Left facial numbness Ann Schmidt Oct 2005

Patient Presentation 54 yo female 54 yo female Left facial swelling, left leg swelling and left arm weakness Left facial swelling, left leg swelling and left arm weakness Headache Headache

Past Medical History Hypothyroidism Hypothyroidism Hx of panic attacks Hx of panic attacks Postmenopausal Postmenopausal Surgeries - hysterectomy Surgeries - hysterectomy

Family history Father with carcinoid, hypertension and dementia Father with carcinoid, hypertension and dementia Mother died of brain aneurysm, also had breast cancer Mother died of brain aneurysm, also had breast cancer

Social history Owns a large business Owns a large business Recent family stress Recent family stress Loss of a friend to breast cancer Loss of a friend to breast cancer

Exam 148/94 Pulse 76 temp 97 resp /94 Pulse 76 temp 97 resp 16 No sign. Findings No sign. Findings Diag Panic attack Diag Panic attack

Future visits 7/20 7/20 Review of Urgent care visit. Question of panic attack vs. other etiology. Review of Urgent care visit. Question of panic attack vs. other etiology. Set up MRI TIA? Set up MRI TIA?

Future visits 7/29 patient presents to the ER with new drooping of left eye lid, numbness of her face No headache, fever or neck pain. Exam noted slight ptosis of right eyelid. 7/29 patient presents to the ER with new drooping of left eye lid, numbness of her face No headache, fever or neck pain. Exam noted slight ptosis of right eyelid. CT scan ordered CT scan ordered Diagnosis Bells palsy Start on Prednisone and Val acyclovir. Diagnosis Bells palsy Start on Prednisone and Val acyclovir.

Future visits 7/30 Clinic visit – review ER note and MRI. 7/30 Clinic visit – review ER note and MRI.

Future visits 7/30 Clinic visit- review clinic note and MRI 7/30 Clinic visit- review clinic note and MRI Order MRI/MRA Order MRI/MRA

Future visits MRA results MRA results Neurosurgery consult Neurosurgery consult CT angio completed CT angio completed

Intracranial Aneurysms

Goals of this talk include Goals of this talk include Review the prevalence of aneurysms Review the prevalence of aneurysms Review the etiology/ pathogenesis of aneurysms Review the etiology/ pathogenesis of aneurysms Discuss the treatment of unruptured aneurysms. Discuss the treatment of unruptured aneurysms.

Intracranial Aneurysms IA Prevalence Prevalence Incidence Incidence Pathogenesis Pathogenesis Heritable connective tissue disorders, autosomal dominant – Ehlers Danlos Syndrome, Neurofibromatosis, Marfans syndrome, Polycystic kidney Heritable connective tissue disorders, autosomal dominant – Ehlers Danlos Syndrome, Neurofibromatosis, Marfans syndrome, Polycystic kidney Familial Familial

Familial aggregation 1954 Chambers 1954 Chambers 1995 reported in J Neurosurgery “Familial aneurismal subarchnoid hemorrhage : a community based study” 1995 reported in J Neurosurgery “Familial aneurismal subarchnoid hemorrhage : a community based study” Did family members of patients with ruptured aneurysms have an increase risk of developing a SAH Did family members of patients with ruptured aneurysms have an increase risk of developing a SAH

Familial trends patients had SAH patients had SAH Families contacted and fhx obtained Families contacted and fhx obtained 76 had complete fhx 76 had complete fhx 15 had a 1 st or 2 nd degree relative with SAH 15 had a 1 st or 2 nd degree relative with SAH The number observed with a 1 st degree was 11 – expected was 2.6 The number observed with a 1 st degree was 11 – expected was fold increase risk among 1 st degree relatives 4 fold increase risk among 1 st degree relatives

Study results Risk may be highest among siblings in the index patient Risk may be highest among siblings in the index patient Earlier age, may be smaller and recur. Earlier age, may be smaller and recur. Affected siblings are often the same decade of life. Affected siblings are often the same decade of life.

Diagnosis Clinical Presentation Clinical Presentation Anterior communicating artery – 34% Anterior communicating artery – 34% Middle cerebral artery- 20% Middle cerebral artery- 20% Posterior communicating artery- 23% Posterior communicating artery- 23% Internal carotid artery 4% Internal carotid artery 4% Asymptomatic IC Asymptomatic IC Most aneurysms never rupture Most aneurysms never rupture

Natural History of Aneurysms The International Study of Unruptured Intracranial Aneurysms Investigators The International Study of Unruptured Intracranial Aneurysms Investigators In a group of 1449 patients the rate of rupture per year was eleven times higher if the patient had a history of previous rupture In a group of 1449 patients the rate of rupture per year was eleven times higher if the patient had a history of previous rupture Surgery did not decrease M and M if lesion was less than 10 mm and no previous history of rupture. Surgery did not decrease M and M if lesion was less than 10 mm and no previous history of rupture.

Neurology 1999 Johnston,Gress Which unruptured cerebral aneurysms should be treated? A cost utility analysis Which unruptured cerebral aneurysms should be treated? A cost utility analysis For aneurysms >10 mm those producing symptoms by compressing neighboring nerves and brain structures or in patients with a history of SAH from a different aneurysm treatment was cost effective. For aneurysms >10 mm those producing symptoms by compressing neighboring nerves and brain structures or in patients with a history of SAH from a different aneurysm treatment was cost effective.

Task force of the Stroke Council AHA 2000 Recommendations Recommendations The treatment for small intracaverous ICA is not generally indicated. The treatment for small intracaverous ICA is not generally indicated. Symptomatic intradural aneurysms of all sizes should be considered for treatment. Symptomatic intradural aneurysms of all sizes should be considered for treatment. Coexisting or remaining aneurysms of all sizes in patients with SAH due to another treated aneurysm carry a higher risk for further hemorrhage. Coexisting or remaining aneurysms of all sizes in patients with SAH due to another treated aneurysm carry a higher risk for further hemorrhage. 10 mm consider treatment 10 mm consider treatment

Management Aneurysms <10 mm annual rupture.05-2% Aneurysms <10 mm annual rupture.05-2% Presence of smoking, Fhx Polycystic kidney disease or lupus elevates risk. Presence of smoking, Fhx Polycystic kidney disease or lupus elevates risk. Considerable mortality/morbidity with treatment – 3.8%- 15.7% Considerable mortality/morbidity with treatment – 3.8%- 15.7% Quality of life living with an aneurysm Quality of life living with an aneurysm