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Cerebrovascular Flashcards

1
Q

SAH Overview

A

General principles:
- Endovascular vs Clipping
- Parent artery preservation
- Proximal control
- Stent-assisted not favorable in rupture

Complications of SAH and peri-operative management

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2
Q

Give the Hunt and Hess Grading

A
  1. Asymptomatic or minimal headache
  2. Severe headache, non-focal deficit
  3. Drowsiness, confusion, mild focal deficit
  4. Stupor, hemiparesis, early decerebrate posturing
  5. Deep coma, moribund appearance
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3
Q

Give the World Federation of Neurosurgery grading

A

I. GCS15 with no motor deficit
II. GCS13-14 with no motor deficit
III. GCS13-14 with motor deficit
IV. GCS7-12
V. GCS3-6

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4
Q

Give the Radiographic Fisher grade

A

(% predictive of vasospasm risk)
1. No SAH present (21%)
2. SAH in cistern <1mm thickness (25%)
3. SAH in cistern >1mm thickness (37%)
4. IVH or IPH (31%)

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5
Q

Give the Radiographic MODIFIED Fisher grade

A

(% predictive of vasospasm risk)
0. No SAH present (0%)
1. Focal or diffuse thin SAH, no IVH (24%)
2. Focal or diffuse thin SAH, with IVH (33%)
3. Thick SAH, no IVH (33%)
4. Thick SAH, with IVH (40%)

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6
Q

What are complications of SAH?

A

Hydrocephalus: EVD and VP shunt

Vasospasm:
- Screen (daily TCD, hyponatremia, serial neurological exams)
- Treatment (induced hypertension, endovascular therapy)

Seizures: Keppra, phenytoin

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7
Q

Management of high grade SAH

A
  1. EVD (keep open at 25)
  2. SBP management (arterial line, SBP<140)
  3. Daily TCDs, nimodipine for 21 days
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8
Q

Rule out SAH

A
  1. Non contrast CT scan
  2. Lumbar puncture (elevated RBCs with no clearance tubes 1-4 and xanthochromia)
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9
Q

ISUIA natural history: cavernous aneurysm

A

0/0/0/3/6%
(<7mm, <7mm, 7-12, 13-24, >25)

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10
Q

ISUIA natural history: anterior circulation

A

0/1/2/14/40
7/7/7-12/13-24/25

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11
Q

ISUIA natural history: posterior circulation

A

2/3/14/18/50
7/7/7-12/13-24/25

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12
Q

ISAT trial (Lancet 2002)

A

Multi-center clip vs coil of ruptured aneurysm

Confirmed SAH CT or LP within 28 days, IA by angio/CTA
Equipoise

Majority (9559) treated outside trial, and almost all were anterior circulation (97.3%). MCA underrepresented

23% coiling vs 30% clipping poor outcome (mRS3-6) at 1 year

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13
Q

Aneurysm Conclusions

A

No single treatment can work for all aneurysms. Patient selection critical.

Preop planning critical.

Don’t force one treatment modality over another.

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14
Q

NASCET (1991)

A

2885 patients with TIA/minor stroke within 4 months: Best Medical vs. CEA

70-99%: 26% vs 9% (17%) after 2 years
50-69%: 6.5% after 5 years
<50%: no benefit

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15
Q

ECST

A

3024 pts with TIA, retinal infarct, non-disabling strokes within 6 months

70-99%: 21% ARR/5 years
50-69% 5.7% ARR/5 years
<50%: no benefit

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16
Q

ACAS (JAMA 1995)

A

1662 pts with angio or doppler>60%

11% vs 5% after 5 years
Low surgical M&M (1.5%)
No statistical benefit in women

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17
Q

ACST (Lancet 2004)

A

3120 pts /w doppler>60%
11% vs 6% after 5 years

Results more robust than ACAS
Surgical M&M at 3%

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18
Q

Walk through Carotid Endarterectomy steps

A

Set up:
General anesthesia, SBP<140, aspirin preop
Neuromonitoring (motor/ssep)
Shunt ready

Positioning:
Supine slight head turn away from surgical site
Incision: longitudinal incision anterior border of SCM
Dissect down platysma
Careful superiorly avoid CN12, vagus nerve
Expose bifurcation, ICA, ECA
Loop around ICA and CCA in case we need to use shunt
Induce burst suppression during cross clamping (EEG, motor and step)
Clamp: distal ICA, CCA, and then ECA, and superior thyroid
Make arteriotomy from CCA to proximal ICA under microscope
Excise plaque circumferentially
Close sutures
Unclamp ECA, CCA, ICA
Confirm careful hemostasis

Considerations: positioning, accessible, spinal level, mandible, neuomonitoring, clamp order, and shunt/patch

Post op SBP90-140 (concern for reperfusion hemorrhage)

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19
Q

High risk criteria for CEA

A

(Commit to memory)
Patient factors: age>80, heart failure, active CAD, Severe COPD

Carotid factors: high anatomical lesion, contralateral carotid lesion, prior neck radiation or surgery, tandem intracranial stenosis

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20
Q

CAS vs CEA data (CREST, NEJM 2010)

A

Overall rate of CVA, MI or death not differ between CEA or CAS
Stroke higher in CAS, MI higher in CEA

CAS more effective in younger, CEA more effective in older

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21
Q

Post op complications after CEA

A
  • Vigilance for neck hematoma/airway
  • Blood pressure control/perfusion breakthrough hemorrhage
  • Carotid occlusion with stroke symptoms
22
Q

Natural history of AVM and high risk angiographic features

A

2-4% annual risk of hemorrhage
Elevated for prior rupture

High risk angiographic feature
- Feeding artery/intranidal aneurysms
- Restricted venous outflow

23
Q

Spetzler-Martin Grade

A

Size (<3, 3-6, >): 1-3
Venous drainage (superficial or deep): 0-1
Eloquence: 0-1

Total 1-5
Adverse outcome: <1% in SM1-2
14% in grade 3
30% in grade 4
50% in grade 5

24
Q

AVM Treatment Options

A

Conservative
Primary Surgery
Endovascular embolization
Gamma knife radio surgery (<3cm)

25
ARUBA trial (2014)
Multi-center, non-blinded, randomized Halted early Medical management alone vs intervention (surgery, embolization, radiation) Primary endpoint: death or symptomatic stroke 30% met primary endpoint interventional arm vs 10% (Conservative management 10% risk of stroke or death over 33 months)
26
AVM Pearls
High Flow AVM - venous status, consider immediate resection Surgery without embolization great option for SM1 and II AVM
27
Criticisms of ARUBA trial
1. Short term follow up (33 months) - stopped early. Many may remain asymptomatic over time - benefit intervention may not be evident short term Untreated AVM may rupture later wile intervention early complication rate 2. All interventions grouped: surgery, embolization, radio surgery; some only embolization alone may not be curative 3. Selection bias of high grade AVMs (Grade 3-4) - known to have higher treatment risks. 4. Lack of consideration for delayed radio surgery effects - radio surgery takes 2-3 years to achieve AVM obliteration - short term follow up may not have gained protective benefit
28
Cavernous Malformation Epidemiology
Rare - 0.56 per 100K Symptoms: ICH, headache, seizure, focal neurological deficit Familial forms: CCM 1,2,3 mutations
29
Cavernous malformation: annual risk of hemorrhage
First hemorrhage: 0.4-2.4% (lower risk with incidental discovery) Subsequent hemorrhage: 3-29% (decreases over time)
30
Work up for Cavernous
CT (symptomatic in ED), but MRI is test of choice Limited role of angiography Associated with DVA Family history/Genetic testing
31
Management of Cavernous
Asymptomatic: Conservative ICH/IVH: standard medical management Surgery: reserved for symptomatic ICH, or uncontrolled seizure; morbidity varies with location Radiosurgery unproven - do not suggest on boards
32
Epidemiology of dural AV fistula
10-15% of intracranial AVM Thought to develop as thromboses sinus attempts to recanalize Venous hypertension Almost always acquired - thrombosis, trauma or iatrogenic
33
Arterial supplies of dAVF
Commonly ECA branches Middle meningeal, transosseous branches of occipital, post auricular, ascending pharyngeal Also post meningeal branches of vertebral and cavernous/petrous branches of ICA
34
dAVF clinical presentation
Commonly asymptomatic; headache, tinnitus, and/or bruits Depends on location/pattern of venous drainage. May lead to remote ischemic type symptoms from venous hypertension, hemorrhage, seizures
35
Borden Classification
Type I: Drainage into dural venous sinus Type II: Drainage into dural venous sinus with retrograde venous drainage Type III: Drainage into leptomeningeal veins, fistula 20% of type II and 40% type III present with hemorrhage
36
Cognard Classification
Type I: Sinus, anterograde, no CVD Type IIA: Sinus, retrograde, no CVD Type IIB: Sinus, anterograde, CVD Type IIA+B: Sinus, retrograde, CVD Type III: direct to cortical vein Type IV: direct to cortical vein + venous ectasia Type V: spinal perimedullary venous drainage with progressive myelopathy
37
Natural history of Cognard and Borden dAVFs
Borden I and Cognard I and IIA - Benign course (Direct sinus, anterograde or retrograde, no CVD) Borden II/III and Cognard IIB-V - Aggressive course - annual risk of hemorrhage 8% - annual combined mortality rate 10%
38
Treatment for dAVF
Low grade: conservative, follow up Treatment: Endovascular: first line treatment - trans arterial or venous Surgical: exploration and skeletonization of sinus/ligation of fistula Radiosurgery: Rare
39
Carotid cavernous fistula: Etiology
Trauma - MVA most common cause with basilar skull fx lacerating ICA or branch Spontaneous: ruptured cavernous ICA aneurysm, Ehlers dances, fibromuscular dysplasia Iatrogenic: carotid angioplasty/stent, transracial trigeminal rhizhotomy, sphenoid sinus surgery
40
Carotid cavernous fistula: Presentation
Intracranial bruit, proptosis, chemises, pulsatile exopthalmos, declining vision/elevated IOP, ophthalmoplegia
41
Carotid cavernous fistula: Barrow classification
Type A - Direct (intracavernous ICA to cavernous) Type B - Indirect dural ICA branches Type C - Indirect dural ECA branches Type D - Dural ICA and ECA branches
42
Treatment for CCF
Indication: ocular symptoms Embolization is first line - coils (arterial)
43
Carotid artery dissection - Etiology
Spontaneous, connective tissue disorder Iatrogenic Traumatic (blunt/penetrating/direct trauma)
44
Classic triad of carotid artery dissection
Ipsilateral pain Horner's syndrome Cerebral or retinal ischemia (mostly embolic 90% hemodynamic 10%) Pulsatile tinnitus 25%
45
Denver Grading Scale
Grade I: mild intimal injury (<50%) - heal regardless of treatment Grade 2: dissection>50%, flow limiting, 70% progress despite heparin Grade 3: pseudoaneurysm (grade III), only 8% heal without intervention, 79% improve with endovascular Grade 4: Occlusion - no spontaneous recanalization Grade 5: Transection/Death
46
Treatment guideline for carotid dissection
Antiplatelet or warfarin for 3-6 months (Beyond 3 months, antiiplatelet for stroke/TIA patients) Definite recurrent ischemic events despite antithrombotic therapy, endovascular therapy (stenting) may be considered) Patients who fail or not candidate for endovascular therapy - may be considered for surgical treatment
47
Stroke - Multiple Positive Studies
MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT, SWIFT PRIME, THRACE Extended time - DAWN and DEFUSE3
48
Initial management of Stroke
IV tPA within 4.5h of last known normal - Know contraindications: ICH, recent head trauma, coagulopathy/thrombocytopenia, anticoagulation, non-compressible arterial bleeding <7 days, glucose<50mg/dL
49
tPA dosing
0.9 mg/kg IV (not exceed 90mg) 10% IV bolus over 1 minute, 90% over 60 min
50
Endovascular management of Stroke
Acute window (<6h) - LVO on CTA or MRA - NIHSS>6 - CT ASPECTS>6 Extended window (6-24h) - CT perfusion or MR perfusion/DWI - Mismatch less than 30-70cc ischemic core - volume of ischemic tissue to initial infarct ratio >1.8

Neurosurgery Oral Boards (5 decks)

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