cerebral aneurysm & subarachnoid hemorrhage...

Cerebral Aneurysm &

Subarachnoid Hemorrhage (SAH)

ROZMEEN SHIVJI, ACNP-BC

Objectives:

Define Brain Aneurysm

Recognize different types of aneurysm

List causes and S & S of aneurysm

Identify diagnosis of aneurysm

Discuss treatment of aneurysms

Discuss complications of aneurysm

Understand nursing care of a patient with aneurysm & SAH

What Is An Aneurysm?

A cerebral aneurysm is a

bulge or balloon like

dilatation/swelling of the wall of

a blood vessel in the brain.

Aneurysm develops because of a

weakness in the wall of the

blood vessel, usually at the

bifurcation point.

Also called as intracranial aneurysm

or brain aneurysm.

Demographics

Unruptured Aneurysms are found in 2-4% of the USA population

6 million Americans are affected with Unruptured Aneurysms

More likely to occur in adults of age 40-60 years

They are more common in women

There are as many as 27,000 aneurysms that could be diagnosed and treated per year in the U.S.

The annual rupture rate is approximately 1.5%

Rupture of an aneurysm results in approximately 50% mortality and 25% stroke incidence

Annual incidence of SAH is 15 cases/100,000 or about one hemorrhage every 18 minutes

Brisman, et al (2006), New England Journal of Medicine, 355, 928-939.

Hickey, J.V. (2014). The Clinical Practice of Neurological and Neurosurgical Nursing

Etiology

AV malformation

Connective Tissue Disorder

Family history of brain aneurysms

Smoking

Hypertension

Traumatic head injury

Alcohol use

Use of oral contraception

Post menopausal women

Infection: Bacterial and Fungal

Disorders: Ehler’s syndrome, polycystic kidney disease, Marfan syndrome

Suarez, et al. (2006), New England Journal of Medicine, 354, 387-396.

Familial Intracranial Aneurysm (FIAs)

FIAs : Two or more family members among 1st and 2nd degree relatives with aneurysmal SAH or incidental finding of aneurysm.

Incidence of FIAs among SAH patients is 6% - 20%. Prevalence of FIAs among SAH patients is 7% to 10%.

Patients with FIAs are more likely to have multiple aneurysm and they have higher tendency to rupture even with a small size.

FIA study completed in Nov 2011, 542 families and 2,874 subjects from 26 clinical centers suggests genetic disposition plays an important role in development of cerebral aneurysm.

Screening: Family members should be screened (MRI, MRA, CTA) in their 20s and every 5-10 years thereafter.


Classification:

Aneurysm are present in various size and shape.

Classification by size

Small: up to 10 mm

Medium: 10 to 15 mm

Large: 15 to 25 mm

Giant: 25 to 50 mm

Super-Giant: >50 mm

Giant Aneurysm


Classification:Classification by shape

Berry aneurysm: most common, berry or saccular shape with stem

or neck. Develop over time.

Fusiform aneurysm: an outpouching of an arterial wall, without

stem. Common in hypertension, atherosclerosis and advancing age.

Traumatic aneurysm: Infrequent; resulting from trauma

Mycotic aneurysm: rare; resulting from septic emboli due to

infection, such as bacterial endocarditis


Location

Generally aneurysm occur at the bifurcation and branches of

large arteries at the base of the brain, Circle of Willis.

85% develop in the anterior part of circulation (Carotid

System).

15% are found in posterior circulation (vertebrobasilar

system).

Important to understand Circle of Willis.

Suarez, et al. (2006), New England Journal of Medicine, 354, 387-396.

Circle of Willis

Location of Aneurysm

Anterior Communicating Artery (Acomm) is the single most

common: 30-40%

Posterior Communicating Artery (Pcomm): 25-30%

Middle Cerebral Artery (MCA): 20%

Basilar Artery (BA): general at basilar tip, 10%

20-30% patients who suffer an aneurysm will have multiple

aneurysms


Location of Aneurysm

Diagnosis of Aneurysm

An unruptured aneurysm is generally asymptomatic thus

incidentally found.

Unruptured are generally diagnosed based on sign and

symptoms.

Aneurysms > 10mm, located at Basilar apex or Posterior

Communicating artery have higher chance to rupture.

Imaging of Aneurysm

CT- Angiography (CTA)

Sensitivity: 0.77-0.97 (reduces if aneurysm is < 3mm)

Specificity: 0.87-1.00

Takes app. 30 mins

Use of contrast: careful with Renal Failure patients

Magnetic Resonance Angiography (MRA)

Sensitivity: 0.69-0.99

Specificity: 1.00

Takes > 30 mins

Imaging of Aneurysm

Cerebral- Angiography

Arterial catheterization (femoral)

Benchmark for diagnosis aneurysms

More invasive and expensive

Three dimensional rotational

Helpful in finding aneurysm: location, shape, size, cerebral

vasculature, and presence of vasospasm

Major Threat of Aneurysm

Subarachnoid Hemorrhage (SAH)

Ruptured arterial aneurysm 95% cases of SAH

SAH

10 % of patients with aneurysmal SAH die prior to reaching

the hospital

25 % die within 24 hours of SAH onset

45 % die within 30 days; only one-third of patients will have a

good outcome after treatment

The most important predictive factors for acute prognosis after

SAH include

Level of consciousness and neurologic grade on admission

Patient age (inverse correlation)

Amount of blood on initial head computed tomography

(CT) scan (inverse correlation)

Signs and Symptoms

The worst headache of the life

Loss of consciousness or decrease LOC

Nausea and vomiting- very common

Stiff neck or neck pain

Blurred or double vision

Pain above and behind eye

Dilated pupils

Sensitivity to light

Loss of sensation

Cerebral edema and Increased ICP (may cause seizure, bradycardia, hypertension, wide pulse pressure).

Circle of Willis: Multiple aneurysms Brain: SAH

Hunt and Hess Scale (Clinical Grading of SAH)

Grade & Description

Grade1: Asymptomatic or minimal headache and slight nuchal rigidity

Grade 2: Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy

Grade 3: Drowsiness, confusion, or mild focal deficit

Grade 4: Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances

Grade 5: Deep coma, decerebrate rigidity, moribund appearance

Modification added:

Grade 0: Unruptured aneurysm

Grade1a: No brain reaction but fixed neurological deficit

Diagnosis of SAH

Non-Contrast CT Scan

Preferred method of imaging: wider availability, lower cost,

convenient for sicker patient, provider experience with CT

4th generation-CT can detect SAH in 95% if done within 48 hrs.

Blood appears as high density (white) in subarachnoid space.

Lumbar Puncture (LP)

Indicated if clinical presentation suggest SAH and CT is negative

Presence of xanthochromia (the yellow discoloration indicating

the presence of bilirubin in the cerebrospinal fluid)

Presence of erythrocytes

Diagnosis of SAH

CTA

Frequently used

MRA

Not recommend with acute hemorrhage

Cerebral Angiography

Gold standard. May even require repeat study.

Transcranial Doppler (TCD)

Commonly used for patients with SAH to monitor blood flow

velocities in major cerebral arteries to detect early vasospasm.

120 cm/sec: Mild vasospasm

150 cm/sec: Moderate vasospasm

200 cm/sec severe vasospasm

Ruptured Ant CoA

aneurysm

SAH 20 ruptured

right PCA

Normal Circle of Willis 3-D CTA

SAH 20

ruptured

ACA

aneurysm

3-D CTA

SAH 20

ruptured

PCoA

aneurysm

3-D CTA

Where is the aneurysm?

Normal Caliber

Vasospasm

Vasospasm

Treatments for Cerebral Aneurysms

Surgical Clipping

Endovascular Coiling

Surgical clipping (approximately 60-65% in the United States)

Endovascular coiling (approximately 30-35% in the United States)

In certain countries such as Finland, Great Britain and France, close to 90% of aneurysms are treated with endovascular coiling

Aneurysm Therapy

Aneurysm Clipping

Done under general anesthesia through a craniotomy (hole in the head)

The brain is gently retracted in order to gain visual access to the aneurysm

A clip is placed at the neck of the aneurysm

1 week in the hospital

1 month recovery

Surgical clip

ANEURYSM COILING

A minimally invasive procedure

Performed under general anesthesia

Performed by an interventional neuroradiologist

A microcatheter is threaded from the groin to the aneurysm

Coils (platinum threads ) are inserted into the aneurysm

The catheter is then removed

For an unruptured aneurysm, the patient is discharged home within 24 to 48 hours

The History of Coiling

1987-1989: Dr. Guido Guglielmi(University of Rome) visits DrViñuela (Interventional Neuroradiologist) at UCLA and research work on coiling concept started

1989: Dr Guglielmi came permanently to UCLA

1989-1990: Animal research

March 6, 1990: First clinical use of Guglielmi Detachable Coil

FDA approval in 1995

ANEURYSM COILING

Video

https://www.youtube.com/watch?v=kCE1zSM1TaA

https://www.youtube.com/watch?v=kCE1zSM1TaA

SAH

Basilar Artery Aneurysm

before after

Pros and Cons of Coiling

PROS

Minimally invasive

Short recovery

Safer than surgery

Cheaper than surgery

CONS

Shorter track record

Possibly less durable

Requirement for follow-

up angiography

What about Aneurysms with Wide Necks?

Aneurysms with wide necks must be treated in a slightly

different manner.

The use of a Neuroform stent or some similar stent must

first be placed across the base or neck of the aneurysm.

This is done so that the coils will remain within the

aneurysm sac.

Wide neck mid basilar aneurysm

Stent + Coil

Stent + coils

Balloon Remodeling

Balloon remodeling is the use of a

balloon while placing coils within the

aneurysm.

The balloon is inflated while the coil

is placed and then deflated once coil

is in place.

Onyx is another possible choice to treat

aneurysms

Complications of Aneurysm

Rebleeding:

4% chance on day 1, post rupture of aneurysm

1.5% daily for 13 days (15-20% within 14 days)

50% within 6 months

3% / year and mortality rate of 2% /year

Acute Hydrocephalus

Caused by obstruction of CSF and reabsorption Ischemic

Neurological deficit due to vasospasm

Seizures

DVT and PE

Hyponatremia and Hypovolemia

Goals of Treatment

Maintaining Hemodynamics

Close Cardiac Monitoring; NICU admission

A-Line

PAC (Hunt-Hess grade 111 or higher)

Euvolemic State (0.9 NS/Albumin)

Strict I/O

Maintaining Blood Pressure – Goal SBP: 120-150 mm Hg

(labetalol, nitroprusside or nicardipine)

Airway Protection

Intubation

Oxygenation optimization

Goals of Treatment Neuroprotection

HOB > 30 and patient must be bed rest

Neuro check q 1

Optimizing Cerebral Blood Flow (CBF)

Maintaining Cerebral Perfusion Pressure (CPP)

Maintaining Intracranial Pressure (ICP)- (use of Mannitol of ICP)

Preventing from vasospasm – Nimodipine (Nimotop)

Maintaining Blood Pressure (labetalol, nitroprusside or nicardipine)

Preventing seizures- Keppra

Treat Cerebral Edema- Steroids (Decadron)- controversial

Avoid activities that increases ICP- Stool Softener

Pain control- Analgesic (Dilaudid, Morphine, Codeine)

Avoid agitation- Sedative (Haldol, Seroquel)

Goals of Treatment

General Care

GI Prophylaxis (PPI)

Prevent DVT (Heparin or Lovenox)

Glycemic Control (Accu Checks and sliding scale)

Electrolyte Replacements

Skin Ulcer Prevention Care

Nutrition (Sooner the better)

Family Support

Rehabilitation

References

Brisman, J.L., Song, J.K., & Newell, D. W. (2006). Cerebral Aneurysms. New

England Journal of Medicine, 355, 928-939.

Hickey, J.V. (2014). The Clinical Practice of Neurological and Neurosurgical

Nursing (7th ed). New York, NY: Lippincott Williams & Wilkins.

Suarez, J.L., Tarr, R. W., & Selman, W. R. (2006). Aneurysmal Subarachnoid

Hemorrhage. New England Journal of Medicine, 354, 387-396.

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