Surgery for Cerebrovascular Diseases(CVDs) Jian-min Zhang Dept. of Neurosurgery 2nd Affiliated Hospital Zhejiang University College of Medicine

Cerebral vascular diseases (CVDs) are series of diseases with high mortality, which have loaded a heavy burden to the society. Classification ： Hemorrhagic and Occlusive Treatment ： medicine and surgery With the development of basic science, microneurosurgery and endovascular techniques, more and more CVDs can be treated by means of surgery. introduction

1.Hemorrhagic CVDs intracranial aneurysm cerebral vascular malformation hypertensive hemorrhage

(1). intracranial aneurysm

general knowledge incidence: % in autopsy; 6-8/10 5 /year for ruptured aneurysms. It is the third common CVDs and the incidence is increasing. Most common in years old Morphology: abnormal dilation of intracraniaarteries- ---saccular, fusiform and dissecting Often diagnosed when ruptured and cause subarachnoid hemorrhage(SAH). Mortality decreased with the improvement of diagnose and management.

Etiology Congenital Acquired: Infectious Traumatic Caused by angiosclerosis Caused by disecting of blood vessels

Common Location anterior circulation: 85% ～ 95% anterior a. -30% posterior communicating a. -25% middle cerebral a. -20% ； Posterior circulation: 5% ～ 15% basilar a. -10% ； vertebrate a. -5% ，

Risk factors age Genetic background Homodynamic factors Defects in medial layer of blood vessels Hypertension

Natural history Ruptured :7% die on the spot,7% misdiagnosed Re-bleeding: peak at 7-10th days

Pathology SAH Intracranial hemorrhage hydrocephalus Cerebral vasospasm

Symptoms bleeding ： headache, nausea and consciousness disturbance Local neurological symptoms Systematic symptoms

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Hunt-Hess scale I Asymptomatic or minimal headache and slight nuchal rigidity II Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy III Drowsiness, confusion, or mild focal deficit IV Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances V Deep coma, decerebrate rigidity, moribund appearance

diagnosis Lumbar pucture CT/MRI DSA,CTA, MRA

（ＣＴ） CT could not directly detect the body of aneurysms unless it is very large radiology

managements medical surgical endovascular

１.medical Lying in bed for more than 4 weeks Avoiding agitation or excertion haemostatic Dehydration to reduce intracranial pressure Anti-vasospasm external ventricular drainage Controlling the blood pressure Symptomatic treatment

２.surgical history ： 1885,Horsley ligation of internal carotid a cerebral angiography 1931 encapsulate the aneurysms with muscles 1937 aneurysm clipping ( by Dandy) and trapping 1942 ligation of the neck of the aneurysms Purpose of the operation ： avoiding re-rupture and re- bleeding, keep the aneurysm-bearing arteries open and controlling vasospasm Operation: direct—clipping, ligation or trapping Indirect: ligation of carotid artery or blocking the aneurysm-bearing atery Trapping (preoperative tests)

indication age ＜ 75 ； Hunt-Hess scale: I － III Hunt-Hess scale IV-V should be operated when the patients recover to I-III In acute phase: with intracerebral hemorrhage or large volume of SAH Infectious aneurysm

Operation time Immediate operation for Hunt-Hess I -II ； Patients with recurrent bleeding ； Patients with vasospasm should be operated on after days from the initial bleeding; Patient >50 years should avoid operation with in 1 week from the last bleeding ； Patients with giant aneurysms, wide base aneurysms should wait for the retraction of the brain edema, for the operations are difficult.

Open surgery for aneurysm clipping approach By microsurgery and special instruments Endoscope-assisting operation Close the neck of the aneurysms keep the aneurysms-bearing artery open and protect the nearby blood vessels and nerves

Pros of the aneurysm clipping For the reconstruction of endomembrane of the blood vessels, which is the most important against the pressure of the blood flow. Anatomically “cure”: better durance, less incidence of recurrence Can remove the haematoma in the subarachnoid space and in the cerebral tissue, reduce the intracranial pressure and alleviate the vasospasm.

Require skilled neurosurgeons Invasive, with many complications: retracting the brain tissues and cranial nerves, poor tolerance by severe, aged patients or patients with systematic co-morbidities High risk for posterior circulation aneurysms Cons of the aneurysm clipping

３.endovascular treatment

history 1974: Self made latex balloon 1988: mechanic detachable coil system 1991: Guglielmi detachable coil, GDC recent development ： Trufill DCS Orbit ； Hydrocoil Matrix coil stent assisted coil Onyx glue emblization

Endovascular treatment is best suitable for the aneurysms located between posterior cerebral artery and anterior inferior cerebelar artery on the basilar artery.

broad neck aneurysms are difficult to treat by endovascular techniques. Endovascular stent could be placed inside the aneurysm-bearing arteries to constrain the coil. The stent assisted coiling is broadly applied in intracranial broad neck aneurysm, giant aneurysm, dissecting aneurysm, pseudoaneurysm, fusiform aneurysm. The intracranial stent is necessary for the re-construction of the arteries, and for reducing the pressure to the artery wall. It is also helpful to the embolization inside the aneurysms and to the formation of the endomembrane of the arteries to closed the neck of the aneurysms 。 Stent assisted coiling

Indication of endovascular treatment endovascular treatment is suitable for more than 90% aneurysms, except for the infectious aneurysms or aneurysms with large haematoma.

Pros of endovascular treatment Avoid open surgery, less invasive, no retraction of the brain, less complications ； Do not limited by the operation approaches ； Less in-hospital time, faster recovery

Cons of endovascular treatment Not suitable for the reconstruction of the endomenbrane of the arteries. More cases with incomplete embolization, higher rate of re-rupture and need for further treatment; Higher rate of cerebral infarction and vasospasm. Higher cost in China (but more inexpensive in some countries).

(2).Vascular malformation

Classification Arteriovenou malformation cavernous hemangioma telangiectasis Venous maformation

（ 1 ） Arteriovenous malformation,AVM

AVM is the direct communication of arteries and veins in the brain. The blood in the arteries directly goes in to veins without passing through capillaries this pathophysiology cause a series of homodynamic disturbance.

Clinical manifestation 1.bleeding: 68% of the AVM patients 2.Epilepsy seizures: 17%-47% of the patients begin with epilepsy seizures, which is caused by the lack of blood supply resulting from the steal phenomenon, the incidence of the seizures is associated with the size, locations and the type of AVM 3.headaches (not a specific symptoms) 15%- 24% of the patients begin with headache

diagnosis Clinical manifestations CT 、 MRI/MRA 、 DSA

Treatment Surgical endovascular Stereotaxic radial therapy Combined therapies

Operation Remove the AVM, improve the blood supply, control the seizures

Endovascular therapy Only simple AVM can be controlled by endovascular therapy, any residual will lead to recurrence The improvement of endovascular therapy will reduce the rate of incomplete embolization and recurrence

Gamma knife and x-knife Indicated for minor AVM (<3cm in diameter, high risk for operation, small residual after operation or embolization, lesions in functional areas or patients that can not tolerant open surgery. It often take 2-3 years for the closure of the AVM. About 20% cases failed. Less than 25% cases are suitable for stereotaxic RT. Stereotaxic radial therapy

Combined therapy For most of the AVM patients, combined therapies of the 3 treatments are the optimal therapies. Open surgery, endovascular embolization and stereotaxic radial therapy will not replace each other.

（ 2 ） Cavernous angioma

20-40 years old epilepsy seizures, repeated bleeding or neurological deficit treatment: operation (microsurgery, with navigation) stereotaxic observe

(3). (3). Hypertensive hemorrhage

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Open procedure to reduce intracranial pressure Stereotaxic respiration combine with urokinase

2.Occlusive cerebral vascular diseases Stenosis of carotid artery or vertebral-basilar artery Acute embolization

(1).Carotid Artery Stenosis

Ischemic stroke claims for 85% of the stroke patients. The world wide incidence is 200/10 5. the most common cause of ischemic stroke is the carotid stenosis caused by Atherosclerotic thrombosis. The narrower the carotid artery, the more incidence of the stroke. The plaque in carotid artery is composed of cholesterol cellulose and platelets. In severe narrowed carotid artery, the micro- thrombi are flushed by the unsteady blood flow and detach from the endomembrane, causing transient ischemic attack (TIA) or cerebral infarction. Timely intervention of the sclerotic stenosis of the carotid artery is crucial for the prevention of the transformation of TIA or reversible ischemic neurological deficit (RIND) to complete infarction.

Treatment Carotid endarterectomy Endovascular therapy

Surgical treatment of carotid stenosis Firstly performed in 1954, Carotid endarterectomy CEA have become an effective method to alleviate carotid stenosis. According to a study, 9% patients with carotid stenosis about 70%-90% that receive CEA have ipsilateral ischemic stroke, while 26% patients that received optimal medical treatment have ipsilateral stroke.

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Interventional therapy PTAS have become one of the most commonly used methods to treat carotid stenosis. This method restored the diameter of the narrowed carotid artery, improve the blood flow to the brain by placing a stent in the locus of the stenosis. The stent also help to avoid the detachment of the atherosclerotic plaque. Effect rate of PTAS is %, restenosis incidence is 4%. Main purpose of stenting is to improve the blood flow to the brain. In recent 5 years, better catheter, sheath and stent and better protection of the distal arteries make the interventional therapy become more and more interested by neurological doctors.

(2) Moyamoya Dieases

Moyamoya: “Puff of smoke” - term coined by Suzuki and Takaku in 1969 and now accepted worldwide

Trends With the development of microsurgical devices, interventional materials and clinical techniques, the surgery treatment of cerebral vascular diseases will be more widely applied Time is brain, time is important in both hemorrhagic and ischemic CVDs. Early transport to clinical center of CVDs, early diagnosis and early treatment will bring about good recovery.