Post on 16-Jul-2015
Supervisior / VS Chen shiu-jau Presenter / R2 Chiang kuan-yu
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
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
Introduction-Treatment
Craniotomy and clippingCraniotomy and clipping Endovascular coilingEndovascular coiling
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
Case 1
• 47 y/o male• History: HTN• Chief Complaint :
– Acute onset and persisted headache
Physical examinationConsciousness: alert, E4V5M6Nausea or vomiting(+)
Hunt and Hess scale 1 WFNS grade 1
Image study
Diffuse SAH
r/o A-Com aneurysm
A 15.88x10.34x11.83mm aneurysm at A-com with 7.43mm base
3D Reconstruction Cerebral Angiography3D Reconstruction Cerebral Angiography
Operation
Left pterional approach aneurysm clipping
– Intraoperative ICG study [Video]
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 (-)
Case 2
• 74 y/o male• History: BPH• Chief Complaint : –Persisted Headache with Dizziness
Physical examinationConsciousness: alert, E4V5M6Neck stiffness(+)Nausea or vomiting(+)
Hunt and Hess scale 2 WFNS grade 1
Image study
• Diffuse SAH
Ruptured saccular aneurysm 7.8x7.3x12.2mm at A-com. a.
Operation
Right pterional approach clipping aneurysm
–Intra-operative sonography [Video]
Residual neck : Nil
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
Residual neck : Nil
Parent artery stenosis (-)
Angiographic vasospasm (-)
Electrolyte imbalance (-)
Rebleeding (-)
Our Experiences
From 2009 Jan to 2014 May
Mackay Memorial Hospital, Medical Center
Sample : 50 aneurysms (47 patients)4 unruptured
Craniotomy and aneurysm clipping
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
Case Series: Demography
Table1 Patient’s demographic and selected characteristics
N %Sex Female 31 66
Male 16 34
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
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
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
Patient Outcome
GOS Patient Number
1 6
2 7
3 2
4 8
5 24
Age / Sex / Lesion size
Predictors
Complications
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)
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)
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.
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)
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)
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)
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)
DiscussionDiscussion
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
Vasospasm
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
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
Complications During Aneurysm Surgery
• Diagnosis– 3D reconstruction
cerebral angiography
• Treatment– Endovascular
Coil, stent
• Surgery– Intraoperative
sonography– Intraoperative ICG– Intraoperative cerebral
angiography
THANKs !!