Neurosurgical Emergencies

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Acute InterventionalSAH Management
Paul J. Camarata, MD, FACS The Kansas City
Neurosurgery Group University of Missouri, Kansas
City pcamarata_at_kcneurosurgery.com
Paul J. Camarata, MD, FACS The Kansas City
Neurosurgery Group University of Missouri, Kansas
City pcamarata_at_kcneurosurgery.com
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Subarachnoid Hemorrhage

• Definition
• Etiology
• Prevalence
• Pathophysiology complications
• Acute Interventional Management

• Definition
• Etiology
• Prevalence
• Pathophysiology complications
• Acute Interventional Management

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Subarachnoid Hemorrhage
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Subarachnoid Hemorrhage

• Blood vessel on brains surface bleeds into the
  spinal fluid, that is between the brain and the
  arachnoid membrane
• Most commonly caused by ruptured intracranial
  aneurysm
• Aneurysm negative SAH
• Less frequent causes
• Arteriovenous malformation
• Arterial dissection

• Blood vessel on brains surface bleeds into the
  spinal fluid, that is between the brain and the
  arachnoid membrane
• Most commonly caused by ruptured intracranial
  aneurysm
• Aneurysm negative SAH
• Less frequent causes
• Arteriovenous malformation
• Arterial dissection

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Cerebral Aneurysms

• Congenital
• Absence of media, internal elastic lamina
• Degenerative
• Flow-related

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ExperimentalCerebral Aneurysms
Kerber, et al.
Kerber, et al.
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Cerebral Aneurysms

• Saccular
• small, medium, giant (gt2.5 cm)
• Fusiform
• atherosclerotic

• Saccular
• small, medium, giant (gt2.5 cm)
• Fusiform
• atherosclerotic

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Giant Aneurysm
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Subarachnoid Hemorrhage

• Prevalence (aneurysm)
• Autopsy series .3-5
• Overall prevalence probably 1-2
• SAH - 12 per 100,000
• gt30,000 in North America

• Prevalence
• Autopsy series .3-5
• Overall prevalence probably 1-2
• SAH - 12 per 100,000
• gt30,000 in North America
• ,000 in North America

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Risk factors
Subarachnoid Hemorrhage

• Hypertension
• Smoking
• heavy alcohol use
• Sympathomimetic drugs
• certain genetic syndromes

• Hypertension
• Smoking
• heavy alcohol use
• Sympathomimetic drugs
• certain genetic syndromes

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Prevention
Subarachnoid Hemorrhage

• Control hypertension
• Stop smoking
• Screening?

• Control hypertension
• Stop smoking
• Screening?

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Subarachnoid Hemorrhage

• Sudden, intense headache (lightning-like)
• Sudden nausea and vomiting
• Brief loss of consciousness (fainting, confusion,
  convulsions)

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Cerebral Aneurysm
Diagnosis

• History and Physical
• Sudden, severe HA, Thunderclap, meningismus,
  photophobia
• Radiologic
• Subarachnoid blood on CT
• Angiography

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Cerebral Aneurysms
Complications

• Rebleeding
• 27 in first two weeks
• 4 in first 24 hours
• Vasospasm
• Hydrocephalus, other
• Hydrocephalus
• Seizures
• Other medical problems

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Days

• Rebleeding
• 27 in first two weeks
• 4 in first 24 hours
• Vasospasm
• Hydrocephalus, other
• Hydrocephalus
• Seizures
• Other medical problems

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Cerebral Aneurysms
Complications

• Rebleeding
• Early Treatment in good grade patients
• Vasospasm
• Increased recognition
• Treatment with hypervolemia, hemodilution,
  hypertension, balloon angioplasty

• Rebleeding
• Early Surgery in good grade patients
• Vasospasm
• Increased recognition
• Treatment with hypervolemia, hemodilution,
  hypertension, balloon angioplasty

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Acute Interventional Management

• ABCs
• Treatment of Hypertension
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

• ABCs
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

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• Guidelines for Mgmt of SAH,
• Stroke, March 2009
• Class I Evidence
• Blood pressure should be monitored and controlled

Guidelines for Mgmt of SAH, Stroke, March
2009 Class I Blood pressure should be monitored
and controlled
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Acute Interventional Management

• ABCs
• Treatment of Hypertension
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

• ABCs
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

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Acute Interventional Management
Subarachnoid Hemorrhage

• Treatment of Hydrocephalus
• Subarachnoid hemorrhage producing acute
  hydrocephalus
• Intraventricular hemorrhage
• Urgent ventriculostomy

• Treatment of Hydrocephalus
• Subarachnoid hemorrhage producing acute
  hydrocephalus
• Intraventricular hemorrhage
• Urgent ventriculostomy

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Acute Interventional Management

• ABCs
• Treatment of Hypertension
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

• ABCs
• Treatment of Acute hydrocephalus
• Management of Aneurysm
• Surgery
• Endovascular management

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Acute Interventional Management
Subarachnoid Hemorrhage

• Goal of Surgery/Interventional Tx
• complete obliteration of aneurysm
• preservation of all arterial branches

• Goal of Surgery/Interventional Tx
• complete obliteration of aneurysm
• preservation of all arterial branches

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Aneurysm
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Clipped Aneurysm
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Aneurysm Clipping
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Acute Interventional Management
Subarachnoid Hemorrhage

• Endovascular Management
• Coiling
• Stent-assisted coiling

• Endovascular Management
• Coiling
• Stent-assisted coiling

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Acute Interventional Management
Subarachnoid Hemorrhage

• Endovascular Management
• Platinum Coil inserted into aneurysm
• Blood clot created
• Aneurysm sealed off

• Endovascular Management
• Coil inserted into aneurysm
• Blood clot created
• Aneurysm sealed off

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Guglielmi Detachable Coils
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New Techniques

• Liquid Embolic Agents

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New Techniques

• Pipeline endovascular device

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Pipeline Endovascular Remodeling Device
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• Pipeline endovascular remodeling device

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Guidelines

• Surgical clipping or endovascular coiling should
  be performed to reduce rebleeding Class I
• Incompletely clipped/coiled aneurysms have
  increased hemorrhage risk and require long-term
  F/U angio Class I
• If team judges clippingcoiling, coiling can be
  beneficial Class I
• Early treatment is probably indicated in majority
  of cases Class IIa

• Surgical clipping or endovascular coiling should
  be performed to reduce rebleeding Class I
• Incompletely clipped/coiled aneurysms have
  increased hemorrhage risk and require long-term
  F/U angio Class I
• Experienced team approach beneficial Class I
• Early treatment is probably indicated in majority
  of cases Class IIa

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Guidelines
Treatment of Vasospasm

• Oral nimodipine is indicated to reduce poor
  outcome related to SAH Class I
• Maintain normal blood volume, avoid hypovolemia
  Class IIa
• One reasonable approach - volume expansion,
  hypertension, hemodilution Triple H Class IIa
• Angioplasty and/or intraarterial vasodilator may
  be reasonable Class IIb

• Oral nimodipine is indicated to reduce poor
  outcome related to SAH Class I
• Maintain normal blood volume, avoid hypovolemia
  Class IIa
• One reasonable approach - volume expansion,
  hypertension, hemodilution Triple H Class IIa
• Angioplasty and/or intraarterial vasodilator may
  be reasonable Class IIb

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CONCLUSIONS

• Acute SAH Management
• ABCs
• Treat hydrocephalus
• Treat aneurysm early
• Treat complications

• Acute SAH Management
• ABCs
• Treat hydrocephalus
• Treat aneurysm early
• Treat complications

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CONCLUSIONS

• Secure aneurysm by
• Surgical clipping
• Coil embolization
• /- stent

• Secure aneurysm by
• Surgical clipping
• Coil embolization
• /- stent

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Acute InterventionalSAH Management
Paul J. Camarata, MD, FACS The Kansas City
Neurosurgery Group University of Missouri, Kansas
City pcamarata_at_kcneurosurgery.com
Paul J. Camarata, MD, FACS The Kansas City
Neurosurgery Group University of Missouri, Kansas
City pcamarata_at_kcneurosurgery.com