Endovascular Treatment of

Subarachnoid Hemorrhage

Sharon Webb, MD, FAANS,

FACS, FAHA

Aneurysms

MCA Aneurysm

Subarachnoid

Hemorrhage

• Blood in subarachnoid space

• Causes:

– Aneurysm Rupture (75-80%)

– Arterial- Venous malformation

– Trauma

– Vasculitis

– Tumor

– Spinal AVM

SAH

Hemorrhagic Stroke - SAH

Diagnosis

• CT scan

• Lumbar Puncture

• CTA

• Angiography

Aneurysm Risk Factors

• Hypertension

• Substance Abuse

• SMOKING!!

• Family history

• PCKD

Aneurysms

• 50% mortality

• Rupture rate based on size and location –

ISUIA data

• Rerupture rate highest in first 48 hours

• Hydrocephalus, arrhythmias

• Vasospasm

SAH PROTOCOL

• 1. Nimotop : x21d. (only FDA approved drug)

• 2. Statinx14d

• 3. Mag oxideX14d

• 4. Echo

• 5. Troponin x3

• 6. TCD x10d

Medical Treatment

• Admitted to ICU

• Nimotop, zocor, Magnesium

• MAP 70-90 before treatment

• MAP >80 after treatment

• IVFs

• TCDs

• Watch Na – cerebral salt wasting

VASOSPASM

• 1. One of leading

causes of morbidity and

mortality post SAH.

• 2. Peak Day 3-10.

• 50-70% have it, 30-

50% have symptoms.

• Diagnosis: CLINICAL

most important, TCD,

cerebral angio

• CLINICAL:

• Lethargy

• Change in speech,

weakness, hemiparesis

• Vision change

• Any NEURO change

Vasospasm

Cascade

• 1. Increased levels of

Ca+ in smooth muscle:

increased muscle

contraction and vessel

contraction of vessel

wall

• 2. Increased vasoactive

substances

• 3. Structural arterial

wall injury

Treatment Vasospasm

• 1. Induced HTN: Map >110 NEO/LEVO

• 2. Fluid Volume normal

• 3. Intra-arterial Verapamil

• 4. Nimotop. Ca+blocker. Relaxes smooth muscle cells in brain.

• 5. Magnesium: Ca+ antagonist, decrease free radicals, inflammation.

• 6. Statin: neuro protective. Stabilize endothelium.

• 7. HHH: Hypertension/hemodilution/hydration

TCD

TRANSCRANIAL

DOPPLER

• Measure velocity of

blood flow in cerebral

arteries.

• Daily for 10-14days

• Monitor for vasospasm.

(3-10d)

• Not 100%, need clinical

exam.

• PEAK: <150

ALBUMIN

• 25% Albumin: volume expander

• ALISAH study 2006-2010.

• Has neuroprotective properties, increase

cerebal blood flow/collateral flow in animal

studies

• Keep hydrated, hold on to NA.

HYPONATREMIA

FLORINEF NA TABS

• Glucocorticoid

• Help maintain salt and

H20 balance.

• Most common electrolyte

imbalance in SAH. (30-

50%).

• 1-2gm TID

• Taper upon dc/transfer

Fisher Grade 3 SAH

Before VASOSPASM

Coiling

3D Picture Post Coiling

After Vasospasm

Surgical Treatment

• Clipping: 0.01%

recurrence

• Coiling: 8-12%

recurrence

• Pipeline: 0%

Aneurysm Surgery

Aneurysm Surgery

Large Right MCA – Non

Ruptured

Intraoperative

Post Clipping

SAH from MCA Aneurysm

Angiogram – Right MCA

Aneurysm

Post Clipping – No Residual

but Vasospasm

Post Clipping - Edema

Endovascular

Endovascular Surgery

SAH From Mycotic

Aneurysm

MCA Mycotic Aneurysm

MCA Mycotic Aneurysm

BEFORE EMBO AFTER EMBO

SAH From Dissecting

Aneurysm

Dissecting Aneurysm

PREVIOUS DISSECTION FORMATION OF ANEURYSM

Right MCA Dissecting

Aneurysm

Peforation During

Treatment

Angiogram After Occlusion

Contrast Staining After

Perforation

Pipeline

Pipeline Embolization

Pipeline Embolization

Pipeline Embolization

AVM

• Considered to be congenital lesions

• Bed of dilated arteries and veins directly

connected with no capillary bed

• Prevalence:0.14%

• Usually presents with ICH or seizures

• Bleeding risk 2-4% per year

• Morbidity 30-50%, mortality 10%

AVM

Treatment

• Surgery

• Embolization

• Gamma Knife

• Combination therapy

SAH from Prenidal AVM

Aneurysm

AVM with Prenidal PICA

Aneurysm

AVM s/p Embo of Aneurysm

AVM s/p Treatment

BEFORE EMBO AND RESECTION

AFTER EMBO AND RESECTION

AVM

Right Sylvian AVM

Treated with Radiosurgery

1 Year Follow UP

Angiogram After

Radiosurgery

Spinal AVM

QUESTIONS?