[Applause]
thanks Stefan I think I misunderstood
your directions I thought you needed two
items not three so I'm going to talk
about repair of intracranial aneurysms
but there's two surgery and endovascular
three million people in the US have
intracranial aneurysms and about one
percent or thirty thousand have them
rupture each year this is a condition
which despite decreases in smoking and
better hypertension control the
incidence of subarachnoid hemorrhage has
not decreased over the years the outcome
has improved somewhat in the 1970s the
fatality rate was 57 percent in the 80s
it was 42% and 2000 and Beyond it's gone
from 36 to 26 percent in that range an
aneurysm is a dilated part of artery but
it's not a normal artery wall it has
disordered connective tissue it has gaps
in a smooth muscle and it lacks the
internal elastic lamina so when it
ruptures the blood as we heard goes
around it goes to the outside of the
blood vessels which is very toxic toxic
when it happens the the body seals it
off for most patients the patients who
make it to the hospital it probably
seals off within about a minute and it
seals off because for about a minute the
intracranial pressure almost reaches a
systolic blood pressure or equals it and
a fibrin clot develops and closes it off
but you end up with a scan like that in
a severe case with major hemorrhage the
problem is it can rear up sure the rear
up sure in the first 24 hours is 4 to 14
percent and this was recognized in the
early part of the last century and dr.
dandy did the first surgery to clip an
aneurysm they realize they were seeing
these patients and when the patient rear
up sure's the mortality rate doubles so
he put a clip across it this is without
an angiogram the patient presented with
a third nerve
and ironically he used the cushing clip
they were kind of competitive colleagues
so he used the cushioning silver clip to
go across it this hyper clip was just
the a once and done clip you put it on
and could not do anything with it the
patient did did well
however the surgery did not catch on
craniotomy had high mortality rate so
when people presented with hemorrhage
for the most part surgeons were
including the carotid in the neck even
when they knew it was aneurysm because
that was a safer procedure but not
nearly as effective because patients
still could rear up sure in the 1950s
there were advances with technology so
the clips now became dr. Mayfield
develop a clip that had a spring
mechanism which allowed a clip to be
able to go on and come off so that means
you could temporary clip arteries and
you could reposition a clip on the
aneurysm dr. Drake was an innovator in
the field he developed some
modifications where it's called a
fenestration where the clip could go
around and adjacent artery to keep the
artery open but still pinch off the
aneurysm dr. Yasser Gil introduced neuro
micro surgery he brought the microscope
into our field before the surgeons were
operating with with glasses and a light
overhead so this opened a whole new
world literally surgeons could see
Anatomy that they couldn't see before so
the the success of clipping the aneurysm
well and not damaging surrounding
structures improved this is current a
micro neurosurgery and what we see on
the left is that we have a wide range of
titanium clips of all different sizes
and shapes different fenestrations and
curves so we can tailor it to a aneurysm
and the angiogram shows a very small
pretty close artery Handerson which had
ruptured three millimeters at and
biggest and we have that's a photograph
through the microscope it shows the clip
across it the proper size for it in
general when you do surgery for
aneurysms only four to eight percent
will have some residual and usually we
leave a residual
most times it's because we're trying to
preserve the parent artery or vessels
that are going by and not to include
them in the clip when an aneurysm is
completely clipped with no residual the
chance of occurrence is very low it's
about one and a half percent over five
years if there is residual however they
do tend to enlarge with a 25% recurrence
over about four years so that's the
surgery and the vascular therapy really
evolved over the same time period
you guys and moniece was a neurologist a
portuguese neurologist who did the first
angiogram he did it to actually see
tumors better but ended up being very
good for for aneurysms Brooks was a
surgeon who did an embolic procedure
it's not what we think of today as
endovascular but he the person had a cc
fistula karate cavernous fistula he
clamped the carotid opened the carotid
put a piece of muscle in closed the
carotid took the clamps off and the
muscle went up to the fistula and
blocked it off so that was an embolic
treatment Werner had a young woman with
a giant cavern giant carotid aneurysm he
placed silver wire through the orbit
into the aneurism several millimeters of
wire heated it's 80 degrees centigrade
and the patient evidently did well the
idea was to thrombosed the aneurism a
major advance came in fit 1953 when sal
dinger developed the approach through
the femoral artery so now surgeons
didn't have to cut down directly on an
artery to gain access they could go
through a catheter Sean Mullan was a
neurosurgeon who had the idea of
thrombosis lling the aneurism from the
inside so he would place a trocar
through a burr hole down right on top of
the aneurysm and then place a little
wire in and give an electric current and
the idea was that blood is negatively
charged and the current would cause
thrombosis which in the angiogram
picture there the the aneurysm is gone
and in 1974 Serban Yenko developed a
balloon embolization so these are
balloons that could be placed through
the catheter they can include an artery
like shown here that included the
carotid artery temporarily or then they
could be released so the 1980s in
endovascular surgery was the era of the
balloons he would place balloons into
aneurysm endovascular surgeons would
place them into aneurysms multiple
wounds to try to occlude the aneurysm
unfortunately some balloons deflated and
blood could also go around the balloon
so the aneurism sealed me some of them
grew the field was revolutionized in
1991 when a Italian neurosurgeon guido
Google eme developed a platinum wire
that was helical so it's wound very
tightly and when you can pass through
the catheter when it's released from the
catheter it forms predetermined diameter
coils these are two-dimensional here but
when you release them in the aneurysm
they form like a basket and they form a
three-dimensional structure like that
and that can include the aneurysm it
actually it blocks about 30% of the
aneurysm volume inside but it's meant to
tamponade and eventually cause
thrombosis of the artery initially it
was thought that the electrode from
BOCES would cause a I mean the electro
the electrode stimulation would cause
the thrombosis but it's probably more
the deterrent of the flow and thrombosis
other blood products that way this is an
example of a patient with a large
anterior communicating are your aneurysm
which is completely coiled there about
30 to 40 percent of aneurysms can be
completely coiled in a large the first
large international trial for
subarachnoid hemorrhage 58% of the
aneurysms who are completely coiled when
there's complete coiling 40% of patients
will get recurrence over about five
years of their aneurysm now not all the
recurrences are major
some are small right at the base so 25%
of those who require recoiling to
prevent hemorrhage there are two
randomized trials that are often
referred to one is an international
trial ISAT and the other is a barrel
trial in Arizona and that was a single
institution trial the other was
multi-institution the results are
identical
patience either had coiling or clipping
and at one year the poor outcome was 23%
for coiling and higher for clipping 30%
significant same for at 23 and well
about 33 percent roughly the same now we
have long-term follow-up from those
studies so the 10-year follow-up from
ISAT shows that coiling still has more
survivors 83 percent versus 79 percent
for clipping there were more recurrent
hemorrhages with coiling there's more
retreatment but the patient still had
less mortality with the coiling the Brat
trial six year follow-up they found no
difference in the clinical outcome and
they found a complete occlusion was
according 40 percent clipping
ninety-five percent the two really have
to work the two techniques really have
to work together so how do we put them
into clinical practice the upper left
shows the end of vascular treatment arm
when a patient comes in with a ruptured
aneurysm and if it can be equally
treated either way by the surgeon the
endovascular surgeon then we tend to
lean towards coiling that's the that's
the first treatment of choice if it
could be treated either way if there's
vasospasm or if the patient is poor
grade or has comorbidities or advanced
age then coiling is actually preferred
even if they could be treated by both
techniques I mean even if it could be
better treated by surgery technically we
would lean towards coiling and attempt
at coiling for those conditions also
posterior circulation aneurysms basilar
apex aneurysms have a very high risk
surgically in the acute phase so those
would tend to be endovascularly treated
for surgical treatment aneurysms of the
middle cerebral location which is the
cat scan down there in the CTA the
n-c-a-a location is often better for
surgery because there's really no neck
to the aneurysm so the coils have a
tough time staying in without including
the arteries that are going by the m2
segments and also in patients who have a
hematoma this patient actually had more
of a clot higher up on the scan they do
better with a decompression
attempted clipping as shown on the left
the upper slide is a complex pecan
aneurysm and that is a good cording
there that was a recent patient what do
we do after the surgery securing the
anterior aneurysm is really one step the
first step but then we rely on the
intensive care unit and actually and our
intensivists it has been shown in
multiple studies that institutions that
do higher volume more than 35 aneurysms
per year of combined treatments and have
neuro intensivists the outcomes are
clearly better and that's actually an
American Heart guideline is to if you do
less than ten aneurysms per year and
institution you probably should refer to
a center that does higher volume' okay
so once they're in the ICU and the
aneurysm secured we used to do triple H
therapy hypertensive hypervolemic chemo
dilution now we do single h therapy
hypertension we do hypertension if the
patient's going into vasospasm about 15
percent of people will end up having
clinical vasospasm but to start with we
keep the blood pressure normal we
maintain the volume normal we don't want
people to be anemic because of the lower
oxygen delivery so we keep a normal
hemoglobin we don't want a patient to be
hyponatremic because of brain swelling
so we keep their sodium up normal or a
little above normal
you don't want hyperglycemia because
that has a clear poor effect on outcome
and normal temperature hyperthermia is
not good and hypothermia has not shown
benefit we administered Animoto peen to
prevent our vasospasm as a calcium
channel blocker magnesium statins and
endothelial antagonists have not been
shown to be effective so those are not
in the clinical practice for prevention
of vasospasm
we do not do prophylactic angioplasty or
even significant hypertension we do it
if they become symptomatic and then they
go to the angio suite for balloon
angioplasty or administration of
intra-arterial I like Hardeen
and then finally the best way to prevent
all this from happening is predicting
rupture so there's a lot of patients out
there who have aneurysms and you all see
them in your clinic they have incidental
aneurysms they present with headache
unrelated or dizziness or other things
and you find these things there are
certain things that predict rupture in
these patients probably should be
referred for endovascular or surgical
treatment one is size if it's greater
than seven millimeters it has a higher
risk of rupture
if the aspect ratio is greater than two
the aspect ratio is the size of the dome
divided by the parent artery diameter so
basically if the aneurysm is twice the
size are greater than though the artery
that feeds it it's at higher risk of
rupturing family history or multiplicity
of aneurysms puts the patient at higher
risk and they should be treated likely
the previous subarachnoid hemorrhage if
the patient has other aneurysms that
have not ruptured they're at higher risk
for aneurysm rupture and they should be
followed very closely and probably
treated certain locations are higher
risk anterior communicating posterior
communicating and post air circulation
those aneurysms all have higher risk of
hemorrhage
once an aneurysm grows and this raises
the under the underscores the final
point is with these treatments surgery
and coiling these patients probably
should be followed with surveillance
studies they don't necessarily have to
be every year maybe every few years but
more is being found that that once
there's some recurrence the hemorrhage
risk per year goes way up at close to
20% 18% in one study so those patients
should be treated and anyone who is an
active smoker that's that's a very
that's being linked very closely to
aneurysm growth and rupture