MANAGEMENT OF SAH: WHAT IS WORKING FOR ME (US)
Vipul GuptaInterventional Neuroradiology/Neurointerventional SurgeryInstitute of Neurosciences Medanta the Medicity
SAH… We work as part of neurosurgery Common ICU rounds and counseling Ward rounds separate OPD in neurosciences area On pay, group practice Stroke and neurovascular reporting
done by us Called – neurointerventional Surgery
(Interventional Neuroradiology)
SAH reports to emergency, Neurosurgery on call and NI on call At night NS on call Co-admission – NI and NS , even directly
referred ones Standard medications ICU admission, Neuro-critical care review ,
PAC Detailed counseling by NI team about course
of management Repeat NCCT if needed
Aneurysmal management
Planned for DSA with 3D , If late evening, then for next day (90% within 24 hours)
Repeat bleed – early Hematoma – CTA/DSA and surgery Neurointerventional Lab Regular angiogram – 2D based on 3D Family counselled, clearence Coiling if possible in same session
Aneurysmal management
General anesthesia 3000IU of heparin Long sheath in all Guiding as high as possible (DAC) DAC – co-axial NTG before guiding placement First coil – another 1500-2000 IU
heparin bolus
large-/giant aneurysms
Aneurysmal management Balloon (more and more) – Sceptre,
Transform , Synchro wire – double curve
Echelon , SL 10 First coil – balloon deflated and check Thereafter – longer inflations All coils – Target, Microplex, G2,
Axium, Orbit
Aneurysmal management
Tight packing is the key – frequently 1.5 mm as last coil
Increasing heaprinization – ACT >250, in broad neck > 300
MC removal with wire AP & lat runs DynaCT Repeat run in working projection – for
20 min after the removal of catheter
Very small berry aneurysms
Aneurysmal management
Very careful shaping Mostly straight tip in ACOM,DACA,
MCA, Basilar top, (ophthalmic, blister)
Reverse curve in poster-superior ACOMs
Double curve – sup hypohsyeal, PCOM, ICA bifrucation
Most > 90% we donot wire the aneurysm (ophthalmic, sup hypopsheal, ICA bifurcation)
DYSPLASTIC BIFURCATION ANEURYSMS
Flow diverters (stents)-
Giant/large aneurysms
Fusiform dissecting aneurysms
38 yr old male patient, 2-day old SAHKnown hypertensive
Clinically grade II
Small Blister/dissecting Friable, continued growth, re-rupture
F
A
Clot formation
Look for fuzziness Increase heaprinization – ACT 350
sec Reopro – 10 mg over 10 min intra-
arterial through microcatheter Post – Heparin, followed by aspirin If coil – heparin +/- anti-platelet
Immediate 5 min 8 min-Reopro
25 min Post reopro 7 mg
35 min Post reopro 10 mg
Post reopro 10 mg- after 50 min
Aneurysmal management Extubation on table Delayed extubation – significant filling,
poor grade, difficult airway etc Discharge 10-days Grade I/II earlier Advised to say nearby Follow-up DSA – 6-months Partially coiled/dissecting/blister –
earlier
Preventive Oral nimodipine Hydration
Strict monitoring Clinical, TCD, CTP Training staff, relatives, direct calls
Therapeutic - “It is stroke” HHH therapy (bridging)
IV Milrinone
IA Nimodipine and IA Milrinone
Continuous Intra-arterial dilatations
Our ProtocolVasospasm
1 ampoule of milrinone (10
mg)
Dissolve it in 40ml of
saline( total volume 50 ml)
Start at rate of 9ml /hour and
can increase up to 22 ml/hour
Dose Simplified
Our IAVD approach..• We do as soon as possible – like acute stroke • HHH – bridging therapy • Local anesthesia • Anesthesia cover• Diagnostic catheter • 3 mg of nimodipine • Followed by 6-8 mg of Milrinone• Duration as important as amount • Followed by HHH and IV milrinone • High rate of angiographic success (90%)
Vasospasm- 15-25% morbidity and mortality
28 y.o female SAH 1 day H & H Grade II
Day 6 Confused, weak on right side
CBF CBV MTT
CTP• Poor grade• Existing hemiparesis• Early or delayed
When nothing works
Day 5
Post Nimodipine
Day 7
Continuous intra-arterial dilatation
Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage Musahl, Christian; Henkes, Hans; Vajda, Zsolt; Neurosurgery. 68(6):1541-1547, June 2011.
20 mg milrinone
20 mg nimodipine
Start at rate of 50 ml/hour can be increased to
100 ml/ hour
1000ml saline
Day 11
Most probably partially thrombosed Will need stent…. Will recur
Referred for surgery
Patient not agreeing for follow-up and re-treatment
95%
5%
Mgt. outcome in good grade patients- 87.6 % mRS 0-2
Conclusion
Integrated team with NS – clinically and financially
Dedicated team Neurovascular center approach Clinical responsibility Management outcome approach Aggressive vasospasm management Awareness programs, direct referrals
B/L MCA aneurysms
Most probably partially thrombosed Will need stent…. Will recur
Dysplastic bifurcation aneurysms- Needing complicated stenting- Partially thrombosed
“COMPLEX” ANEURYSMS•Giant aneurysms• Dissecting fusiform•Blister aneurysms•Aneurysms with near the neck rupture/lobules•Dysplastic bifurcation aneurysms •Aneurysm with artery from the sac
May be..• Aneurysm with vasospasm•Aneurysm with tortuosity •Small aneurysms•Multilobulated aneurysms •Aneurysm with thrombus
Giant/large aneurysms
Stent-assisted coiling – safe, follow-up and possible repeat treatment
Flow diverters - evolving, paraclinoidal aneurysms, ?risk
(Parent vessel occlusion – may be the ideal treatment for cavernous aneurysms)
Flow diverters (stents)-
38 yr old male patient, 2-day old SAHKnown hypertensive
Clinically grade II
Small Blister/dissecting Friable, continued growth, re-rupture
Classical blister aneurysm
F
A
Very small berry aneurysms
Complex aneurysms… Important to recognize and
analyze (3D) Comfortable with all approaches
and techniques Strategy with back-up plan Better outcomes in high volume
centres with expertise, technology (Biplane) and teamwork
Vascular Neurosurgery co-ordination
Issue- stent thrombosis on pasugrel ? too much metal, flow change opening; control- ???, ? staged
Large – giant aneurysms ISUIA Trial
Flow diverters (stents)-
Giant fusiform, no collateral, mass effect
Thrombosed after a week Decompression Independent, mild UL weakness
Giant/large aneurysms Stent-assisted coiling – safe,
follow-up and possible repeat treatment
Flow diverters - evolving, paraclinoidal aneurysms, ?risk
(Parent vessel occlusion – may be the ideal treatment for cavernous aneurysms)
Fusiform giant ICA with no collaterals– need bypass
Fusiform dissecting aneurysm…
56 yr old, ischaemic stroke
Fusiform-dissecting aneurysms & blister aneurysms
Extremely difficult to treat Overlapping stents with coils as much
as possible to buy time/promote thrombosis
Continued growth common- early check Flow diverter
However , Distal fusiform dissecting
aneurysms.. Stent/FD not possible ---
bypass/surgical reconstruction..
Small Blister/dissecting Friable, continued growth, re-rupture
F
A
Very small berry aneurysms
Near the neck rupture
Catheter reposition
1-mm coil
A B C
DYSPLASTIC BIFURCATION ANEURYSMS
Hemtoma – not conscious
Hematoma ….M6
Thank you
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