Endovascular Management of Aneurysms and Subarachnoid

Hemorrhages

Lorri McCourt-O’Donnell RN, MSN, ACNP, CNRNAdvance Practice Nurse

Endovascular Neurosurgery/Interventional Neuroradiology

Advocate Neurovascular Center

March 14, 2015

Disclosures/Thanks

• Nothing to disclose• My family for letting me

do what I do• The physicians I am

privileged to work with• My chauffer for getting

me here safely : )• The Northern Illinois

Chapter of AANN

Objectives:• Differentiate treatment for Ruptured and Un-Ruptured

Aneurysms• Cerebral circulation and common places for aneurysm

development• Epidemiology and risk factors, Morbidity and Mortality• Clinical presentation/diagnostic testing • Nursing care pre/postoperative

– Ruptured aneurysm aSAH – Non ruptured aneurysm

• Treatment options• Commonly used grading scales• aSAH complications

What is Endovascular Neurosurgery?

• Treat diseases and pathology involving the vessels of the head, neck and spine using minimally invasive technology

• AKA– Interventional Neuroradiology– Interventional Neurovascular – Plus many more…

Disease Treated

• Aneurysm– Ruptured– Non ruptured

• Acute Ischemic Stroke• AVMs, Dural fistulas, Vein of Galen• Carotid and Intracranial stenosis• Tumor and epistaxis embolization

• Bi-Plane – real time images– Performed in IR

• Conscious Sedation, MAC or General Anesthesia

• Femoral Artery Catheterized – 6 French– Catheters and wires are navigated through the anatomy– Right groin access

• Interventions performed if indicated– Purely diagnostic

• Groin sealed with closure device and or manual pressure

What is an Aneurysm• Weakening of the blood vessel wall

– Berry, saccular• Wide neck

– Fusiform– Mycotic– Traumatic

• Pseudo aneurysm– Giant >2.5cm

• Location– Bifurcations in the Circle of Willis

• Anterior Circulation = 85%• Posterior Circulation = 15%

• Neck– Wide– Narrow

• Dome to Neck ratio

bostonscientific.com

Giant Aneurysm

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Cerebral Circulation

• Four Major Arteries– 2 Large Internal Carotid

Arteries (ICA)• Supply blood to the

anterior portion of the brain

– 2 Smaller Vertebral Arteries

• Supply blood to the posterior portion of the brain

– Brainstem– Spinal Cord

Epidemiology:• Aneurysms (unruptured)

– 5% of US population = 10-15 million individuals– Brain Aneurysm Foundation

• 1:50 Individuals– 20-30% have multiple aneurysms

• Risk of rupture related to size– 0.05% risk for <10mm and no prior aSAH– 1% risk per year >10mm– Most aneurysms at time of rupture 4-7mm

• Risk of rupture is 1-2% per year

Aneurysmal Subarachnoid Hemorrhage (aSAH)

• 6-12 cases per 100,000 – 15,000 to 30,000 persons per year– Mean age 55 (40-60)– Risk of rupture is positively correlated with:

• Aneurysm size• Hypertension• Smoking• Illicit drug use

– Cocaine

Risk Factors• aSAH

– Smoking– Hypertension– Increasing age– Alcohol– Illicit Drugs– AA>Caucasians– Females>Males 2-3:1– Genetic

• Polycystic kidney diseases• Connective tissue diseases• Family history

– 1st degree relative

Morbidity and Mortality

• 10-15% die before reaching the hospital– Overall mortality at 6 months

• 40-50%

• Of those who arrive to the hospital– 25% die within 24 hours

• Re bleeding is catastrophic– Mortality of 48-75%

• 1/3 of survivors have functional independent lives• Improving outcomes

– Being admitted to a Major Medical Center– Interventional Neuroradiology within 7 hours of presentation/bleed

Clinical Picture• Symptoms begin abruptly

– ‘Worst headache of life’, ‘Thunderclap’– 30% lateralized to side of aneurysm– Maybe associated with

• LOC – brief• Seizure• Nausea, Vomiting• Meningeal signs

• Sentinel Bleed 10-43%– 30-50% minor hemorrhage– aSAH occur within 6-20 days

Mechanism of Action

• Initial Injury– Aneurysm ruptures

• Releases blood into the CSF– Quickly– Under arterial pressure

• Thus increasing ICP– Monroe Kellie Doctrine

Diagnostics

• Good History and Physical• Diagnostic Testing

– CT scan – shows subarachnoid blood• Diffuse bleeding pattern

– Lumbar puncture• Traumatic tap will clear

– CT angio (CTA)– MRI/MRA– Cerebral Angiogram ‘Gold Standard’ (DSA)

Securing Aneurysms More Than One Way To Get The Job Done

• Surgical Clipping– ? ‘gold standard’

• Craniotomy for visualization and clipping of aneurysm

• Endovascular Coiling– May not be suitable for all aneurysms– Better outcomes at 90 days in coiling vs. clipping

• The International Subarachnoid Aneurysm Trial

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Surgical Clipping

Endovascular Coiling

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Stent Assisted CoilingNot commonly used in acute SAH

Pipeline EmbolizationNot Commonly used in acute SAH

• Used to redirect blood flow away from the aneurysm– Flow diverter

Nursing care preoperative• ABCs• Neuro Checks• BP management

– Systolic between 90-140mmhg– AVOID Hypotension

• ICP Monitoring– EVD if indicated

• Labs– CMP, CBC, Cardiac Enzymes, Coags, T&C, ABGs if

intubated, 12 lead EKG, Chest X-Ray

Preoperative Care• NPO• IVF

– Maintain euvolemia– 0.9 NS at 80-100ml per hour

• Activity – quiet environment, limit visitors• DVT – No anticoagulation until aneurysm

securement– Teds, SCDs

Medications• Nimodipine 60mg Q4 hrs• Seizure prophylaxis

– Phenytoin load 1000mg then 100mg Q8 hrs– 10-20% of aSAH have seizures??– Side effects of Phenytoin

• Pain Management• Antiemetics• GI Protection• Stool Softeners

Nursing Care Postoperative• ABCs• Frequent Neuro exam Q1hr

– Or as exams dictate• HOB 30 degrees, neck midline• Reduce stimulation, quiet, dark room

– Headaches continue, until blood clears CSF• BP Management

– DO NOT TREAT BLOOD PRESSURE ONCE ANEURYSM IS SECURE• Maintain perfusion to the brain• Allow BP to be 200mmhg systolic• CPP to be >60 to 70 mmHg

• Fever management• Daily Labs

– Electrolytes, CBC, Cardiac Enzymes (1st 5 days), ABGs, Chest X-Ray, Anticonvulsant levels

– Consider baseline 2D-Echo

Postoperative Nursing Care• DVT prophylaxis

– Continue TEDs and SCDs– SQ heparin/lovenox

• Trans cranial Doppler (TCDs)– Consistently measure MCA mean velocity– <120 cm/sec = less risk of vasospasm– >200 cm/sec = greater risk of vasospasm– Used in conjunction with neuro exam

• Repeat Cerebral Angiogram – Day 7-10– Regardless of securement methodology

Medications

• Nimodipine 60mg Q4 hrs– For 21 days

• Divided dose 30mg Q2 for hypotension

• Seizure prophylaxis???– 100mg Q8 hrs– Only 10-20% of aSAH have seizures– Side effects of Phenytoin

• Pain Management• Antiemetic• GI Protection• Stool Softeners

Aneurysm Grading Scales

• Glasgow Coma Scale• Hunt and Hess

– Most widely used– Predicts clinical outcomes

• World Federation of Neurological Surgeons (WFNS)– Combines GCS and presence of motor deficits– Predicts clinical outcomes

• Fisher Scale– Vasospasm risk

• All scales have some issues with validity/ reliability

Glasgow Coma Scale

ccn.aacnjournals.org

Hunt and Hess

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Fisher Scale

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WFNS

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aSAH Complications

• Re-Bleeding– >risk first 24 hours 2-4%

• Increases 15-20% during the next 2 weeks

– 48-75% mortality– Risk increases with conservative treatment

• Acute Hydrocephalus - 65%– Enlargement of ventricles– Occurs within the first 24hours

• Abrupt MS changes and 6th Nerve Palsy

– Can be life threatening

• Late Hydrocephalus – 10-15%– 10 or more days– Incontinence, gait instability, cognitive issues

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SAH-induced Vasospasm

• Occurs angiographically in 30-70% of patients• Clinical symptoms seen in 20-45% of patients• Adds 10-20% significant morbidity/mortality• Smooth muscle constriction and vessel wall

edema, infiltration and fibrosis leads to luminal narrowing and decreased compliance

• Time course– Range: 4-14 days– Peak: 7-10 days

Detection of Vasospasm

• Clinical exam– Focal deficit– Mental status changes

• Increasing TCDs• CTA/CTP• MRI/A/P• Angio

Triple H Therapy (Modified)

• Hypertensive therapy– SBP >160 mm HG– Don’t treat BP – patients will usually auto regulate

• In symptomatic vasospasm vasopressors are used• Hypervolemia

– Maintain PCWP at 10 to 16 mm Hg– Urinary output >/= 250ml per hour

• Euvolumia– Using fluids and vasopressors for symptomatic patients

• Hemodilution– IV fluids at 100-150 ml per hour– Hematocrit <0.40

T

Vasospasm Treatment

• Nimodipine– 60mg Q4hr for 21 days

• Cerebral Angiogram– Intra arterial calcium channel blockers

• Verapamil

– Angioplasty– Stent

Verapamil Infusion

aSAH Complications

• Hyponatremia – 50%– Associated with poor outcomes– More common in higher grade SAH

• Mechanism– Excessive renal secretion of sodium

• Cerebral Salt Wasting (CSW)

• Leads to cerebral edema• Treatment

– Related to volume and salt replacement

• Fluid restriction could be detrimental to patients

aSAH Complications

• Cardiac Dysfunction– Tako–tsubo Cardiomyopathy

• Neurogenic myocardial stunning• Thought to be related to excessive release of

catecholamine

• Left Ventricle– Apical ballooning

• MUST rule out coronary artery disease first

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Myocardial Stunning

• Normal Left Ventricle

• Tako-Tsubo or Myocardial Stunning Left Ventricle

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EKG Changes

• Stage I (acute stage)– Few hours

• ST elevation• Short QT interval• R wave may be present

• Stage II (sub acute stage)– Lasts days

• QT segment prolongation• Large deep negative T waves

• Stage III– Recovery

• Flipped T waves (days to weeks)• Normal QT interval

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Treatment of Myocardial Stunning

• Supportive– Unload the left ventricle– Reduce vasopressors

• Started due to low BP– Results in increased SVR and afterload

– Contractility Agents• Dobutamine

– Address Pulmonary Edema• Lasix

Left ICA/PCOM Aneurysm• D.G.

– 58 year old AA female• Went to bed the night prior to admission complaining of headache• Family discovered her unresponsive

– Taken to OSH -> Transferred to ACMC

– PMH• Has not seen provider in ‘years’

– PSH – tubal ligation• 1 PPD Smoker, social ETOH, no illicit

– Physical Exam• Drowsy but arousable• VSS• Neuro exam non focal

– Hospital course• Taken to the OR for surgical clipping – day 1• Follow up angiogram demonstrated approx. 5mm

residual aneurysm, no vasospasms – day 8• Developed symptomatic vasospasms – day 12

– Treated with intra arterial verapamil

• Developed aphasia – day 18– MRI – sub acute infarct in left ACA territory

» No neruo deficits– Treated for focal seizures

» Additional antiepileptic was started

• Residual treated – day 22• Transferred to rehab – day 26• Discharged home 14 days post rehab• 40 day Hospitalization/Rehab stay

Unruptured Aneurysms• To Treat or not To Treat?

– That is the question?• Patient Counseling

– Family history• Strong family history of aneurysms or first degree relative

with aSAH– Medical history

• Polycystic kidneys• Hypertension• Lifestyle

– Discussion regarding natural history of aneurysms• Rate of rupture

Risk of Unruptured Aneurysm

Size (mm) Anterior circulation Posterior circulation

< 7 0% 2.5%

7-12 2.6% 14.5%

13-24 14.5% 18.4%

25> 40% 50%

Five year risk of SAH from an unruptured aneurysm

ISUIA study (Lancet July 2003)

Decision to Treat• Guidelines

– 75mg Plavix and 325mg Aspirin for 7 days prior to procedure– Loaded with 300mg Plavix prior to procedure

• Dependent on device– Admitted to ICU as 23 hour observation patient

• Majority are discharged from ICU• Restrictions

– No heavy lifting– No swimming or tub baths– Most resume normal activity one week post op

– Compliance with Aspirin and Plavix regime is reinforced• Plavix for 90-180 days

– Dependent on device• Aspirin for life

– 325mg 81mg– 6 month post op angiogram– Yearly MRA with contrast

• Tapered to biannual once follow up exams are stable (~3 yrs)– Nimodipine is not used for unruptured aneurysm

Treatment Complications• Thromboembolic

– clot formation on coil ball, catheter– push clot out of aneurysm

• Aneurysm rupture– more likely in ruptured aneurysms

• Device malfunction– premature detachment of coil– unraveling

• Vascular damage– spasm, dissection

• Coil Compaction

Overall treatment risk around 3-5%

Elective Aneurysm Embolization• KM, 45 y/o female

– PMH/PSH• Chari Malformation repair, Migraines, Fibromyalgia, Tubal ligation

– PFH• Mother, Sister(multiple) aneurysms• Grandmother deceased from subarachnoid hemorrhage

– Known ICA aneurysm being followed for years by Neurosurgery• Recent interval growth• Sent by Neurosurgeon for evaluation

– PE• Non focal exam

– Scheduled for Pipeline Embolization of aneurysm

Endovascular follow up Guidelines

• Initial treatment– SAH

• 1 week follow angiogram– Evaluate for vasospasm

• 6 month follow up angiogram• Yearly MRAs with contrast

– Elective• 6 month follow up angiogram• Yearly MRAs with contrast

– Once stable for several years Q2 year MRAs

Evidence Based Care

Treatment Outcomes

• ISAT trial– Comparative study of coiling vs. clipping

• 2143 patients enrolled– 1070 Clipping 1055– 1073 Coiling 1063

• WFNS Grade 1-2

– Outcomes at 1 years • mRS of greater than 2 (dependent or dead)

– 326 or 30.9% clipping– 250 or 23.5% coiling

• Risk reduction of 7.4%• Lower risk of post SAH epilepsy

– Rebleeding at 1 year• 7 coiling• 2 clipping

– Advantage followed out for 7 years

Barrow Ruptured Aneurysm Trial• Eligible patients assigned in an alternating fashion to surgical

aneurysm clipping or endovascular coil therapy– 239 clipping– 233 coiling

• Not all aneurysms were amenable to coiling– Cross over from coiling to clipping– Cross over patients did worse, but no worse than those

randomized to clipping• Overall 1 year results (defined as mRS >2)

– 33.7% of clipped – 23.2% of coiling

Guidelines for the Management of AneurysmalSubarachnoid Hemorrhage

-Stroke 2012

• For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of Evidence B).

• Microsurgical clipping may receive increased consideration in patients presenting with large (>50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms.

• Endovascular coiling may receive increased consideration in the elderly (>70 years of age), in those presenting with poor-grade and in those with aneurysms of the basilar apex (Class IIb; Level of evidence C).

Should patients be offered the option of coiling vs. clipping in the acute setting?

Future Research

• Magnesium – Cerebral vasodilatory effects

• Ability to penetrate CNS– Readily available, inexpensive– Recent research

• DNI – 12/54 in the Magnesium Group = 22%– 27/53 in the Control Group = 51%

• Mortality– 6/54 in the Magnesium Group = 11%– 10/53 in the control Group = 19%

– Recommendations• Do not induce hypermagnesaemia• Avoid hypomagnesaemia• Further research is needed

Future Research

• Statins– Several small randomized clinical trials

• Shown to reduce vasospasms and DNI• Reactivation of the Stash Study

– Multicenter study on the use of statins in aSAH

– Recommendation• If patient is taking statin continue• May consider in statin naive patients• More research is recommended

Future Research

• Phenytoin Prophylaxis– Three day course of Phenytoin

• 1.9% of patients had seizures with 3 day prophylaxis– 1.3% in retrospective group

• 80% treated with craniotomy– Drug Reaction

• 8.8% to 0.5% with three day course• Hospital length of stay 14.2 to 13.1

– Recommendations• Use of anticonvulsants is not recommended• If anticonvulsant prophylaxis is used

– 3-7 days• If patient presents with history of seizure

– Institution’s protocol

Take Home Points

• Sentinel leak is often overlooked• Aneurysmal rebleeding is fatal in 75% of

patients• Neurogenic Pulmonary Edema occurs

independent of cardiac dysfunction• Cerebral Salt Wasting is real and important

• Phenytoin Prophylaxis in aSAH causes more problems then it solves

• Symptoms of Vasospasm and Hydrocephalus are similar

• Angiographic signature of vasospasm does not explain patient findings

• Vascular Treatments for vasospasms are inadequate

• Treatments for High Grade Patients remain poor

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The End

???Questions???

Brain Aneurysm Support Group Offering a supportive enviroment for survivors, families and friends of

Brain Aneruysms, AVMs, Subarachnoid Hemorrhages, and Intracrainal Hemmorhages

Professional guidance and resources to help answer questions.

When: The first Monday of the Month

7:00 to 8:30 PM

May 4th, July 6th, September 7th, November 2nd

Where: Advocate Christ Medical Center

4440 W. 95th Street, Oak Lawn, IL 60453

Community Room located in the new Outpatient Pavilion – Ground Floor Corner of 95th and Kilbourn

Mission: To gather in a supportive enviroment and share experiences, challenges and

recovery tools to aid survivors, families and friends. Provide professional guidance and support for those recovering from Brain Aneurysms and associated diseases.

For further information please contact Maureen Gill or Lorri McCourt-O’Donnell at 847-430-6108

References:• AANN (2009). Care of the Patient with Aneurysmal Subarachnoid Hemorrhage. AANN

Clinical Practice Guideline Series• Connolly, S., et al. (2012). Guidelines for the Management of Aneurysmal

Subarachnoid Hemorrhage. Stroke• Bader, M., Littlejohns, L. (2004). AANN Core Curriculum for Neuroscience Nursing• Chumnanvej, S. (2007). Three day phenytoin prophylaxis is adequate after

subarachnoid hemorrhage. Neurosurgery• Diringer, M., Bleck, T., et al. (2011). Critical Care Management of Patients Following

Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference

• McDougall, C., et al. (2012). The Barrow ruptured aneurysm trial. Journal of Neurosurgery

• Molyneux, A., et al. (2005). International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2153 patients with ruptured intracranial aneurysms: a randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. The Lancet

• Naidech, A., (2005). Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage. Stroke

• Schmid-Elsaesser, R. et al. (2006). Intravenous Magnesium versus Nimodipine in the treatment of patients with aneurysmal subarachnoid hemorrhage: A randomized study. Neurosurgery

• Society for Critical Care Medicine. (2006). Ten things we hate about subarachnoid hemorrhage (or, the taming of the aneurysm. Critical Care Medicine

• Up-to-date. Retrieved 8/30/2010. Etiology, clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage. Subarachnoid hemorrhage grading scales

• Westermaier, T., et al. (2010). Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: A randomized, placebo-controlled, clinical study. Critical Care Medicine