The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon...
Transcript of The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon...
![Page 1: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/1.jpg)
Aneurysm treatment redefinedAneurysm treatment redefined
The cerebrovascular program at the The cerebrovascular program at the Oregon Oregon Neurosciences Neurosciences InstituteInstitute
By Erik Hauck, MD, PhD; Medical Director
![Page 2: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/2.jpg)
ObjectivesObjectives
• Natural history of aneurysms
• Standard treatment for aneurysms
• Advanced treatment for giant aneurysms
• Dealing with complications of SAH:
- Hydrocephalus
- Ischemia
• Watch real-time surgery
• Case discussion
Dr. Hauck patient iphone.wmv
![Page 3: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/3.jpg)
Aneurysms & Evolution in medicineAneurysms & Evolution in medicine400 BC400 BC Hippocrates: Apoplexy
1658 Wepfer: Ischemia vs Hemorrhage
1664 Willis: Circle of Willis
1765 Biumi: First clear description
1885 Horsley: Carotid Ligation for AN
1891 Quincke: LP - SAH
1927 Moniz: Cerebral angio
1931 Dott: Wrap
1937 Dandy: Clip
1966 Pool: Microscope
1991 Guglielmi: Coil
1997 Higashida: Stent
![Page 4: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/4.jpg)
Dandy’s Dandy’s
sketchsketch
of the first of the first
Aneurysm Aneurysm
Clip 1937Clip 1937
![Page 5: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/5.jpg)
Incidence of stroke in the USIncidence of stroke in the US
Aneurysms:
![Page 6: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/6.jpg)
(GCNKSS: 1993-94 and 1999). Source: Stroke 2006;37;2473-2478.
206
247
42
11
44
11
156
181
226 219
0
50
100
150
200
250
Ischemic Intracerebral
hemorrhage
Subarachnoid
hemorrhage
Inc
ide
nc
e p
er
10
0,0
00
White '93-94 White '99 Black '93-94 Black '99
Incidence of stroke in the USIncidence of stroke in the US
Relevance
![Page 7: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/7.jpg)
Year #1 Summary: 467 proceduresYear #1 Summary: 467 procedures
• Craniotomies 69 aneurysm (tumor) 2323 (11)
AVM 77
EC-IC bypass 3
Gamma Knife 5
• Cath proc 274 aneurysm 2626
AVM 1010
Stroke acute/delayed 12/17
dx angio 186
• Carotid proc 22 CEA 8
CAS (inc. 11 AN) 14
• CSF Shunting 42
• Spine 67 AVM (tumor) 33 (3)
50 aneurysms50 aneurysms
![Page 8: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/8.jpg)
Year 1, 50 aneurysmsYear 1, 50 aneurysms
• 40 Patients treated (1.2 AN/pt)– 20 ruptured (50%), 2 pt had add. unrupt. ANs
treated
– 20 unruptured (50%)
• 49 intra-cranial Aneurysms treated (49 proc)– 26 coil (5 stent/coil) [55.3%]
– staged x 2 patients, 2 aneurysm per session x 2
– 23 crani [46.9%]
• 1 extra-cranial Aneurysm treated (1 proc)
![Page 9: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/9.jpg)
Lane County (n=351,715 in 2010)Lane County (n=351,715 in 2010)
![Page 10: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/10.jpg)
Prevalence of aneurysmsPrevalence of aneurysms
• ~ 3% in the US population
![Page 11: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/11.jpg)
Prevalence of aneurysmsPrevalence of aneurysms
• ~ 3% in the US population
• 10.551 people in Lane county
![Page 12: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/12.jpg)
Prevalence of aneurysmsPrevalence of aneurysms
• ~ 3% in the US population
• 10.551 people in Lane county
• 6 people here now
![Page 13: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/13.jpg)
SizeSize
Small & Giant
![Page 14: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/14.jpg)
LocationLocation
Brisman JL, Song JK, Newell DW. Cerebral aneurysms. NEJM 2006; 355:928-939
![Page 15: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/15.jpg)
Risk of Rupture (ISUIA)
ISUIA. Lancet. 2003 Jul 12;362(9378):103-10.
Size Anterior Circulation Posterior Circulation
0 - 6 0 – 1.5% 2.5 – 3.4%
7 – 12 2.6% 14.5%
13 - 24 14.5% 18.4%
25+ 40% 50%
5 year cumulative risk
![Page 16: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/16.jpg)
Average size for ruptured ANAverage size for ruptured AN
• 7.5 mm (n= 161) J Neurosurg. 1987 Jan;66(1):23-9.
• 7.1 mm (n=64) Neurosurgery. 2011 Feb 4.
• 6.28 mm (n=889) J Kor Neurosur Soc. 2009;45(2):85-89.
6 6 –– 7 mm7 mm
![Page 17: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/17.jpg)
Outcome after ruptureOutcome after rupture
• Mortality 33% Inhouse. J Neurosurg.2003;99:810–817.
• Mortality 45% (30 days). Stroke. 1994;25:1342–1347.
• Mortality 50% (29 days). Practical Applications. 1969.
Mortality of rupture ~ 40%Mortality of rupture ~ 40%Quoted after the American Stroke Association, Guidelines for SAH, 2009
![Page 18: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/18.jpg)
Treatment Goals
Introduction
~ Prevent Rupture
~ Prevent Spasm
~ Prevent Stroke
~ Treat ICP
~ Treat HCP
~ Ensure Functional
Survival
![Page 19: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/19.jpg)
Treatment Option
• Endovascular (needle puncture in the groin)
• Surgery
![Page 20: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/20.jpg)
The The cerebrovascularcerebrovascular teamteam
MD Erik Hauck, MD
PA Nicole Wydra, PA
Clinic nurse Rosemary Parnell, RN
Clinic organizer Debi Steinbrenner
Clinic Manager Michele Daniels, RN (OHVI)
![Page 21: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/21.jpg)
The The cerebrovascularcerebrovascular familyfamily
Hauck,Hauck,CerebrovascularCerebrovascular
Neurosurgery Neurosurgery &Interventional &Interventional
RadiologyRadiology
Gallo, NSIGallo, NSI
Kokkino, ONSKokkino, ONSThompson, IRThompson, IR
KeiperKeiper, SBC, SBC
Englander, Englander, NeurologyNeurology
Lippincott, Lippincott, NeurologyNeurology
Skalabrin, Skalabrin, NeurohospitalistNeurohospitalist
Rughani, Rughani, IntensivistIntensivist
Littell, Littell, HospitalistHospitalist
Jill Jill HoggardHoggard--GreenGreen, ,
PeaceHealthPeaceHealth
Young, EDYoung, ED
Duke, CT Duke, CT surgerysurgery
DeHaas,DeHaas,Vascular SurgeryVascular Surgery
Padgett, Padgett, CardiologyCardiology
![Page 22: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/22.jpg)
NeuroNeuro--biplane Room, Smart ORsbiplane Room, Smart ORs
![Page 23: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/23.jpg)
DSA R VADSA R VA• 58 yo man
• TIA with LOC / confusion
• Complete recovery
• HTN
![Page 24: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/24.jpg)
R R PteryonalPteryonal ApproachApproach
![Page 25: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/25.jpg)
- No deficit
- D/c POD #3
![Page 26: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/26.jpg)
# Sex Age Size Side TAO IOAR 3rd nerve paresis f/u LOS comp symptom GOS
[mm] [min] temporary permanent [months] [days]
1 F 29 5 R 14 no Yes no 12 3 - - 5
2 F 37 3 R none no No no 1 6 - - 5
3 M 38 4.4 L 20 no No no 6 5 - - 5
4 F 42 6 R 10 no No no 1 4 - - 5
5 F 45 4.2 R 11 no No no 6 5 - - 5
6 F 46 3.3 R 2 no Yes no 12 3 small ICH - 5
7 F 48 5 L 9 no No no 12 4 - - 5
8 F 50 3.8 R none no No no 24 6 post op ileus resolved 5
9 F 51 6 R 11 no No no 2 4 - - 5
10 F 52 2 R none no No no 12 4 - - 5
11 M 52 2.5 L 5 no Yes no 12 4
4th nerve
palsy
intermittent double
vision 4
12 F 54 5 R none no No no 6 4 - - 5
13 F 55 4 R none no No no 12 5 -
unchanged minor
preoperative
disability 4
14 F 55 2.6 R 7 no Yes no 1 5 -
overall 'less energy' as
prior to surgery 4
15 F 63 6 R 8 no No no 12 5 - - 5
16 F 65 5 R 10 no Yes no 12 4 -
unchanged minor
preoperative
disability 4
17 M 65 4 R 8 no No no 2 4 - - 5
18 F 70 3 L 8 yes Yes no 2 5 small infarct
temporary weakness,
completely
resolved 5
19 F 70 6 R 8 no Yes no 12 5 - - 5
20 F 71 4.5 R 5 yes Yes no 12 7 - - 5
21 F 74 5.1 L none no No no 24 4 - - 5
ClipClip
![Page 27: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/27.jpg)
Larger basilar apexLarger basilar apexAneurysm,Aneurysm,Stent/CoilStent/Coil
![Page 28: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/28.jpg)
Small Aneurysm, Small Aneurysm, ClipClip
![Page 29: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/29.jpg)
Multiple aneurysms Multiple aneurysms 48 F, ruptured a-com
![Page 30: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/30.jpg)
Giant aneurysmsGiant aneurysms
![Page 31: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/31.jpg)
DirectDirectclippingclipping
![Page 32: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/32.jpg)
‘Saccular’(based on a ‘normal’ parent vessel)
![Page 33: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/33.jpg)
‘Fusiform’(no ‘normal’ parent vessel)
Drake CG, PeerlessSJ. Giant fusiform intracranial aneurysms:
review of 120 patients treated surgically from 1965 to 1992. J
Neurosurg. 1997 Aug;87(2):141-62.
![Page 34: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/34.jpg)
Giant Aneurysm, ClipGiant Aneurysm, Clip
36 mm
![Page 35: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/35.jpg)
Carotid ligationCarotid ligation
26 yo M, L eye blind, 3.1 cm AN
![Page 36: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/36.jpg)
TraditionalTraditionalBypassBypass--InterpositionInterposition
![Page 37: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/37.jpg)
Low Low –– flow bypass, STA flow bypass, STA -- MCAMCA
![Page 38: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/38.jpg)
HarvestingHarvesting
the the
graftgraft
![Page 39: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/39.jpg)
Opening the DuraOpening the Dura
![Page 40: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/40.jpg)
Exposing the Exposing the recipientrecipient
![Page 41: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/41.jpg)
Custom fittingCustom fitting
![Page 42: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/42.jpg)
Starting the Starting the anastomosisanastomosis
![Page 43: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/43.jpg)
StitchingStitching
![Page 44: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/44.jpg)
Bypass techniqueBypass technique
![Page 45: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/45.jpg)
Inspection of the final resultInspection of the final result
![Page 46: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/46.jpg)
Post op Post op angioangio & safety pin& safety pin
![Page 47: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/47.jpg)
ELANA ELANA Technique Technique –– high flow high flow graftgraft
![Page 48: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/48.jpg)
ELANA ELANA ‘High flow bypass’‘High flow bypass’
![Page 49: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/49.jpg)
Direct Direct coilingcoiling
![Page 50: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/50.jpg)
Waffle Cone Technique
Please, avoid the ‘leaky cherry’ !
![Page 51: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/51.jpg)
Pipeline Pipeline EmbolizationEmbolization DeviceDevice
- Braided mash cylinder
- 48 microfilaments
- platinum and cobalt chromium strands
- mounted on a flexible microwire
![Page 52: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/52.jpg)
Carotid cavernous giant aneurysmCarotid cavernous giant aneurysmPRE PRE –– POST POST
a/p view
![Page 53: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/53.jpg)
Treating complications of SAHTreating complications of SAH
Vasospasm
• medical management
• surgical treatment of ICP & HCP
• interventional treatment
![Page 54: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/54.jpg)
Treating complications of SAHTreating complications of SAH
Hydrocephalus
• lumbar drain
• ventric
• shunt
• endoscopy
![Page 55: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/55.jpg)
Real time brain endoscopyReal time brain endoscopy
![Page 56: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/56.jpg)
Detailed CASE PresentationDetailed CASE Presentation
02668138
![Page 57: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/57.jpg)
Clinical backgroundClinical background
• Young mother with a 7 months old baby boy
• Bad H/A, N/V, lethargy, but fully oriented
• Hx of migraines
• Left homonymous hemianopsia
![Page 58: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/58.jpg)
CT on admission
![Page 59: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/59.jpg)
MR on admission
![Page 60: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/60.jpg)
VA AngiogramVA Angiogram
![Page 61: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/61.jpg)
R & L CCA AngiogramR & L CCA Angiogram
![Page 62: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/62.jpg)
FindingsFindings
• R occipital AVM, 61 mm largest diameter
• Deep venous drainage
• Eloquent brain
• No clear feeding artery aneurysms
• Spetzler-Martin Grade V AVM
• Intraparenchymal / intraventricularhemorrhage
• Large Venous Varix (Venous aneurysm)
![Page 63: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/63.jpg)
Treatment PlanTreatment Plan
• Preoperative embolization in 1 or 2 stages
• Surgical resection of the AVM after sufficient embolization
• Patient was awaiting treatment the following day
![Page 64: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/64.jpg)
Catastrophic eventCatastrophic event
• I am at home, ‘not’ on call
• Around midnight, the phone rings
• The pt, while talking to the nurse, turned over and became unresponsive, comatose, the nurse reports: “the right pupil does not respond to light, she is barely breathing”
• The pt is sent for a CT and requires intubation
• I rush to the hospital within minutes
![Page 65: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/65.jpg)
New CTNew CT
![Page 66: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/66.jpg)
Emergent ventric immediately after CT
![Page 67: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/67.jpg)
Clinical courseClinical course
• The patient is in a deep coma in near death condition
• The patient is prepared for emergent embolization and emergency surgery
• Then, the fixed pupil on the right side starts to react
• The intracranial pressure is high normal
![Page 68: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/68.jpg)
Pre & Post Pre & Post emoblizationemoblization, single shot, single shot
![Page 69: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/69.jpg)
Then to the OR…Then to the OR…
• Hours under the microscope …
• Then back to the cath-lab …
![Page 70: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/70.jpg)
Post op Post op angioangio: Complete resection: Complete resection
![Page 71: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/71.jpg)
Hospital courseHospital course
• Patient made slow improvements (such as little movements here and there)
• Was eventually weaned from the ventilator
• Was eventually transferred to rehab
• Followed up with me in the office after 2 months
![Page 72: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/72.jpg)
II--phone video taken in the officephone video taken in the office(2 months follow(2 months follow--up)up)
![Page 73: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/73.jpg)
THANKS!!!THANKS!!!
![Page 74: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/74.jpg)
Thanks !!!Thanks !!!
![Page 75: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/75.jpg)
mRS baselinemRS dischargemRS 3 monthsmRS 6 monthsmRS 12 months
Mean f/u time 6.4 ± 4.9 months
FollowFollow--upup
![Page 76: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/76.jpg)
![Page 77: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/77.jpg)
![Page 78: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/78.jpg)
![Page 79: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/79.jpg)
![Page 80: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/80.jpg)
Aneurysms: Eugene Aneurysms: Eugene vsvs the worldthe world
..
![Page 81: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/81.jpg)
1 year Disability & Death (1 year Disability & Death (mRSmRS > 2)> 2)
• All patients (n=40): 6/40 15% [2.5%/12.5%]
• Unruptured (n=20): 1/20 5% [ 5% / 0% ]– ISUIA data (n= 2368): 7.1% - 13.7% [ 7.2% - 12% / 0% - 2.7%]
• Ruptured (n=20): 6/20 30% [ 5% / 25% ]- ISAT data (n= 1594): 23.7% - 30.6% [ 18.2 – 20.6% / 8.1% - 10.1%]
![Page 82: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/82.jpg)
SAH: Eugene SAH: Eugene vsvs ISATISAT
Eugene ISAT
SAH grade I – III 11 / 20 (55%) 1611 / 1736 (92.8%)
SAH grade IV & V 9 / 20 (45%) 125 / 1736 (7.2%)
Eugene SAH patients presented in the worst possible condition with the worst prognosis 6.2 x
more often than included ISAT patients
![Page 83: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/83.jpg)
![Page 84: The cerebrovascular program at the Oregon Neuroscience ...The cerebrovascular program at the Oregon Neurosciences Institute By Erik Hauck, MD, PhD; Medical Director. ... LP - SAH 1927](https://reader033.fdocuments.in/reader033/viewer/2022041900/5e601183da5d68209d3f2710/html5/thumbnails/84.jpg)
IschemicIschemicStrokeStroke