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INRC > Vascular > Flashcards

Vascular Flashcards

1
Q

What is the mortality of SAH?

A

Up to 50%

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2
Q

Which studies have looked into the natural history of unruptured aneurysms?

A

ISUIA

UCAS - unruptured intracranial aneurysms of Japan

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3
Q

What score helps to determine risk and whether to treat an unruptured incidental aneurysm?

A

UIATS - unruptured intracranial aneurysm treatment score

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4
Q

What is the rate of recannalisation for coiling?

A

10%

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5
Q

Which studies have looked into coiling vs clipping?

A

ISAT
BRAT
Finnish aneurysm study
All show significant improvement with coiling at one year but not by 2 years

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6
Q

Which aneurysms have highest incidence In the anterior circulation?

A

ACOM > PCOM > MCA

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7
Q

What is the most common approach for aneurysm clipping?

A

Pterional Approach

Lateral supra orbital approach (less invasive)

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8
Q

What approach is used for distal ACA / pericallosal artery aneurysm?

A

Anterior interhemispheric approach

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9
Q

What are the steps during aneurysm clipping after craniotomy?

A
  1. Arachnoid dissection
  2. Proximal control
  3. Distal control
  4. Aneurysm dissection - dissection of perforators, placement of clip, ICG angiography
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10
Q

What are the strategies to control aneurysm rupture?

A

Targeted tamponade
Suction
Proximal control with temporary clipping

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11
Q

What are the indirect treatment options for aneurysm treatment?

A 
Hunterian ligation (parent vessel sacrifice without bypass)
Aneurysm trapping with EC-IC bypass (radial artery, saphenous vein and STA)
In-situ bypass (2 close vessels are sutured side by side)
Aneurysm trapping with vessel re-implantation
Remodelling by flow reversal
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12
Q

When to clip vs bypass?

A

Fusiform aneurysm or previously coiling = bypass

Saccular aneurysm = clip

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13
Q

What are the goals of aneurysm treatment?

A

Complete occlusion with avoidance of recurrence

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14
Q

What proportion of aneurysms are found in children?

A

1% are

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15
Q

How do paediatric aneurysms present?

A

80% with haemorrhage - most are Fusiform > saccular

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16
Q

What is the risk of vasospasm in paediatric SAH?

A

10-20% - which is much lower than adults!

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17
Q

What are the % of complete long-term aneurysm occlusion with clip vs coil?

A

96 and 48% at 9 years from BRAT trial

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18
Q

What intraoperative test can be performed to ensure brain perfusion following bypass?

A

ICG and Laser speckle

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19
Q

What is the aneurysm rupture rate within 24 hours?

A

4% followed by 1% for every subsequent day

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20
Q

What is the concern with clipping with vasospasm?

A

Operating has a poorer outcome in patients with vasospasm

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21
Q

What is the role of bypass for ischaemia?

A

Flow augmentation of a chronically hypoperfused brain

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22
Q

What were the outcomes of the EC/IC bypass trial (NEJM 1985)

A

Surgery did not show any benefit over best medical treatment

But wrong patient selection and no stratification for haemodynamic compromise

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23
Q

What proportion of patients develop ischaemia due to vessel stenosis?

A

10%

80% are due to acute thrombus on a ruptured atherosclerotic plaque that are not helped by bypass!

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24
Q

How do you test cerebrovascular reserve capacity?

A

In patients with chronic haemodynamic insufficiency you measure brain perfusion pre and post DIAMOX iv which causes vessel vasodilation. In patients without reserve the blood flow remains the same or reduces due to steal phenomenon. These patients may be best treated with bypass (see JET and COSS studies no difference)

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25
Q

What are the histological findings with Moyà Moyà

A

Intimal and media thickening causing vessel obliteration resulting in significant collateralisation

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26
Q

Who described the first cavernoma?

A

Luschka in 1854

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27
Q

What is the incidence of cavernoma?

A

0.5%
No difference between M & F
90% are supratentorial

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28
Q

What proportion of cavernomas are associated with DVAs?

A

20%

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29
Q

What are the risk factors for cavernoma?

A

Previous radiotherapy

Familial mulitple cavernomas

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30
Q

What is the histology of cavernoma?

A

Mulberry appearance macroscopically

Sinusoid thin walled venous channels

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31
Q

What is the classical finding of cavernoma on MRI?

A

Pop-corn lesion

Haemosiderin ring

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32
Q

What is the bleeding rate of a cavernoma?

A

Previously thought to be higher but now 1% per year per cavernoma
Bleeding risk is 2.5-5% if infratentorial and higher if there is an associated DVA
2% annual new seizure onset risk

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33
Q

What are the indications for brainstem cavernoma resection?

A

Repeat symptomatic haemorrhage (2 or more)

Superficial

34
Q

What is the rupture rate of AVM (previously unruptured)?

A

2-3% per year

Higher if there is an associated nidal aneurysm

35
Q

What are the treatment strategies for high grade AVMs?

A

Staged fractionated gamma knife to down stage the AVM followed by surgery if not completely obliterated

36
Q

What is the CREST study?

A

Carotid revascularisation endarterectomy vs stenting trial
Composite endpoint of stroke, MI and death showed no difference between the two overall, but stroke risk is higher with stenting (4%) compared to endarterectomy (2%) whilst MI risk is 1% stenting and 2% endarterectomy.

37
Q

Which studies have compared surgery vs stenting for carotid disease?

A 
CREST
SPACE
3S
ICSS
SAPPHIRE
Meta-analysis has shown endarterectomy is better: Symptomatic patients have double stroke rate with stenting vs surgery
38
Q

What is the relationship of the hypoglossal nerve to the common facial vein with carotid endarterectomy?

A

Hypoglossal nerve lies under the common facial vein;

Hypoglossal nerve runs over the artery to SCM more superiorly

39
Q

What nerve can lie over the carotid bifurcation?

A

Ansa cervicalis

40
Q

What arteries are clipped / occluded in carotid endarterectomy?

A

Superior laryngeal artery
ICA distal
ECA
Common carotid

At the end take off the ECA, Common carotid then distal ICA

41
Q

What is the outcome of the ISAT and BRAT trials at one year?

A

7.4% absolute risk reduction at 1 year which reduces to 5% by 2 years that is not significant

42
Q

Which studies have shown the benefit of acute endovascular clot retrieval in stroke?

A

MR CLEAN
ESCAPE
EXTEND IA
Etc

43
Q

What proportion of strokes at ischaemic vs haemorrhagic?

A

85% vs 15%

44
Q

What is the ischaemic threshold of brain?

A

18ml / 100g / min (normal is 50!)

45
Q

What is the definition of the ischaemic penumbra?

A

Region of brain with decreased cerebral perfusion but not infarction (so salvageable brain)

46
Q

What are the important velocities to know with TCDs?

A

Look this up

47
Q

What is the prevalence of an unruptured intracranial aneurysm?

A

0.6-6% as per ISUIA (the majority do not rupture!)

48
Q

Histologically thickened vessels without an internal elastic lamina. What are these?

A

Arterialised veins

49
Q

What are internal elastic cushions?

A

Fibromuscular hyperplasia in AVMs

50
Q

When is the highest risk of AVM haemorrhage in pregnancy?

A

15-20th week gestation

51
Q

Histologically tightly packed vessels with hyalinised vascular channels (no elastic lamina). What is the diagnosis?

A

Cavernoma

52
Q

What genes are involved with familial cavernoma syndrome?

A

CCM1 = KRIT1 (hispanic)

CCM2 & 3 (non-hispanic)

53
Q

What is the main histological difference between AVM and cavernoma?

A

AVM has intervening brain and vessels have internal elastic lamina (arterial)

54
Q

What are the 4 types of aneurysm?

A

Saccular
Fusiform
Myoctic
Dissecting

55
Q

What factors are associated with aneurysms?

A 
Hypertension
FHx
AVM
Collagen diseases (FMD / Ehler's danlos)
Smoking
56
Q

What type of aneurysms cause hypertensive haemorrhages?

A

Charcot-Buchard (occur of perforators)

57
Q

What should be ruled out in a patient with mycotic aneurysms?

A

Bacterial endocarditis

58
Q

What diseases affect large arteries?

A

Atherosclerosis
Moya Moya
Fibromuscular dysplasia
Giant cell arteritis

59
Q

Histologically what condition has fibro-muscular intimal hyperplasia?

A

Atherosclerosis

60
Q

What cells are found within the intima in moya moya?

A

T-lymphocytes

61
Q

What condition has granulomatous inflammation of arterial walls?

A

Giant cell arteritis

62
Q

What are the causes of an arterial vasculitis?

A 
Polyarteritis nodosa
Wegeners granulomatosis
Behcets
Churg-strauss
SLE
63
Q

Look up the aneurysm clipping vs coiling meta-analysis!

A

Coiling has better clinical outcome than clipping

Coiling has a greater rebleed rate

64
Q

What is Dolenc’s triangle?

A

Anteromedial triangle

65
Q

What is the meningo-orbital band?

A

Look up

66
Q

Anterior clinoidectomy 3d anatomy

A

look up in Neurosurgery

67
Q

How do you interpret TCD values

A

PI, EDV etc

68
Q

What is the significance of a PCA infarct in a patient with low GCS after aneurysm rupture?

A

PCA infarct suggests poor outcome

69
Q

What are the platelet function tests?

A

P2Y12 for clopidogrel

Arachidonic acid reaction units for Aspirin

70
Q

What are the guidelines for reintroduction of anti-platelet agents in patients with drug eluting coronary stents?

A

Look it up

71
Q

Where are the hypothalamic and Heubner perforators in relation to an ACom aneurysm?

A

Know the anatomy of this

72
Q

What is the incidence of AVM?

A

10 x less common than aneurysms

73
Q

What AVM classifications do you know?

A

Spetzler-martin
Lawton
Sekhar

74
Q

What are the important consideration when assessing an AVM?

A 
Nidus - compact / diffuse / shunts
Feeding arteries - incl perforators
Draining veins - deep supfl
Pathological - aneurysms / venous stenosis
Shape - usually connical
75
Q

What is the rebleed rate of AVM?

A

6% in the first year and 2% every year after that

76
Q

Are the findings of the ARUBA trial applicable to patient management?

A

Have a good answer to this

77
Q

How would you investigate a young patient with recurrent atraumatic SDH?

A

DSA incl ECA for DAVF

78
Q

What makes you treat a DAVF?

A

Cortical venous reflux or severe symptoms

79
Q

What should be surgically occluded in DAVF?

A

The venous side of the fistula (venous leptomeningeal drainage)

80
Q

What is the Aminoff-Logue grading?

A

??

81
Q

What is the Denis grading in spinal DAVF?

A

??

82
Q

What structure lies behind the common facial nerve?

A

The hypoglossal nerve

INRC (7 decks)

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