Left facial numbnessLeft facial numbness

Ann SchmidtAnn Schmidt

Oct 2005Oct 2005

Patient PresentationPatient Presentation

54 yo female54 yo female Left facial swelling, left leg swelling and left Left facial swelling, left leg swelling and left

arm weaknessarm weakness HeadacheHeadache

Past Medical HistoryPast Medical History

HypothyroidismHypothyroidism Hx of panic attacksHx of panic attacks PostmenopausalPostmenopausal Surgeries - hysterectomySurgeries - hysterectomy

Family historyFamily history

Father with carcinoid, hypertension and Father with carcinoid, hypertension and dementiadementia

Mother died of brain aneurysm, also had breast Mother died of brain aneurysm, also had breast cancercancer

Social historySocial history

Owns a large businessOwns a large business Recent family stressRecent family stress Loss of a friend to breast cancerLoss of a friend to breast cancer

ExamExam

148/94 Pulse 76 temp 97 resp 16148/94 Pulse 76 temp 97 resp 16 No sign. FindingsNo sign. Findings Diag Panic attackDiag Panic attack

Future visitsFuture visits

7/207/20 Review of Urgent care visit. Question of panic Review of Urgent care visit. Question of panic

attack vs. other etiology.attack vs. other etiology. Set up MRI TIA?Set up MRI TIA?

Future visitsFuture visits

7/29 patient presents to the ER with new 7/29 patient presents to the ER with new drooping of left eye lid, numbness of her face drooping of left eye lid, numbness of her face No headache, fever or neck pain. Exam noted No headache, fever or neck pain. Exam noted slight ptosis of right eyelid.slight ptosis of right eyelid. CT scan orderedCT scan ordered Diagnosis Bells palsy Start on Prednisone and Val Diagnosis Bells palsy Start on Prednisone and Val

acyclovir.acyclovir.

Future visitsFuture visits

7/30 Clinic visit – review ER note and MRI.7/30 Clinic visit – review ER note and MRI.

Future visitsFuture visits

7/30 Clinic visit- review clinic note and MRI7/30 Clinic visit- review clinic note and MRI Order MRI/MRA Order MRI/MRA

Future visitsFuture visits

MRA resultsMRA results Neurosurgery consultNeurosurgery consult CT angio completedCT angio completed

Intracranial AneurysmsIntracranial Aneurysms

Intracranial AneurysmsIntracranial Aneurysms

Goals of this talk includeGoals of this talk include Review the prevalence of aneurysmsReview the prevalence of aneurysms Review the etiology/ pathogenesis of aneurysmsReview the etiology/ pathogenesis of aneurysms Discuss the treatment of unruptured aneurysms.Discuss the treatment of unruptured aneurysms.

Intracranial Aneurysms IAIntracranial Aneurysms IA

PrevalencePrevalence IncidenceIncidence PathogenesisPathogenesis

Heritable connective tissue disorders, autosomal Heritable connective tissue disorders, autosomal dominant – Ehlers Danlos Syndrome, dominant – Ehlers Danlos Syndrome, Neurofibromatosis, Marfans syndrome, Polycystic Neurofibromatosis, Marfans syndrome, Polycystic kidneykidney

FamilialFamilial

Familial aggregationFamilial aggregation

1954 Chambers1954 Chambers 1995 reported in J Neurosurgery “Familial 1995 reported in J Neurosurgery “Familial

aneurismal subarchnoid hemorrhage : a aneurismal subarchnoid hemorrhage : a community based study”community based study” Did family members of patients with ruptured Did family members of patients with ruptured

aneurysms have an increase risk of developing a aneurysms have an increase risk of developing a SAHSAH

Familial trendsFamilial trends

1970-1989 81 patients had SAH1970-1989 81 patients had SAH Families contacted and fhx obtainedFamilies contacted and fhx obtained 76 had complete fhx76 had complete fhx 15 had a 115 had a 1stst or 2 or 2ndnd degree relative with SAH degree relative with SAH The number observed with a 1The number observed with a 1stst degree was 11 degree was 11

– expected was 2.6– expected was 2.6 4 fold increase risk among 14 fold increase risk among 1stst degree relatives degree relatives

Study resultsStudy results

Risk may be highest among siblings in the Risk may be highest among siblings in the index patientindex patient

Earlier age, may be smaller and recur.Earlier age, may be smaller and recur. Affected siblings are often the same decade of Affected siblings are often the same decade of

life.life.

DiagnosisDiagnosis

Clinical PresentationClinical Presentation Anterior communicating artery – 34%Anterior communicating artery – 34% Middle cerebral artery- 20%Middle cerebral artery- 20% Posterior communicating artery- 23%Posterior communicating artery- 23% Internal carotid artery 4%Internal carotid artery 4%

Asymptomatic ICAsymptomatic IC Most aneurysms never ruptureMost aneurysms never rupture

Natural History of AneurysmsNatural History of Aneurysms

The International Study of Unruptured The International Study of Unruptured Intracranial Aneurysms InvestigatorsIntracranial Aneurysms Investigators In a group of 1449 patients the rate of rupture per In a group of 1449 patients the rate of rupture per

year was eleven times higher if the patient had a year was eleven times higher if the patient had a history of previous rupturehistory of previous rupture

Surgery did not decrease M and M if lesion was Surgery did not decrease M and M if lesion was less than 10 mm and no previous history of less than 10 mm and no previous history of rupture.rupture.

Neurology 1999 Neurology 1999 Johnston,Gress Johnston,Gress

Which unruptured cerebral aneurysms should Which unruptured cerebral aneurysms should be treated? A cost utility analysisbe treated? A cost utility analysis For aneurysms >10 mm those producing For aneurysms >10 mm those producing

symptoms by compressing neighboring nerves and symptoms by compressing neighboring nerves and brain structures or in patients with a history of brain structures or in patients with a history of SAH from a different aneurysm treatment was cost SAH from a different aneurysm treatment was cost effective. effective.

Task force of the Stroke CouncilTask force of the Stroke CouncilAHA 2000AHA 2000

Recommendations Recommendations The treatment for small intracaverous ICA is not The treatment for small intracaverous ICA is not

generally indicated.generally indicated. Symptomatic intradural aneurysms of all sizes Symptomatic intradural aneurysms of all sizes

should be considered for treatment.should be considered for treatment. Coexisting or remaining aneurysms of all sizes in Coexisting or remaining aneurysms of all sizes in

patients with SAH due to another treated aneurysm patients with SAH due to another treated aneurysm carry a higher risk for further hemorrhage.carry a higher risk for further hemorrhage.

<10 mm observe, >10 mm consider treatment<10 mm observe, >10 mm consider treatment

ManagementManagement

Aneurysms <10 mm annual rupture .05-2%Aneurysms <10 mm annual rupture .05-2% Presence of smoking, Fhx Polycystic kidney Presence of smoking, Fhx Polycystic kidney

disease or lupus elevates risk.disease or lupus elevates risk. Considerable mortality/morbidity with Considerable mortality/morbidity with

treatment – 3.8%- 15.7%treatment – 3.8%- 15.7% Quality of life living with an aneurysmQuality of life living with an aneurysm