(19.1) 11(14.9)≧65 8(17) 7(14.9) 15(31.9)
SexF 10(21.3) 21(44.7) 31(66) 0.944M 5(10.6) 11(23.4) 16(34)
![Page 32: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/32.jpg)
Patient OutcomeVariable GOS Total
N=47N(%)
p
1-3n=15n(%)
4-5n=32n(%)
Size 0.119
≦6 9(19.1) 26(55.3) 35(74.4)
≧6 6(12.8) 6(12.8) 12(25.6)
![Page 33: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/33.jpg)
Patient Outcome
Variable OR (95% CI) p value
WFNS
1-2 1 (reference)
3-5 1.310 (0.005-0.727) 0.027
Hunt and Hess
1-3 1 (reference)
4-5 1.310 (0.016-1.288) 0.083
Table. Multiple logistic regression associated with Poor outcome (GOS1-3)
(n=47) OR, odds ratio; CI, confidence interval.
![Page 34: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/34.jpg)
Patient OutcomeVariable GOS Total
N=47N(%)
p1-3
n=15n(%)
4-5n=32n(%)
Parent artery stenosisYes 3(6.5) 6(13) 9(19.5) 0.833No 11(23.9) 21(56.5) 37(80.4)
Residual neckYes 5(10.9) 8(17.4) 13(28.3) 0.458No 9(19.6) 24 (52.2) 33(71.7)
VasospasmYes 5(10.9) 6(13) 11(23.9) 0.215No 9(19.6) 26(56.5) 35(76.1)
![Page 35: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/35.jpg)
Patient OutcomeVariable GOS Total
N=47N(%)
p1-3
n=15n(%)
4-5n=32n(%)
HydrocehpalusYes 11(23.4) 10(21.3) 21(44.7) 0.007**No 4(8.5) 22(46.8) 24(55.3)
EncephalomalaciaYes 6(12.8) 9(19.1) 15(31.9) 0.416No 9(19.1) 23(48.9) 32(68.1)
![Page 36: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/36.jpg)
Patient OutcomeVariable GOS Total
N=47N(%)
p1-3
n=15n(%)
4-5n=32n(%)
HypernatriemiaYes 14(29.8) 15(31.9) 29(61.7) 0.002No 1(2.1) 17(36.2) 18(38.3)
HyponatriemiaYes 7(14.9) 3(6.4) 10(21.3) 0.004No 8(17) 29(61.7) 37(78.7)
HyperkalemiaYes 6(12.8) 11(23.4) 17(36.2) 0.708No 9(19.1) 21(44.7) 30(63.8)
HypokalemiaYes 3(6.4) 2(4.3) 5(10.6) 0.154No 12 (25.2) 30(63.8) 42(89.4)
![Page 37: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/37.jpg)
Patient Outcome
Variable GOS TotalN=47N(%)
p1-3
n=15n(%)
4-5n=32n(%)
Peri-Operative Rebleeding
Yes 11(23.4) 7(14.9) 18(38.3) 0.001No 4(8.5) 25(53.2) 29(61.7)
![Page 38: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/38.jpg)
DiscussionDiscussion
![Page 39: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/39.jpg)
Treatment of Aneurysm
• Craniotomy with Clippingdistal location, wide base, young age, mass effect
• Endovascular with Coil posterior circulation, dissecting aneurysm
Controversial Recannulization / Intraoperative rupture / InfarctionCoil material migration stenosis
Controversial Recannulization / Intraoperative rupture / InfarctionCoil material migration stenosis
![Page 40: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/40.jpg)
Vasospasm
![Page 41: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/41.jpg)
Treatment of Vasospasm– Medical strategies
• Nimodipine• Hypertension, Hypervolemia,
Hemodilution
– Endovascular balloon angioplasty techniques*
By Andrew M. Bauer* and Peter A. Rasmussen, 2014By Andrew M. Bauer* and Peter A. Rasmussen, 2014
![Page 42: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/42.jpg)
WFNSGrading
Hunt and HessGrading
Good (GOS 4,5) Poor (GOS 2,3) Death (GOS 1)
Grade 1-3 (GCS 13-15)
Grade 1-3 25 (89.3%) 1 (3.6%) 2 (7.1%) 28
Grade 4 (GCS 7-12)
Grade 4 4 (40%) 4 (40%) 2 (20%) 10
Grade 5 (GCS 3-6)
Grade 5 3 (33%) 3 (33%) 3 (33%) 9
32 (68%) 8 (17%) 7 (15%) 47
Harsimrat Bir Singh Sodhi, et al, Journal of Neurosciences in Rural Practice, 2014
![Page 43: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/43.jpg)
Complications During Aneurysm Surgery
![Page 44: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/44.jpg)
• Diagnosis– 3D reconstruction
cerebral angiography
• Treatment– Endovascular
Coil, stent
• Surgery– Intraoperative
sonography– Intraoperative ICG– Intraoperative cerebral
angiography
![Page 45: Grand rounds Cranial Aneurysm treatment advance seris](https://reader033.vdocument.in/reader033/viewer/2022042817/55a73b5f1a28abe6258b462d/html5/thumbnails/45.jpg)
THANKs !!