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Endovascular Management of Aneurysms and Subarachnoid Hemorrhages

Endovascular Management of Aneurysms and Subarachnoid Hemorrhages. Lorri McCourt-O’Donnell RN, MSN, ACNP, CNRN Advance Practice Nurse Endovascular Neurosurgery/Interventional Neuroradiology Advocate Neurovascular Center. March 14, 2015. Disclosures/Thanks. Nothing to disclose

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Endovascular Management of Aneurysms and Subarachnoid Hemorrhages

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  1. Endovascular Management of Aneurysms and Subarachnoid Hemorrhages Lorri McCourt-O’Donnell RN, MSN, ACNP, CNRN Advance Practice Nurse Endovascular Neurosurgery/Interventional Neuroradiology Advocate Neurovascular Center March 14, 2015

  2. Disclosures/Thanks • Nothing to disclose • My family for letting me do what I do • The physicians I am privileged to work with • My chauffer for getting me here safely : ) • The Northern Illinois Chapter of AANN

  3. Objectives: • Differentiate treatment for Ruptured and Un-Ruptured Aneurysms • Cerebral circulation and common places for aneurysm development • Epidemiology and risk factors, Morbidity and Mortality • Clinical presentation/diagnostic testing • Nursing care pre/postoperative • Ruptured aneurysm aSAH • Non ruptured aneurysm • Treatment options • Commonly used grading scales • aSAH complications

  4. What is Endovascular Neurosurgery? • Treat diseases and pathology involving the vessels of the head, neck and spine using minimally invasive technology • AKA • Interventional Neuroradiology • Interventional Neurovascular • Plus many more…

  5. Disease Treated • Aneurysm • Ruptured • Non ruptured • Acute Ischemic Stroke • AVMs, Dural fistulas, Vein of Galen • Carotid and Intracranial stenosis • Tumor and epistaxis embolization

  6. Bi-Plane – real time images • Performed in IR • Conscious Sedation, MAC or General Anesthesia • Femoral Artery Catheterized – 6 French • Catheters and wires are navigated through the anatomy • Right groin access • Interventions performed if indicated • Purely diagnostic • Groin sealed with closure device and or manual pressure

  7. What is an Aneurysm • Weakening of the blood vessel wall • Berry, saccular • Wide neck • Fusiform • Mycotic • Traumatic • Pseudo aneurysm • Giant >2.5cm • Location • Bifurcations in the Circle of Willis • Anterior Circulation = 85% • Posterior Circulation = 15% • Neck • Wide • Narrow • Dome to Neck ratio

  8. bostonscientific.com

  9. Giant Aneurysm

  10. www.wrongdiagnosis.com/bookimages/7/2093.1.png

  11. Cerebral Circulation • Four Major Arteries • 2 Large Internal Carotid Arteries (ICA) • Supply blood to the anterior portion of the brain • 2 Smaller Vertebral Arteries • Supply blood to the posterior portion of the brain • Brainstem • Spinal Cord

  12. Epidemiology: • Aneurysms (unruptured) • 5% of US population = 10-15 million individuals • Brain Aneurysm Foundation • 1:50 Individuals • 20-30% have multiple aneurysms • Risk of rupture related to size • 0.05% risk for <10mm and no prior aSAH • 1% risk per year >10mm • Most aneurysms at time of rupture 4-7mm • Risk of rupture is 1-2% per year

  13. Aneurysmal Subarachnoid Hemorrhage (aSAH) • 6-12 cases per 100,000 • 15,000 to 30,000 persons per year • Mean age 55 (40-60) • Risk of rupture is positively correlated with: • Aneurysm size • Hypertension • Smoking • Illicit drug use • Cocaine

  14. Risk Factors • aSAH • Smoking • Hypertension • Increasing age • Alcohol • Illicit Drugs • AA>Caucasians • Females>Males 2-3:1 • Genetic • Polycystic kidney diseases • Connective tissue diseases • Family history • 1st degree relative

  15. Morbidity and Mortality • 10-15% die before reaching the hospital • Overall mortality at 6 months • 40-50% • Of those who arrive to the hospital • 25% die within 24 hours • Re bleeding is catastrophic • Mortality of 48-75% • 1/3 of survivors have functional independent lives • Improving outcomes • Being admitted to a Major Medical Center • Interventional Neuroradiology within 7 hours of presentation/bleed

  16. Clinical Picture • Symptoms begin abruptly • ‘Worst headache of life’, ‘Thunderclap’ • 30% lateralized to side of aneurysm • Maybe associated with • LOC – brief • Seizure • Nausea, Vomiting • Meningeal signs • Sentinel Bleed 10-43% • 30-50% minor hemorrhage • aSAH occur within 6-20 days

  17. Mechanism of Action • Initial Injury • Aneurysm ruptures • Releases blood into the CSF • Quickly • Under arterial pressure • Thus increasing ICP • Monroe Kellie Doctrine

  18. Diagnostics • Good History and Physical • Diagnostic Testing • CT scan – shows subarachnoid blood • Diffuse bleeding pattern • Lumbar puncture • Traumatic tap will clear • CT angio (CTA) • MRI/MRA • Cerebral Angiogram ‘Gold Standard’ (DSA)

  19. Securing AneurysmsMore Than One Way To Get The Job Done • Surgical Clipping • ? ‘gold standard’ • Craniotomy for visualization and clipping of aneurysm • Endovascular Coiling • May not be suitable for all aneurysms • Better outcomes at 90 days in coiling vs. clipping • The International Subarachnoid Aneurysm Trial

  20. Surgical Clipping knol.google.com/k/-/-/MF8QhHFP/gUO6vQ/Figure4.jpg

  21. Endovascular Coiling www.yalemedicalgroup.org/stw/images/126181.jpg

  22. Stent Assisted CoilingNot commonly used in acute SAH

  23. Pipeline EmbolizationNot Commonly used in acute SAH • Used to redirect blood flow away from the aneurysm • Flow diverter

  24. Nursing care preoperative • ABCs • Neuro Checks • BP management • Systolic between 90-140mmhg • AVOID Hypotension • ICP Monitoring • EVD if indicated • Labs • CMP, CBC, Cardiac Enzymes, Coags, T&C, ABGs if intubated, 12 lead EKG, Chest X-Ray

  25. Preoperative Care • NPO • IVF • Maintain euvolemia • 0.9 NS at 80-100ml per hour • Activity – quiet environment, limit visitors • DVT – No anticoagulation until aneurysm securement • Teds, SCDs

  26. Medications • Nimodipine 60mg Q4 hrs • Seizure prophylaxis • Phenytoin load 1000mg then 100mg Q8 hrs • 10-20% of aSAH have seizures?? • Side effects of Phenytoin • Pain Management • Antiemetics • GI Protection • Stool Softeners

  27. Nursing Care Postoperative • ABCs • Frequent Neuro exam Q1hr • Or as exams dictate • HOB 30 degrees, neck midline • Reduce stimulation, quiet, dark room • Headaches continue, until blood clears CSF • BP Management • DO NOT TREAT BLOOD PRESSURE ONCE ANEURYSM IS SECURE • Maintain perfusion to the brain • Allow BP to be 200mmhg systolic • CPP to be >60 to 70 mmHg • Fever management • Daily Labs • Electrolytes, CBC, Cardiac Enzymes (1st 5 days), ABGs, Chest X-Ray, Anticonvulsant levels • Consider baseline 2D-Echo

  28. Postoperative Nursing Care • DVT prophylaxis • Continue TEDs and SCDs • SQ heparin/lovenox • Trans cranial Doppler (TCDs) • Consistently measure MCA mean velocity • <120 cm/sec = less risk of vasospasm • >200 cm/sec = greater risk of vasospasm • Used in conjunction with neuro exam • Repeat Cerebral Angiogram • Day 7-10 • Regardless of securement methodology

  29. Medications • Nimodipine 60mg Q4 hrs • For 21 days • Divided dose 30mg Q2 for hypotension • Seizure prophylaxis??? • 100mg Q8 hrs • Only 10-20% of aSAH have seizures • Side effects of Phenytoin • Pain Management • Antiemetic • GI Protection • Stool Softeners

  30. Aneurysm Grading Scales • Glasgow Coma Scale • Hunt and Hess • Most widely used • Predicts clinical outcomes • World Federation of Neurological Surgeons (WFNS) • Combines GCS and presence of motor deficits • Predicts clinical outcomes • Fisher Scale • Vasospasm risk • All scales have some issues with validity/ reliability

  31. Glasgow Coma Scale ccn.aacnjournals.org

  32. Hunt and Hess www.ispub.com/.../aneurysm-tbl1.jpg

  33. Fisher Scale img.medscape.com/.../553/105/nf553105.tab4.gif

  34. WFNS www.ispub.com/.../aneurysm-tbl3.jpg

  35. aSAH Complications • Re-Bleeding • >risk first 24 hours 2-4% • Increases 15-20% during the next 2 weeks • 48-75% mortality • Risk increases with conservative treatment • Acute Hydrocephalus - 65% • Enlargement of ventricles • Occurs within the first 24hours • Abrupt MS changes and 6th Nerve Palsy • Can be life threatening • Late Hydrocephalus – 10-15% • 10 or more days • Incontinence, gait instability, cognitive issues

  36. www.adhb.govt.nz/.../Images/PHHC/CT/phhc-ct1.jpg

  37. SAH-induced Vasospasm • Occurs angiographically in 30-70% of patients • Clinical symptoms seen in 20-45% of patients • Adds 10-20% significant morbidity/mortality • Smooth muscle constriction and vessel wall edema, infiltration and fibrosis leads to luminal narrowing and decreased compliance • Time course • Range: 4-14 days • Peak: 7-10 days

  38. Detection of Vasospasm • Clinical exam • Focal deficit • Mental status changes • Increasing TCDs • CTA/CTP • MRI/A/P • Angio

  39. Triple H Therapy (Modified) • Hypertensive therapy • SBP >160 mm HG • Don’t treat BP – patients will usually auto regulate • In symptomatic vasospasm vasopressors are used • Hypervolemia • Maintain PCWP at 10 to 16 mm Hg • Urinary output >/= 250ml per hour • Euvolumia • Using fluids and vasopressors for symptomatic patients • Hemodilution • IV fluids at 100-150 ml per hour • Hematocrit <0.40 T

  40. Vasospasm Treatment • Nimodipine • 60mg Q4hr for 21 days • Cerebral Angiogram • Intra arterial calcium channel blockers • Verapamil • Angioplasty • Stent

  41. Verapamil Infusion

  42. aSAH Complications • Hyponatremia – 50% • Associated with poor outcomes • More common in higher grade SAH • Mechanism • Excessive renal secretion of sodium • Cerebral Salt Wasting (CSW) • Leads to cerebral edema • Treatment • Related to volume and salt replacement • Fluid restriction could be detrimental to patients

  43. aSAH Complications • Cardiac Dysfunction • Tako–tsubo Cardiomyopathy • Neurogenic myocardial stunning • Thought to be related to excessive release of catecholamine • Left Ventricle • Apical ballooning • MUST rule out coronary artery disease first

  44. media.jaapa.com/images/2008/12/03/takotsubo11

  45. Myocardial Stunning • Normal Left Ventricle • Tako-Tsubo or Myocardial Stunning Left Ventricle www.takotsubo.com/tk5.gif

  46. EKG Changes • Stage I (acute stage) • Few hours • ST elevation • Short QT interval • R wave may be present • Stage II (sub acute stage) • Lasts days • QT segment prolongation • Large deep negative T waves • Stage III • Recovery • Flipped T waves (days to weeks) • Normal QT interval www.takotsubo.com/tk5.gif

  47. Treatment of Myocardial Stunning • Supportive • Unload the left ventricle • Reduce vasopressors • Started due to low BP • Results in increased SVR and afterload • Contractility Agents • Dobutamine • Address Pulmonary Edema • Lasix

  48. Left ICA/PCOM Aneurysm • D.G. • 58 year old AA female • Went to bed the night prior to admission complaining of headache • Family discovered her unresponsive • Taken to OSH -> Transferred to ACMC • PMH • Has not seen provider in ‘years’ • PSH – tubal ligation • 1 PPD Smoker, social ETOH, no illicit • Physical Exam • Drowsy but arousable • VSS • Neuro exam non focal

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