DISCLOSUREAmar Siyar, RVT

• No relevant financial relationship reported

Ahmad SiyarVascular Ultrasound Technology

Diagnostic Ultrasound ProgramBellevue College

SWEDISHSwedish Medical Center

Cherry Hill

UW MedicineHarborview

Medical Center

_____________

Clinical Instructor:Anne Moore

Supervisor; Cerebrovascular Lab Harborview Medical Center

o Brain aneurysm statistics and factso Signs and symptomso Risk factorso Treatmento Types of graftso Equipment and transducerso Challenges to imagingo Case study (ECA-ICA Bypass Graft)o Study findingso References

Contents

Brain Aneurysm Statistics and Facts in the US

o 6 million people have unruptured brain aneurysm, 1 in 50.

o 30 Thousand people suffer a brain aneurysm rupture every year.

o 66% of survivors suffer permanent neurological deficit.

o 15% die before reaching the hospital

o Most prevalent in people ages 35-60

o Larger than 1 inch are “giant” aneurysms – difficult to treat.

Unruptured brain aneurysms are typically completely asymptomatic.These aneurysms are typically small in size, usually less than one half inch in diameter. However, large unruptured aneurysms can occasionally press on the brain or the nerves stemming out of the brain and may result in various neurological symptoms.

Warning Signs/Symptoms

Unruptured brain aneurysms

o Localized Headacheo Dilated pupilso Blurred or double visiono Pain above and behind eyeo Weakness and numbness

o Difficulty speaking

Ruptured brain aneurysmso Sudden severe headache, the worst headache of your lifeo Sudden blurred or double visiono Sudden pain above/behind the eye or difficulty seeingo Sudden change in mental status/awarenesso Sudden trouble walking or dizzinesso Sudden weakness and numbnesso Sensitivity to light (photophobia)o Loss of consciousnesso Nausea/Vomitingo Stiff Necko Seizureo Drooping eyelid

Risk factors for brain aneurysm● Smoking and drug use● Hypertension ● Congenital artery wall abnormalities ● Family history of brain aneurysms● Age over 40● Gender, women compared with men at a ratio of 3:2● Disorders such as Ehlers-Danlos Syndrome, Polycystic Kidney Disease,

Marfan Syndrome, and Fibromuscular Dysplasia(FMD)● Presence of an arteriovenous malformation (AVM)● Infection● Tumors● Traumatic head injury● African-Americans and Hispanics at twice the rate of rupture of whites

Treatment of brain aneurysmTo relieve symptoms and to prevent any subsequent strokes vascular surgeons and neurosurgeons try:

1. Improving collateral sources of flow:

a. endarterectomyb. angioplasty

c. stenting

2. Direct intervention:

a. traditional proceduresb. minimally invasive procedures.

1. Improving collateral sources of flow:

o Patients with complete carotid occlusion can be asymptomatic due to adequate collateral system.

o However, patients with recent ischemic symptoms are at high risk for subsequent stroke because of hemodynamic impairment due to poor collateral flow.

Traditional´Huntarian ligation ´Clipping ´Aneurysmorrhaphy´Wrapping ´ECA-ICA bypass

2. Direct Intervention:

Endovascular´Coiling´Stent-assisted coiling´ Pipeline stents´ Flow diversion stents

A- Traditional

Clipping Wrapping

Huntarian ligation

B- Endovascular

CoilingFlow diversion stent

Pipeline stent Stent-assisted coiling

B- Endovascular

Web device

B- Endovascular

Extracranial to intracranial arterial bypass

o Extracranial-intracranial (EC-IC) bypass surgery is being increasingly used in the surgical management of cerebrovascular diseases, especially for the treatment of complex aneurysms not amenable to clipping and occlusive cerebrovascular disease.

o For this purpose either synthetic or autogenous grafts are used as conduit.

Types of graftsDirect extracranial to intracranial arterial bypass of the ipsilateral external carotid artery is performed either by:

A. Superficial temporal artery (STA) bypass;

B. Radial artery (RAD) bypass graft;

C. Saphenous vein (SAPH) bypass graft; or

D. Anterior tibial artery (ATA) graft.

connecting external carotid artery (ECA) to one of the middle cerebral artery (MCA) branches.

Graft anatomy

MCA - M2

Dist. AnastomosisAneurysm

Radial artery graft

Prox. Anastomosis Prox. ECA

Bypass MapDistal MCARAD Graft

Proximal MCA

Philips iU22

Transducers

o Broadband S5-1 sector array transducer

o Hockey Stick L 15-7io Linear array transducer

o L 9-3 Linear array transducer

Challenges to Imaginingo Penetration of bone layer in order to image cerebral

bed.o Patients’ limited maneuverability.o Intensive care equipment such as Intracranial pressure

monitors and drains.

o Patient cooperation. o Immediate post-op staples and bandages.

Case studyo Immediate Post-Op duplex study

o Exam performed in October, 2017o Duration of the exam 45 - 60 minutes

o Inpatient setting

o Patient non-intubated and awake

o Vessels studied CCA, ECA, RAD graft, MCA, ACA, PCA

Patient historyo Hypertension.

o Cerebrovascular accident. o Gastroesophageal Reflux Disease.

o 50-year previous smoker.o Chronic Obstructive Pulmonary Disease.

o No family history of aneurysm.

History of present illnessA 67-year old male patient was admitted early September 2017.

Patient previously had a R MCA aneurysm rupture during attempted clipping in January 2017, causing hemorrhagic stroke with significant deficit followed by decompressive hemicraniectomy.

The significant deficit caused multiple large left MCA territory infarct.

Pre-Op Angio

o Palmar arch is assessed for patency.o Rad graft diameter is assessed.o The predetermined 22 cm segment of radial artery

is harvested.o Proximal RAD graft is end to side anastomosed to

the ECA.o Distal end of the graft is end to end to

anastomosed to MCA-M2.

Operative plan

Post Op Angio

Post Op Angio

Left ECA

Proximal Anastomosis

Mid Graft - Volume Flow

Transcranial Distal Graft

Left MCA

Preliminary findings1. Patent left ECA-MCA radial artery bypass graft with

averaged mid-graft volume flow measuring 78mL/minute.

2. Low velocities with antegrade flow left MCA.

4. Elevated pulsatility indices throughout the bypass graft and in the left MCA, ACA, PCA.

5. Normal velocity in PCA-P2.

Follow upo Patient developed postoperative aspiration

pneumonia and pseudomeningocelehydrocephalus which complicated the course of the treatment.

o Patient responded well to the procedure and started the course of recovery.

o Patient was then discharged to rehabilitation.

Referenceshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1151700/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218175/#B20

J Korean Neurosurg Soc.

https://www.bafound.org/about-brain-aneurysms/brain-aneurysm-basics/warning-signs-symptoms/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218175/

http://www.mayfieldclinic.com/PE-CerebralBypass.htm

https://www.ncbi.nlm.nih.gov/pubmed/2865674

Roh SW1, Ahn JS, Sung HY, Jung YJ, Kwun BD, Kim CJ

J Korean Neurosurg Soc.

https://www.ncbi.nlm.nih.gov/pubmed/2865674#

https://www.sec.gov/Archives/edgar/data/1318310/000095012310001855/c55450exv99w1.htm

C olin P . D erdeyn, R obert L. G rubb, Jr., W illiam J. Pow ers

Skull Base. 2005 Feb; 15(1): 7–14. doi: 10.1055/s-2005-868159

PM C ID : PM C 1151700

Sung W oo R oh, Jae Sung Ahn, H an Yoo Sung, Young Jin Jung, Byung D uk Kw un, C hang Jin K im

J Korean N eurosurg Soc. 2011 Sep; 50(3): 185–190. Published online 2011 Sep 30. doi: 10.3340/jkns.2011.50.3.185

PM C ID : PM C 3218175

2011 Sep;50(3):185-90. doi: 10.3340/jkns.2011.50.3.185. Epub 2011 Sep 30.

PM ID : 22102946

Brain aneurysm foundation, w arning signs and sym ptom s

Zuccarello, M D , review ed, M ayfie ld C ertified health info, M ayfie ld C lin ic 4.2016

Failure of EC -IC A BPG to reduce ischem ic stroke

1985 N ov 7;313(19):1191-200.

PM ID : 2865674

Barnhart, K ris lynn, T ranscrania l D oppler in C urrent Endovascular N eurosurgery, 2017, Pow erPoint file .

References