current treatment for cerebral aneurysms tcd and …...•aneurysm is located and a clip is put on...
TRANSCRIPT
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CURRENT TREATMENT FOR CEREBRAL ANEURYSMS
TCD AND VASOSPASM SAH
Larry N. Raber RVT-RDMS
Clinical Manager General Ultrasound-Neurovascular Laboratory
Imaging institute
Cleveland Clinic, Cleveland Ohio
Michigan Sonographers Society2Nd Annual Fall Vascular Conference
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SUBARACHNOID HEMORRHAGE
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Subarachnoid Hemorrhage
• Ruptured aneurysm – 77%• AVM’s that bleed• Vascular tumors• Head trauma (Skull fractures, gunshots)• Unknown etiology
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Anatomy
What is SAH?
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SAH Symptoms
• Sudden onset of severe headache• Popping or snapping sensation in the head• Nausea and vomiting• Stiff neck• Loss of vision• Seizures
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Imaging•CTA•MRI•ANGIO
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• Angiogram CTA •
Imaging
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CT Angiogram
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Rotational Angiogram
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Rotational Angiogram
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Rotational Angiogram
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Subarachnoid HemorrhageHunt-Hess Grading Scale
• Grade 1 - Alert, mild headache, stiff neck• Grade 2 – Alert, vision problems, moderate to severe
headache, stiff neck• Grade 3 – Confusion, weakness or partial paralysis on one
side of the body• Grade 4 – Stupor, moderate to severe paralysis on one side
of the body• Grade 5 - Comatose
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Subarachnoid Hemorrhage Survival Rates
• Grade 1 - 75%• Grade 2 - 60%• Grade 3 - 50%• Grade 4 - 30%• Grade 5 - 10%
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Aneurysmal SAH
• ½ SAH from aneurysm rupture die before reaching hospital care• Half of the survivors are left with persistent neurological deficit• Average age of onset is 50 years• More common in adults than in children
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Natural History of Outcomes of SAH
• Median mortality rate of SAH in the US is 32% (does not usually account for the pre-hospital death)
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Risk Factors
• Presence of unruptured cerebral aneurysm-Symptomatic, larger size
• Hypertension• Smoking• ETOH abuse
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Risk Factors
• Drug use (cocaine)• Increase risk females• Personal history of SAH• Family history
- at least 1 first degree family member,especially 2 or more
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Risk Factors
• With a history of HTN and smoking aneurysms will rupture when smaller
• Significant life event in the past month may increase the chance of SAH
• Size matters! Aneurysm >7mm is an independent risk factor for aneurysm rupture and SAH
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Risk Factors
• Aneurysm growth is a risk factor of SAH- Aneurysms >8mm have been shown to grow frequently when followed by MRI.
• Aneurysm morphology• Ratio of the size of the aneurysm to the parent vessel
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Treatment of Cerebral Aneurysms
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Treatment
• Depends on many factors• Size• Location• Anatomy• Age• Medical co-morbidities
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Treatment
• 3 Main Options• Conservative management (unruptured aneurysms)• Surgery – Clipping• Endovascular
-Coil-Stent-Flow diverter
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Flow Diverters
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New Devices
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Surgery / Clipping
• Requires a hemicraniectomy• Aneurysm is located and a clip is put on the neck of the aneurysm to
cut off blood supply to the aneurysm• Patient is treated for major surgery of having a hemicraniectomy and
SAH.
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Coiling
• Soft metal wires
• Tightly packed in the aneurysm
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Coiling
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INDICATIONS FOR TCD
VASOSPASMAbnormal narrowing orconstriction of arteriesdue to irritation by bloodin the subarachnoid space
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VASOSPASM
• FOLLOWING SAH
• PEAKS 7-10 DAYS
• MAXIMAL SEVERITY DAYS 7 TO 12
• MAY LAST 3-4 WEEKS
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VASOSPASM
• DEGREE DEPENDS ON AMOUNT OF BLOOD
• VESSELS AFFECTED DEPENDS LOCATION OF BLOOD
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HEMODYNAMIC EFFECTS OF VASOSPASM
• INCREASED MFV
• LOSS OF PRESSURE THROUGH NARROW SEGMENT
• CBF REDUCED WHEN AUTOREGULATION EXHAUSTED
• ISCHEMIA AND INFARCTION
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VALUES MADE SIMPLE
• MCA 60 CM/SEC
• ACA 50 CM/SEC
• PCA 40 CM/SEC
• BASILAR 30 CM/SEC
• VERTEBRAL 20 CM/SEC
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TRANSTEMPORAL WINDOW
TCI TCD
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TRANSTEMPORAL WINDOWTCI
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VASOSPASM MCA
¾MFV 120 -149 CM/SEC ANGIO < 25%(mild vasospasm)
¾MFV 150-179 CM/SEC ANGIO 25-50%(moderate vasospasm)
¾ MFV 180-199 CM/SEC ANGIO 25-50%(severe vasospasm)
¾ MFV > 200 CM/SEC ANGIO > 50%(critical vasospasm)
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TRANSFORAMEN / OCCIPITALWINDOW
TCI TCD
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TRANSFORAMEN / OCCIPITALWINDOWTCI
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BASILAR ARTERY VASOSPASM
¾ MFV 60-89 CM/SEC ANGIO <25%(mild vasospasm)
¾ MFV 90-109 CM/SEC ANGIO 25-50%(moderate vasospasm)
¾ MFV 110-119 CM/SEC ANGIO 25-50%(severe vasospasm)
¾ MFV >120 CM/SEC ANGIO >50%(critical vasospasm)
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THERAPEUTIC INTERVENTIONS
o TRIPLE H THERAPY
1. HYPERTENSION2. HYPERVOLEMIA3. HEMODILUTION
o CALCIUM CHANNEL BLOCKERS
o TRANSLUMINAL ANGIOPLASTY
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CLINICAL
• 72 YO WHITE MALE
• NAUSEA / VOMITING
• LOC AT HOME
• EMS CALLED TAKEN TO OUTSIDE HOSPITAL
• NO PRIOR MEDICAL HISTORY
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CT AT OUTSIDE HOSPITAL
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TCD / TCI RT MCA STENOSIS
CTA
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TCD / TCI RT MCA STENOSIS
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TCD / TCI RT MCA STENOSIS
POST COIL
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RIGHT MCA / STENOSIS / VASOSPASM
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RIGHT MCA / STENOSIS / VASOSPASMTCD
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RIGHT MCA / STENOSIS / VASOSPASMTCI
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CLINICAL• 39YO WHITE MALE• NAUSEA / VOMITING• LOC AT WORK• EMS CALLED TAKEN TO OUTSIDE HOSPITAL• NO PRIOR MEDICAL HISTORY
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SAH/CT
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BASILAR ARTERY
SERIAL TCD’SPOST COIL DAY #4
RT. MCA / 130 CM/SEC
LT. MCA / 136 CM/SEC
BASILAR / 219 CM/SEC
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POSTANGIOPLASTY
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VASOSPASM / LINDEGAARD RATIO
• RATIO BETWEEN THE EXTRACRANIAL ICA MFV AND THE HIGHEST MCA MFV.
• TO HELP DETERMINE TRUE VASOSPASM FROM HYPEREMIA
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VASOSPASM / LINDEGAARD RATIO
• IF RATIO GREATER THAN 3.0 SUGGESTS VASOSPASM
• IF RATIO GREATER THAN 6.0 SUGGESTS CRITICAL VASOSPASM
• A RATIO LESS THAN 3.0 WOULD BE INDICATIVE OF HYPEREMIA RATHER THAN VASOSPASM
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Conclusion
• ANGIOPLASTY WILL DILATE ARTERIES IN CRITICAL SPASM• INCREASING BLOOD FLOW AND PREVENTING A
CEREBRAL VASCULAR ATTACK (CVA)
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Conclusions
• Treating the aneurysm is JUST THE BEGINNING• Any new focal neurological deficits, including
cognitive decline, could be vasospasm or hydrocephalus
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Thank You !
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