Apollo Grand Round -sah
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37/F Spontaneous Subarachnoid Hemorrhage
Episodic headache with blurring of vision and giddiness- 4 months Sudden onset of severe headache followed by brief loc on 20.11.2009. Headache lasted 4 days, recovery complete NCCT head –Normal
Repeat episode of severe headache with loc for 15 mins on 27.11.2009. Headache persisted for 1 week NCCT head – Fourth ventricular bleed with ?subarachnoid hemorrhage in bilateral CP angle cistern (R>L).
Examination
No neurological deficit Neck rigidity present
Imaging
CT angiography:
CT angio : Right vertebral artery fusiform aneurysm.
IADSA
Right V.A.
Left V.A.
RVA- AP
RVALat
LVA-AP
LVA-Lat
PCOM
PCOM
RICA
LICA
IADSA : – Fusiform aneurysm right vertebral artery. – Beaded appearance of bilateral extracranial vertebral artery upto PICA and involvement of external carotid artery branches. – Renal artery and aorta were normal.
Treatment Options
No intervention Surgical clipping of aneurysm Stenting with coiling of aneurysm Occluding the right vertebral artery
No Intervention
PROS – Extensive involvement. – Neurologically intact
CONS: – Risk of rebleeding, similar to any other ruptured aneurysm.
Surgical clipping
PROS – Direct treatment.
CONS – Extensive involvement of vertebral artery – Difficult technically as all the walls involved (blow out)
Right vertebral artery occlusion
PROS: – Flow reversal leading to obliteration of aneurysm. – Extensive involvement of vertebral artery dealt with.
CONS: – Risk of ischemia.
Stenting with coiling of aneurysm
PROS: – Direct treatment of the aneurysm
CONS: – Difficult to negotiate catheter through the involved beaded segment without causing dissection or bleeding.
Concerns
Extensive involvement of bilateral vertebral and external carotid artery branches. Poor flow in posterior communicating artery Large ruptured intracranial fusiform aneurysm just near the right PICA. If later on left vertebral artery involves, chances of ischemia.
RVA- AP (30.11.2009)
RVA- AP (07.12.2009)
RVA -Lat
LVA- AP
RICA- AP
LICA - AP
Post Nimodipin
Post occlusion
Post occlusion
Pre-occlusion
Occluded Rt VA
Fibromuscular Dysplasia
FMD is an angiopathy that affects mediumsized arteries predominantly in young women of childbearing age. FMD most commonly affects the renal arteries and can cause refractory renovascular hypertension. Renal involvement occurs in 60-75%,
Cerebrovascular involvement occurs in 25-30%, Visceral involvement occurs in 9% Arteries of the limbs are affected in about 5% 26% of patients, disease is found in more than one arterial region
Cephalic FMD: 95% have internal carotid artery involvement and 1243% have vertebral artery involvement. Involvement of smaller blood vessels, including intracranial vessels, is rare. FMD is an important cause of stroke in young adults.
Prevalence of aneurysms- 7.3%. FMD is a predisposing factor in 15% of spontaneous cervical carotid dissections.
D/D
Moyamoya Disease Neurosyphilis Takayasu Arteritis Varicella Zoster Vasculitic Neuropathy
Treatment
According to presentation and pathology – – –
Stroke. Dissection. SAH with aneurysm.
Episodic headache with blurring of vision and giddiness- 4 months Sudden onset of severe headache followed by brief loc on 20.11.2009. Headache lasted 4 days, recovery complete NCCT head –Normal
Repeat episode of severe headache with loc for 15 mins on 27.11.2009. Headache persisted for 1 week NCCT head – Fourth ventricular bleed with ?subarachnoid hemorrhage in bilateral CP angle cistern (R>L).
Examination
No neurological deficit Neck rigidity present
Imaging
CT angiography:
CT angio : Right vertebral artery fusiform aneurysm.
IADSA
Right V.A.
Left V.A.
RVA- AP
RVALat
LVA-AP
LVA-Lat
PCOM
PCOM
RICA
LICA
IADSA : – Fusiform aneurysm right vertebral artery. – Beaded appearance of bilateral extracranial vertebral artery upto PICA and involvement of external carotid artery branches. – Renal artery and aorta were normal.
Treatment Options
No intervention Surgical clipping of aneurysm Stenting with coiling of aneurysm Occluding the right vertebral artery
No Intervention
PROS – Extensive involvement. – Neurologically intact
CONS: – Risk of rebleeding, similar to any other ruptured aneurysm.
Surgical clipping
PROS – Direct treatment.
CONS – Extensive involvement of vertebral artery – Difficult technically as all the walls involved (blow out)
Right vertebral artery occlusion
PROS: – Flow reversal leading to obliteration of aneurysm. – Extensive involvement of vertebral artery dealt with.
CONS: – Risk of ischemia.
Stenting with coiling of aneurysm
PROS: – Direct treatment of the aneurysm
CONS: – Difficult to negotiate catheter through the involved beaded segment without causing dissection or bleeding.
Concerns
Extensive involvement of bilateral vertebral and external carotid artery branches. Poor flow in posterior communicating artery Large ruptured intracranial fusiform aneurysm just near the right PICA. If later on left vertebral artery involves, chances of ischemia.
RVA- AP (30.11.2009)
RVA- AP (07.12.2009)
RVA -Lat
LVA- AP
RICA- AP
LICA - AP
Post Nimodipin
Post occlusion
Post occlusion
Pre-occlusion
Occluded Rt VA
Fibromuscular Dysplasia
FMD is an angiopathy that affects mediumsized arteries predominantly in young women of childbearing age. FMD most commonly affects the renal arteries and can cause refractory renovascular hypertension. Renal involvement occurs in 60-75%,
Cerebrovascular involvement occurs in 25-30%, Visceral involvement occurs in 9% Arteries of the limbs are affected in about 5% 26% of patients, disease is found in more than one arterial region
Cephalic FMD: 95% have internal carotid artery involvement and 1243% have vertebral artery involvement. Involvement of smaller blood vessels, including intracranial vessels, is rare. FMD is an important cause of stroke in young adults.
Prevalence of aneurysms- 7.3%. FMD is a predisposing factor in 15% of spontaneous cervical carotid dissections.
D/D
Moyamoya Disease Neurosyphilis Takayasu Arteritis Varicella Zoster Vasculitic Neuropathy
Treatment
According to presentation and pathology – – –
Stroke. Dissection. SAH with aneurysm.
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