Treatment of intracranial aneurysm

Aneurysma a. cerebri media dx.

• rupture of aneurysmhere causes subarachnoid hemorrhage
• the only rational way to prevent recurrent bleeding from an aneurysm is to close its neck with a clamp or to obliterate its sac endovascularly
• the greatest risk of a new rupture is within 48 h after the first bleeding
• 4.-10. the day after the bleeding, a strong vasospasm often occurs, which can cause ischemia and the operation could only become more difficult at this time → the operation must therefore be well timed
• for early surgery we therefore have a period of the first 72 hours after bleeding
• for the indication for surgery, the time since SAK, the patient's condition, CT finding is decisive
• selection of patients - if we find an expansive hematoma on CT, we always operate, the goal is not only to clamp the aneurysm, but also to evacuate the hematoma acutely
  • if no hematoma is present (on CT only blood in cerebral fluid - i.e. only SAH...) - grade I to III. we operate immediately (within 72 hours)
  • for patients in IV. and SAK degree V - it is recommended to wait for an improvement of at least one degree
    • the patient's serious condition is not caused by brain compression, but by ischemic changes, we would not be able to help him now by closing the aneurysm
• timing of surgery - important to prevent rerupture and prevent vasospasm
  • early operations (before the onset of vasospasm) generally have a higher operative mortality, but late operations (up to 21 days after SAH, i.e. after vasospasm has subsided) carry a high risk of repeated bleeding and overall have a worse outcome
  • operation between the 4th and 7th day after SAH is not at all suitable, due to vasospasm

Preoperative Procedure

• even when diagnosing SAK, one must think about the risk of rebleeding → we will ensure absolute bed rest, head elevated to 30°, transport on a stretcher (even if the patient could escape...)
• after confirmation of SAK by CT, he should be transported to neurosurgery, we will perform panangiography

• preoperative care - absolute rest, administration of laxatives (difficulty defecation promotes reruptures), dexamethasone (prevention of edema), antihypertensives, nimodipine ( Ca channel blocker, prevention of vasospasm), anticonvulsants (prevention, an epileptic seizure could lead to rerupture), the patient is in the ICU
  • after SAH, there is often a finding on the ECG that looks like subendocardial ischemia, it is caused by catecholamine washout caused by ischemia of the hypothalamus after SAH, this may manifest as a latent ICH

Treatment methods

Conservative therapy

• for postponed operations – includes the measures mentioned above
• if coagulum blocks the CSF channels, we introduce external ventricular drainage

File:Clipping aneurysmat.png

uzavření krčku aneurysmatu

Surgical therapy

• closure of the neck of the aneurysm while maintaining blood flow through other vessels
• performance is rerupture prevention, does not repair damage caused by previous SAK
• early operations are among the most complex neurosurgical operations

File:Coiling aneurysmatu.png

coiling aneurysmatu

Endovascular methods

• coiling – obliteration of the bulge bag with metal spirals
  • spirals have shape memory and coil themselves in the aneurysm, a coagulum forms on them and the entrance to the aneurysm is re-epithelialized
  • it is done angiographically, under an x-ray lamp, little burden for the patient
  • limitations of coiling – reachability of the aneurysm by catheterization, neck-to-sac ratio (when it is large, coils escape)
  • if the aneurysm has a wide neck, a stent is usually implanted first and coils are inserted through it to prevent leakage

Complications

• ischemia from vasospasm, cerebral edema, bleeding in the operative field, hemostasis disorders, hyporesorptive hydrocephalus

Postoperative Care

• the basis is the monitoring of the neurological condition, in case of deterioration of consciousness or accentuation of focal symptomatology - always CT
• prevention of postoperative vasospasm - "hyperdynamic therapy" - "3 H": hypervolemia, hypertension, hemodilution
  • only if the aneurysm is reliably closed and the patient has a healthy heart

Links

Related Articles

• Subarachnoid hemorrhage from aneurysm and A-V malformation

Source

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  BENEŠ, George. Study Materials [online]. ©2007. [cit. 2009]. <http://www.jirben.wz.cz/>.

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References

• {{#switch: book

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  Incomplete publication citation. ZEMAN, Miroslav, et al. Special Surgery. Prague : Galen, 2004. 575 s. 978-80-7262-438-6.

|collection =

  Incomplete citation of contribution in proceedings. ZEMAN, Miroslav, et al. Special Surgery. Prague : Galen, 2004. 575 s. {{
  #if: 80-7262-260-9 |978-80-7262-438-6} }
  |article = 
  Incomplete article citation.  ZEMAN, Miroslav, et al. 2004, year 2004, 

|web =

  Incomplete site citation. ZEMAN, Miroslav, et al. Galen, ©2004. 

|cd =

  Incomplete carrier citation. ZEMAN, Miroslav, et al. Galen, ©2004. 

|db =

  Incomplete database citation. Galen, ©2004. 

|corporate_literature =

  ZEMAN, Miroslav, et al. Special Surgery. Prague : Galen, 2004. 575 s. 978-80-7262-438-6} }

Done by: Eisa Jbara