MANAGEMENT OF SAH: WHAT IS WORKING FOR ME (US)

Vipul GuptaInterventional Neuroradiology/Neurointerventional SurgeryInstitute of Neurosciences Medanta the Medicity

SAH… We work as part of neurosurgery Common ICU rounds and counseling Ward rounds separate OPD in neurosciences area On pay, group practice Stroke and neurovascular reporting

done by us Called – neurointerventional Surgery

(Interventional Neuroradiology)

SAH reports to emergency, Neurosurgery on call and NI on call At night NS on call Co-admission – NI and NS , even directly

referred ones Standard medications ICU admission, Neuro-critical care review ,

PAC Detailed counseling by NI team about course

of management Repeat NCCT if needed

Aneurysmal management

Planned for DSA with 3D , If late evening, then for next day (90% within 24 hours)

Repeat bleed – early Hematoma – CTA/DSA and surgery Neurointerventional Lab Regular angiogram – 2D based on 3D Family counselled, clearence Coiling if possible in same session

Aneurysmal management

General anesthesia 3000IU of heparin Long sheath in all Guiding as high as possible (DAC) DAC – co-axial NTG before guiding placement First coil – another 1500-2000 IU

heparin bolus

large-/giant aneurysms

Aneurysmal management Balloon (more and more) – Sceptre,

Transform , Synchro wire – double curve

Echelon , SL 10 First coil – balloon deflated and check Thereafter – longer inflations All coils – Target, Microplex, G2,

Axium, Orbit

Aneurysmal management

Tight packing is the key – frequently 1.5 mm as last coil

Increasing heaprinization – ACT >250, in broad neck > 300

MC removal with wire AP & lat runs DynaCT Repeat run in working projection – for

20 min after the removal of catheter

Very small berry aneurysms

Aneurysmal management

Very careful shaping Mostly straight tip in ACOM,DACA,

MCA, Basilar top, (ophthalmic, blister)

Reverse curve in poster-superior ACOMs

Double curve – sup hypohsyeal, PCOM, ICA bifrucation

Most > 90% we donot wire the aneurysm (ophthalmic, sup hypopsheal, ICA bifurcation)

DYSPLASTIC BIFURCATION ANEURYSMS

Flow diverters (stents)-

Giant/large aneurysms

Fusiform dissecting aneurysms

38 yr old male patient, 2-day old SAHKnown hypertensive

Clinically grade II

Small Blister/dissecting Friable, continued growth, re-rupture

F

A

Clot formation

Look for fuzziness Increase heaprinization – ACT 350

sec Reopro – 10 mg over 10 min intra-

arterial through microcatheter Post – Heparin, followed by aspirin If coil – heparin +/- anti-platelet

Immediate 5 min 8 min-Reopro

25 min Post reopro 7 mg

35 min Post reopro 10 mg

Post reopro 10 mg- after 50 min

Aneurysmal management Extubation on table Delayed extubation – significant filling,

poor grade, difficult airway etc Discharge 10-days Grade I/II earlier Advised to say nearby Follow-up DSA – 6-months Partially coiled/dissecting/blister –

earlier

Preventive Oral nimodipine Hydration

Strict monitoring Clinical, TCD, CTP Training staff, relatives, direct calls

Therapeutic - “It is stroke” HHH therapy (bridging)

IV Milrinone

IA Nimodipine and IA Milrinone

Continuous Intra-arterial dilatations

Our ProtocolVasospasm

1 ampoule of milrinone (10

mg)

Dissolve it in 40ml of

saline( total volume 50 ml)

Start at rate of 9ml /hour and

can increase up to 22 ml/hour

Dose Simplified

Our IAVD approach..• We do as soon as possible – like acute stroke • HHH – bridging therapy • Local anesthesia • Anesthesia cover• Diagnostic catheter • 3 mg of nimodipine • Followed by 6-8 mg of Milrinone• Duration as important as amount • Followed by HHH and IV milrinone • High rate of angiographic success (90%)

Vasospasm- 15-25% morbidity and mortality

28 y.o female SAH 1 day H & H Grade II

Day 6 Confused, weak on right side

CBF CBV MTT

CTP• Poor grade• Existing hemiparesis• Early or delayed

When nothing works

Day 5

Post Nimodipine

Day 7

Continuous intra-arterial dilatation

Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage Musahl, Christian; Henkes, Hans; Vajda, Zsolt; Neurosurgery. 68(6):1541-1547, June 2011.

20 mg milrinone

20 mg nimodipine

Start at rate of 50 ml/hour can be increased to

100 ml/ hour

1000ml saline

Day 11

Most probably partially thrombosed Will need stent…. Will recur

Referred for surgery

Patient not agreeing for follow-up and re-treatment

95%

5%

Mgt. outcome in good grade patients- 87.6 % mRS 0-2

Conclusion

Integrated team with NS – clinically and financially

Dedicated team Neurovascular center approach Clinical responsibility Management outcome approach Aggressive vasospasm management Awareness programs, direct referrals

B/L MCA aneurysms

Most probably partially thrombosed Will need stent…. Will recur

Dysplastic bifurcation aneurysms- Needing complicated stenting- Partially thrombosed

“COMPLEX” ANEURYSMS•Giant aneurysms• Dissecting fusiform•Blister aneurysms•Aneurysms with near the neck rupture/lobules•Dysplastic bifurcation aneurysms •Aneurysm with artery from the sac

May be..• Aneurysm with vasospasm•Aneurysm with tortuosity •Small aneurysms•Multilobulated aneurysms •Aneurysm with thrombus

Giant/large aneurysms

Stent-assisted coiling – safe, follow-up and possible repeat treatment

Flow diverters - evolving, paraclinoidal aneurysms, ?risk

(Parent vessel occlusion – may be the ideal treatment for cavernous aneurysms)

Flow diverters (stents)-

38 yr old male patient, 2-day old SAHKnown hypertensive

Clinically grade II

Small Blister/dissecting Friable, continued growth, re-rupture

Classical blister aneurysm

F

A

Very small berry aneurysms

Complex aneurysms… Important to recognize and

analyze (3D) Comfortable with all approaches

and techniques Strategy with back-up plan Better outcomes in high volume

centres with expertise, technology (Biplane) and teamwork

Vascular Neurosurgery co-ordination

Issue- stent thrombosis on pasugrel ? too much metal, flow change opening; control- ???, ? staged

Large – giant aneurysms ISUIA Trial

Flow diverters (stents)-

Giant fusiform, no collateral, mass effect

Thrombosed after a week Decompression Independent, mild UL weakness

Giant/large aneurysms Stent-assisted coiling – safe,

follow-up and possible repeat treatment

Flow diverters - evolving, paraclinoidal aneurysms, ?risk

(Parent vessel occlusion – may be the ideal treatment for cavernous aneurysms)

Fusiform giant ICA with no collaterals– need bypass

Fusiform dissecting aneurysm…

56 yr old, ischaemic stroke

Fusiform-dissecting aneurysms & blister aneurysms

Extremely difficult to treat Overlapping stents with coils as much

as possible to buy time/promote thrombosis

Continued growth common- early check Flow diverter

However , Distal fusiform dissecting

aneurysms.. Stent/FD not possible ---

bypass/surgical reconstruction..

Small Blister/dissecting Friable, continued growth, re-rupture

F

A

Very small berry aneurysms

Near the neck rupture

Catheter reposition

1-mm coil

A B C

DYSPLASTIC BIFURCATION ANEURYSMS

Hemtoma – not conscious

Hematoma ….M6

Thank you

For more information on:STROKE & NEUROVASCULAR INTERVENTIONS:

URL:www.sanif.co.in

Facebook:https://www.facebook.com/strokeawarenessindiahttps://www.facebook.com/vipul.gupta.35175

Twitterhttps://twitter.com/drvipulgupta25

LinkedINhttps://in.linkedin.com/pub/dr-vipul-gupta/51/8a1/25a

YouTubeChannel: Stroke & Neurovascular Interventionswww.youtube.com/c/StrokeNeurovascularInterventionsfoundation

Dr Vipul Gupta