research grant from stryker neurovascular $ & !& $ $ ! )$-%...
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Ajit S. Puri, MD Assistant Professor of Radiology and Neurosurgery
Co-Director, Division of Neurointerventional Surgery, University of Massachusetts Medical Center
• Research grant from Stryker Neurovascular • Research grant from Covidien/ Medtronic • Consultant and proctor for Stryker Neurovascular • Consultant and proctor for Covidien/ Medtronic • Consultant for Codman Neurovascular
• UIAs are relatively common in the general population, found in ≈3.2% of the adults (mean age 50 years) worldwide, increasingly being discovered incidentally due to use of MRIs.
• Majority of UIAs will never rupture. • For example, of the 1 million adults ≈32 000 harbor a
UIA, but only 0.25% of these, or 1 in 200 to 400, will rupture.
• Women had a higher prevalence of UIAs than men, even after adjustment for age and co-morbidities.
• Prevalence overall higher in people aged ≥30 years.
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Schievink N Engl J Med 1997; Hop et al. Stroke 1997; Olafsson et al.Neurology 1997; Ellegala/Day 2005
• Larger UIAs may present with mass effect,
cranial nerve deficits (most commonly a 3rd CN nerve palsy), seizures, motor deficit, or sensory deficit, or they may be detected on imaging for headaches, ischemic disease etc.
• Small UIAs, <7 mm in diameter, uncommonly
cause aneurysmal symptoms and are the most frequently detected incidentally.
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• 1917 patients underwent clipping, and 451 underwent coiling
• The combined surgical morbidity and mortality at 1 year was 10.1% for patients without prior SAH and 12.6% for patients with prior SAH versus 7.1% and 9.8%, respectively, for the endovascular group.
• 2575 person-years FU, 33 (23%) of the 142 patients suffered an SAH, an approximate annual incidence of 1.3%, with an average annual incidence of SAH by group of 2.6%, 1%, and 1.3% for symptomatic aneurysm, incidental aneurysm, and prior SAH groups, respectively.
• UIAs should be treated irrespective of size in the case of patients aged <50 years if it is technically possible and the treatment risk is not compounded by concurrent diseases.
• January 2001-April 2004, 5720 patients, 20 years of age or older (mean age, 62.5 years; 68% women) with UIAs- 3 mm or more in the largest dimension
• 6697 aneurysms studied, 91% were discovered incidentally.
• Mean (+/-SD) size- 5.7+/-3.6 mm.
• During a FU period of11,660 aneurysm-years, ruptures were documented in 111 patients, with an annual rate of rupture of 0.95%
• Rupture risk increased with size of the aneurysm. • As compared with MCA aneurysms, PCoM and
ACoM aneurysms were more likely to rupture. • Aneurysms with a daughter sac (an irregular
protrusion of the wall of the aneurysm)-more likely to rupture
Alshekhlee et al. Stroke 2010
Hospital Mortality and Complications of Electively Clipped or Coiled Unruptured Intracranial
Aneurysms*
• National Inpatient Sample database 2000-2006 • Elective admitted to US hospitals with diagnosis
of un-ruptured aneurysms • 3738 clipping • 3498 endovascular coiling • Basic demographics including race, age, co-
morbidity indices were similar
Alshekhlee et al. Stroke 2010
Clipped Coiled
Length of stay 4 d 1 d P<0.0001
Hospital charges $ 38,166 $ 42,070 P<0.0001
Hospital mortality 1.6% 0.57% OR, 3.63;95% CI,1.57,8.42
Intraprocedural ICH
2.38% 1.37% OR, 1.75;95% CI,1.23,4.49
Postoperative stroke
6.71% 2.92% OR, 2.39;95% CI,1.89,3.03
Composite outcome (death, ICH, stroke)
8.35% 3.69 OR, 2.37;95% CI,1.92,2.93
Endovascular Treatment of Giant Aneurysms: General Principles Robert E. Replogle, MD Operative Techniques in Neurosurgery, V. 8, Iss.2, June 2005, pp67-73.
Endovascular Treatment of Giant Aneurysms: General Principles Robert E. Replogle, MD Operative Techniques in Neurosurgery, V. 8, Iss.2, June 2005, pp67-73.
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It s far more important to know what person the disease has than what disease the person has
Hippocrate
• Wall shear stress (WSS), is a frictional force of the blood flow that is tangential to the wall.
• WSS major determinant of vascular remodeling, with values around 20 dynes/cm2, going up to about 200 for an apex and 100 for the distal neck.
• The anatomical configuration of the arterial tree and the aneurysmal sac determines the hemodynamic stresses in connection with the flow
• Degradation of the extracellular matrix prominent feature.
• Quantitative PCR and immunohistochemistry show increased expression of cathepsin in the late stage of aneurysm progression
• Significant differences between the wall of ruptured and unruptured aneurysms.
• Macrophage infiltration into the wall may play an important role in weakening the aneurysmal structure
• Ex vitro at 4.7T of samples- iron deposits as well as fresh/ organizing luminal thrombus.
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Promise as a marker of
inflammation in the vascular
wall
Nicholls et al. Arterioscler Thromb Vasc Biol. 2005
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• Background: individual patient data from prospective cohort studies to estimate 5-year aneurysm rupture risk.
• Methods: 8382 participants in six prospective cohort studies with subarachnoid hemorrhage as outcome
Six predictors: age, hypertension, history of SAH, aneurysm size, aneurysm location, geographical region.
• Endovascular coiling is associated with a reduction in procedural morbidity and mortality over surgical clipping in selected cases but has an overall higher risk of recurrence (Class IIb; Level of Evidence B).
• Although studies confirm that larger UIA size portends a worse prognosis in terms of bleeding, strict size cutoffs may be less helpful than previously thought.
• Available data also continue to suggest that UIAs in certain locations, with certain morphological characteristics, are more likely to rupture. It also appears that growth of a UIA is associated with rupture.
• Reasonable to more strongly consider repair (1) when the UIA is discovered as a result of a prior SAH from a different lesion, (2) if the aneurysm is symptomatic, causing compressive symptoms, or a likely source of otherwise unexplained embolic stroke, or (3) if the patient has a family history of IA.
• Nonetheless, the risks, benefits, and alternatives to
repair must be considered carefully in each individual case.