1. Surgery of Cerebrovascular Diseases

2. Subarachnoid Hemorrhages Etiologies:
intracranial aneurysms (%75-80)
cerebral AVMs (%4-5)
vasculopathy
tumors
cerebral artery dissections
coagulation disorders
dural sinus thrombosis
spinal AVM
pretruncal nonaneurysmal SAH
pituitary apoplexy
no cause can be determined (%14-22)

3. Subarachnoid Hemorrhage
Incidence: 6-8/
10-15% of patients die before reaching medical care
Overall mortality is 45%
peak age for aneurysmal SAH is years. 20% of cases occur between ages yrs
30% of aneurysmal SAHs occurs during sleep
SAH is complicated by intracerebral hemorrhage in 20-40%, by intraventricular hemorrhage 13-28%, and by subdural blood in 2-5%
rupture incidence is higher in spring and autumn

4. SAH Risc Factors: Hypertension Oral contraceptives Cigarette smoking
Cocain
Alcohol?
Pregnancy

5. SAH Symptoms Signs Sudden unset of severe headache
Usually with vomiting, syncope, neck pain, and photophobia
Loss of consciousness
Focal cranial nerve deficits
Signs
meningismus
hypertension
focal neurological deficits
ocular hemorrhage
coma

6. SAH Diagnosis
Non-contrast high resolution CT will detect SAH in 95% of cases if scanned within 48 hours of SAH
If CT is negative: Lumbar punction in questionable cases
CT angiography
MR angiography
Cerebral angiography

7. Grading SAH (Hunt and Hess)
Grade 1: asymptomatic, or mild headache and slight nuchal rigiditity
Grade 2: moderate to severe headache, nuchal regidity, cranial nerve palsy
Grade 3: mild focal deficit, lethargy, or confusion
Grade 4: stupor, moderate to severe hemiparesis, early decerebrate rigidity
Grade 5: deep coma, decerebrate rigidity, moribound appearance
*add one grade for serious systemic disease or severe vasospasm on angiography

8. Grading SAH (Yaşargil)
Grade 0: a, unruptured aneurysm
b, unruptured aneurysm, neurological deficit (+)
Grade 1: a, asymptomatic
b, focal neurological deficit (+)
Grade 2: a, headache, nuchal rigidity
Grade 3: a, lethargy, confusion, disorientation, agitation
Grade 4: semi coma
Grade 5: deep coma

9. Grading system of Fisher
Grade 1: no subarachnoid blood detected (5.8% mortality)
Grade 2: diffuse or <1 mm blood (10.3% mortality)
Grade 3: localized clot and/or >1 mm blood (32.8% mortality)
Grade 4: intracerebral or intraventricular clot (45% mortality)

10. SAH Initial Management Concerns
rebleeding
hydrocephalus
acute (obstructive) hydrocephalus (20-27%)
chronic (communicating) hydrocephalus (14-23%)
delayed ischemic neurological deficit (DIND) attributed to vasospasm
Hyponatremia with hypovolemia (10-34%)
DVT and pulmonary embolism
seizures (10.5%)

11. SAH Admitting Order Admit to ICU Bed rest with head of bed at 30º
Low level of external stimulation, restricted visitation, no loud noises
IV fluids: 2ml/kg/h or 150ml/h (normal saline + 20 mEq KCl/L)
Medications
Prophylactic anticonvulsants
Sedation, Analgesics, Dexamethasone
Antiemetics, H2 blockers, stool softener
Oxygenation
Cardiac rhythm monitor
Systolic blood pressure mm Hg by cuff

12. SAH (Grade 1-2) Cerebral angiography
If there is cerebral aneurysm, early surgery

13. SAH (Grade 3-4) Arterial line Central venous catheter Urinary catheter
Nasogastric tube (if necessary)
External ventricular catheter (if necessary)
Endotracheal intubation (if necessary)

14. SAH Rebleeding (70% mortality) First 24 hours (4%)
1.5% daily for 13 d.
15-20% rebleed within 14 d
50% will rebleed within 6 months
Thereafter the risk is 3%/yr
50% of deaths occur in the 1st month
The rebleeding risk increases in patients with higher grades
Ventriculostomy and possibly lumbar spinal drainage increase the
risk of rebleeding

15. Cerebral Vasospasm
A delayed focal ischemic neurologic deficit following SAH. Clinically characterized by confusion or decreased level of consciousness with focal neurological deficit
Findings usually develop gradually, and my progress or fluctuate
Radiographic cerebral vasospasm is identified in 30-70% of arteriograms
Symptomatic cerebral vasospasm occurs in only 20-30% of patients
Pathogenesis of cerebral vasospasm is poorly understood

16. Cerebral Vasospasm Almost never before day 3 post-SAH
Maximal frequency of onset during days 6-8 post SAH
Rarely can occur as late as day 17
Usually resolves in 2-4 weeks

17. Vasospasm Diagnosis: Delayed onset or persisting neuro deficit
Onset 4-20 days pos-SAH
Deficit appropriate to involved arteris
Rule-out other causes of deterioration
rebleeding
hydrocephalus
cerebral edema
seizure
metabolic disturbances (hyponatremia…)
hypoxia
sepsis
Ancillary tests
transcranial doppler
CBF studies
SPECT
cerebral angiography

18. Cerebral Aneurysms Etiology: Unrupture aneurysm: 0.5-1%
congenital predisposition (defect in the muscular layer)
Atherosclerotic or hypertensive
Unrupture aneurysm: 0.5-1%
Risk of bleeding 1-2%/per year

19. Cerebral Aneurysms Anterior Circulation (85-95%)
ICA
Oph A
P Com A (%25)
Ach A
ACoA (%30)
ACA
MCA (%20)

20. Cerebral Aneurysms Posterior Circulation (5-15%)
Vertebral Artery (%5)
PICA
VB Junction
Basilar Artery (%10)
Basilar trunk
AICA
SCA
Basilar Tip
PCA

21. Vascular Malformations
Arteriovenous malformations
Cavernous malformation
Venous angioma
Capillary telangiectasia

22. Arteriovenous Malformations
Dilated arteries and veins with dysplastic vessels,no capillary
bed and no intervening neural parenchyma
Usually prents with hemorrhage, less often with seizures
Congenital lesions
Lifelong risk of bleeding of 2-4%/per year
Demonstrable on angiography, MRI, or CT
Prevalence 0.14%

23. Arteriovenous Malformations Presentation
Hemorrhage (50%) (10% mortality, 30-50% morbidity).
Seizures
Mass effect
Ischemia
Headache
Bruit
Increased ICP

24. Arteriovenous Malformations Treatment
Microsurgery
Embolisation
Stereotactic Radiosurgery

25. Cavernous Malformations (Cavernomas)
Usually not demonstrable on angiography
Usually present with seizures, rarely with hemorrhage
No intervening neural parenchyma, no arteries
Low-flow
Surgery best for symptomatic accessible lesions

26. Venous Angiomas Abnormally medullary vein
Usually demonstrable on angiography as a starburst pattern
Represents the venous drainage of the area, and intervening brain is present
Seizures rare, hemorrhage even more rare
Low flow, low pressure
Should not be treated