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Vascula Lesion > Aneurysm > Flashcards

Aneurysm Flashcards

1
Q

Obsolete theory

A

underlying weakness of the media layer at site of bifurcation

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2
Q

Pseudoaneurysm

A

blood clot adjacent to a rent in the arterial wall.

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3
Q

Age of anurysum

A

40-60 🔛AVM
Common female

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4
Q

Most common occurs during

A

Sleep

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5
Q

sentinel headaches befor aSAH

A

by 2-8 weeks

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6
Q

SDH associated with

A

PCOM anurysum

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7
Q

interhemispheric subdural hematoma

A

Distal ACA aneurysm

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8
Q

Seizure occurs in

A

🥇 24hr associated MCA or acom anurysum

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9
Q

Causes of mortality

A

Medical condition ( neurogenic pulmonary edema, stress cardiomyopathy)

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10
Q

,
Major cause of mortality

A

Rebleedign > early tx to reduce risk of rebleeding

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11
Q

Risk of rebleeding

A

15-20% from first 2 weeks

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12
Q

Cause of sever deficit

A

Vasospams

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13
Q

Most predictive of long term outcomes

A

WFNS

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14
Q

strongest prognostic indicator

A

Severity of clinical presentation

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15
Q

MCC etiology

A

Truma

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16
Q

spontaneous SAH” causes

A

80% rupture of aneurysm
AVM
Vasculitis
Dissection VA ➡️ IVH 3,4 ventricle
Rupture of Small VBV
SVT

pretruncal nonaneurysmal SAH (p.1496) (perimesencephalic hemorrhage
SCD

pituitary apoplexy
Rupture of infundibulum

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17
Q

Spinal AVM mc

A

Cervical and thoracic

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18
Q

RF aSAH

A

Behavior ➡️ HTN , 🚬, 🍺,drugs
Sports, vaslalva

Gender ➡️👩‍🦰
Hx of aneurysm ➡️ rupture of unrupture ( sx, large, posterio) bottleneck
FHX 1 st degree and > 2 affected
Syndrome PCKD , type IV Ehlers-Danlos syndrome

Pregnancy 🤰🏼

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19
Q

Headache MCC sx DDX paroxysmal headache

A

aSAH ➡️ warnings 🛑 H/A , seizure and diplopia

Benign thunderclap headaches” (BTH) or crash migraine. 5➡️ intensity < 1 m , 🤮 ,

reversible cerebral vasoconstrictive syndrome (RCVS) 55(AKA benign cerebral angiopathy or vasculitis56)➡️ string beads angio , clear 1-3 m , Hx of vasoconstriction drugs

Airplane ✈️ H/A assistance nasal congestion

benign orgasmic cephalgia:sever throbbing during sexual

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20
Q

Post partum complication

A

During 🥇 week SAH, ICH , RPLS
During 🥈 week TIA , Strok

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21
Q

Meningismus occurs

A

6-24 hr
Postive Kernig ( flex hip and knee pain in hamstring
Brudzinski( hip flex after ( neck flex ion )

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22
Q

Cause of coma in SAH

A

⬆️ ICP , damage brain 🧠 ICH , HC , ischmic due to ⬆️ ICP , seizure , ⬇️ CBF ( ⬇️ CO )

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23
Q

Ocular hemorrhage 👀 🩸 type

A

1-subhyaloid (preretinal)➡️ RBC neear optic disc ➡️ obscures retinal BV ➡️⬆️ mortality
2- intra-retinal hemorrhage ➡️ surround the fovea

3- 🩸 vitreous humor (Terson syndrome➡️ vitreous opacity , common ACoA . Develop 12 days post SAH associated rebleeding , , ⬆️ mortality rate ,
Clear after 6-12 months long term vision good

Vitrectomy consider ➡️ vision final to improve or for rapid improvement
.

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24
Q

pathomechanics OH

A

Extension of blood 🩸 subarachnoid space to vitreous space
No complication how .
Compression central retinal V & retinochoroidal Anastomosis ➡️ ⬆️ CSF pressure ➡️ venous HTN ➡️ disruption of rerinal vein

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25
Q

DX for SAH

A

CT if -ve
LP

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26
Q

Dx location of anurysum

A

MRA no contrast but poor to detect anurysum early
CTA
DSA anatomy , filling and flow

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27
Q

Total contrast for healthy

A

Iodine< 90gm in 24 hr
CTA 65-75 cc = 21 g
if an angiogram is needed after a CTA, in most cases you do not have to wait 24 hours®

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28
Q

CT sensitivity

A

Within 6 hr ➡️ sensitivity and specificity100 %

< 12 hr sensitivity < 98%
After 12 hr sensitivity;
< 24 hr 93%
< 72 hr 80%
1 week 50%

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29
Q

Blood 🩸 in cisterns predict

A

Vasospasm

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30
Q

Things to look Ct

A

Ventricle size
Hematoma ➡️ MCA
Location of aneurysm

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31
Q

Location of anurysum depend on CT

A

IHF ➡️ ACOM,
SF ➡️ PCOM , MCA
IPC ➡️ SCA , BA
IVH 3,4 ➡️ PICA , VA dissection
IVH 3 ventril BA

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32
Q

CTA

A

Detect anurysum size > 3 mm
Detect vaspasm

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33
Q

LP aSAH

A

🚫 ⬇️ CSF pressure ➡️ ⬆️ trans mural pressure ➡️ risk of bleeding ➡️ minimum amount with < 20 GA
OP will ⬆️

xanthochromia (XTC): will paean after 2-4 hr and till 3-4 weeks
Spectrometry sensitive than inspection
RBC> 100,000, ⬆️ protein ,
If ⬇️ RBC > 70% from 🥇 to last tube ➡️ traumatic tap

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34
Q

MRI and MRA

A

Low sensitivity in 🥇 24-48 hr ( low met HG )
After 4-7 days can’t detect
Excellent 10-20 days )
FLAIR is the best to detect
MRA
Sensitivity ⬇️ if size < 3 mm
Useful as screening ( 2 🥇 degree relative IA and HTN , 🚬 )

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35
Q

DSA

A

Gold stander
If SAH but no DSA sorice ➡️ SAH of unknown etiology

4 vessels angio

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36
Q

Infundibulum

A

MC found PCOM
⬆️ multiple or familial aneurysm
< 3 mm less risk of bleeding ,
no true neck
TX
Warping or clipping

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37
Q

Favor clipping

A

Large anurysum > 15 mm
BroAED neck > 5 mm
ICH > 50 ml , MCA anurysum

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38
Q

Coiling

A

Neck narrow < 5 mm
Dome : neck > 2
Elderly
Poor WFNS 4-5
BA anurysum

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39
Q

partially thrombosed aneurysm

A

best detect by CT or MRI

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40
Q

Grading system

A

4
Most widely use H&H and WFNs
Radiological modified fisher

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41
Q

Hunt and Hess

A

Grade 1 and 2 are =
Tx grade 1 and 2 surgical
Grade 3 medical

Mortality with H&H
Grade 1-2 ➡️ 20%
Of taken OR ➡️ 14%
Major cause of death grade 1-2 rebleedign
Meningial irritation ⬆️ surgical risk

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42
Q

Risk of vasospasm H& H

A

1 ➡️25%
2➡️ 33%
3➡️ 52%
4 ➡️ 53%
5➡️ 74%

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43
Q

WFNS

A

Most predict long term outcomes

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44
Q

Modified fisher

A
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45
Q

ICHOP Intracranial hemorrhage of pregnancy

A

MC occurs in settings of eclampsia, ICH
VS HELLP ( hemolysis, ⬆️ LFT , ⬇️ palt,) ➡️ sever form of pre-eclampsia

Sx ICHOP or eclampsia alon ➡️ H/ A , 🔺 LOC , seizure

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46
Q

Risk of bleeding in pregnancy 🤰🏼

A

3.5% if no Hx of hemorrhage
5.8% w/ Hx of hemorrhage
Risk of ICHOP during pregnancy 🤰🏼 33-50%

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47
Q

DX aSAH in pregnancy 🤰🏼

A

CTA with shielding
Angio with shield 🛡️

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48
Q

🚫 aSAH pregnancy 🤰🏼

A

🚫 mannitol, nitroprusside, nimodipine

49
Q

Risk of fetal exposure ☢️ during aSAH in pregnancy 🤰🏼

A

Absorption rate 0.17-2.8 mGRY =➡️ fetal risk of hereditary disease at birth and fetal cancer ♋️ which lower than ⬇️⬇️ natural Hx

50
Q

Obstetric aSAH

A

If fetus < 24 ➡️ treat aneurysm and maintain pregnancy

If fetus 24-28 ➡️ weight risk and benefit

CS better fetal salvage for a moribund mother in the third trimester.
During SVD ➡️ ⬇️⬇️ risk of rebleeding by epidural anesthesia , shortening 🥈 stage , low forceps delivery

51
Q

Factor ⬆️ incidence oF HC in aSAH

A

IVH
Diffuse , thick SAH ,m fisher 3-4
⬆️ age
HTN
Posterior circulation anurysum
⬇️ na
⬇️ GCS

52
Q

Low incidence of HCP in

A

MCA aneurysms

53
Q

EVD in HC with aSAH

A

⬆️ risk of rebleeding if done eralyer and fast ⬇️ ICP ➡️ ⬆️ trnasmural pressure
Keep ICP 15-25 mmhg to avoid this

54
Q

Causes of Chronic HC

A

pia-arachnoid adhesions and

impairment of the arachnoid granulations.

55
Q

Main concern regarding aSAH management

A

1-rebleeding RF ➡️ F , high grade SAH , large anurysum, SBP > 175
2- HC
3- DIND , vasospasm
4- hyponatremia and hypovomia
5- DVT, PE
6- augmenting cerebral O 2delivery
7- seizure
8- determine the source of anurysum

56
Q

Target SBP aSAH un secure anurysum

A

< 160 mmgh

57
Q

Target 🎯 o2 saturation

A

Patient at risk of DCI 100%
Other patient > 92%

58
Q

Target hg

A

8-10

59
Q

Pressors

A

If HR ⬇️ norepinephrine
If HR ⬆️ phenylephrine

60
Q

EVD indication in aSAH

A

Acute HC
Significant IVH
H&H 3+

It improve sx in 2/3 patient

61
Q

Anti HTN in aSAH

A

Nimodipone 60 mg q4
Avoid vasodilation ➡️➡️⬆️ CBV ➡️⬆️ ICP

62
Q

BP mangment in aSAH

A

Tharget < 160 un secure
> 175 ⬆️ rebleeding
If BP 🔺 use clevidipine > nicardipine if volume overload is concerning
Long acting ACE inhibitors PRN and labetalol

63
Q

Hyponatremia

A

3times risk to develop DIND
RF ; DM , CHF, cirrhosis, Adrenal insufficiency, use NSAID , acetaminophen, narcotics, thiazide diuretics.29

CSW more common in aSAH than SIADH
CSW ECFV low , diuresis
SIADH ⬆️ ADH

64
Q

Seizure in aSAH

A

Early within 2 wk
Late after 2 wk
RF ;
Age > 60 , MCA anurysum, thicSAH , clots MF 3-4 ,ICH , SDH , poor neurological grade , rebleeding, infraction, vasospasm, ⬇️ na , HC , HTN

65
Q

Keppra > PHT

A

Keppra ⬆️ recurrent in short term but improve longe term outcome
Use unsecured and 1 wk after

Longe term ASM use in Hx seizure , ICH , HTN , infraction , MCA anurysum

66
Q

Risk of rebleeding aSAH

A

First day 4-13% 1/3 within 3 hr , 1/2 within 6 hr
15-20 % in the 13 days
50% 6 months
3%/y

RF highH &H , large anurysum, HTN SBP > 160 , EVD

67
Q

Prevention rebleeding in aSAH

A

Early colling or clipping
TXA ⬇️ early rebleedign , ⬆️ DIND and function

Dose TXA 1 g then 1 g q6 hr for 72 hr

68
Q

Neurogenic stress cardiomyopathy NSC AKA reversible postischemic myocardial dysfunction, 64neurogenic stunned myocardium.

A

⬇️ CO and EF due to aSAH ➡️ hypothalamic ischemia ➡️ sympathetic activation and ➡️ catecholamine surge➡️ subendocardial ischemia or coronary artery vasospasm

NCS vs MI ➡️ trop normal to low in NCS
Peak 2 days to 2 weeks
RF H&H >3
ECG ➡️ broad or inverted T-waves, Q-T prolongation, S-T segment elevation or depression, U-waves, premature atrial or ventricular contraction, SVT, V-flutter or V-fib, 73bradycardia

69
Q

TX NCS if low SVF and SBP < 90

A

dobutamine

70
Q

TX NCS if SBP > 90 , normal SVR

A

milrinone

71
Q

Neurogenic pulmonary edema Pathophysiology

A

1- ⬆️ ICP , hypothalamic ➡️ sympathetic discharge ➡️ redistribution of blood in pulmonary circulation ➡️ ⬆️ PCWP ⬆️ permeability
2- surge of catecholamines directly disrupts the capillary endothelium ➡️ ⬆️ alveolar permeability.

72
Q

Vasospasm duration and peak

A

Peak day 6-8
Duration 3-14 days

73
Q

RF for vasospasm

A

High SAH grade and more blood in CT ( high modified fisher score. )

74
Q

Clinical vasospasm DIND

A

Incidence 30%
Neurological deification ( motor or speech 🎤) , ⬇️ GCS by 2
Non localizing ➡️H/ A , 🔺 LOC , diorinatation,meningitis
Focal CN palsy
Resolve by 12 day

75
Q

Radiological / angiographic vasospasm

A

Arterial narrowing in angiography ➡️ slowing contrast filling
50% in SAH
Discovered day 7
Resolve over 3-4 weeks

76
Q

Vasospasm high in which artery

A

ACA more than MCA

77
Q

anterior cerebral artery (ACA) syndrome

A

Associated ACOM rupture anurysum

abulia, grasp/ suck reflex, urinary incontinence, drowsiness, slowness, delayed responses, confusion, whispering)

78
Q

middle cerebral artery (MCA) syndrom

A

hemiparesis, monoparesis, aphasia (or apractagnosia of non-dominant hemisphere—inability to use objects or perform skilled motor activities, due to lesions in the lower occipital or parietal lobes; subtypes: ideomotor apraxia and sensory apraxia)

79
Q

Risk of vasospasm

A
80
Q

Pathogenesis of vasospasm

A

Result in changes in the vessels

oxyhemoglobin➡️ contraction

hemoglobin➡️ vasorelaxant

platelet-derived growth factor ➡️ vascular stiffening
⬇️ NO and ⬆️ endothelin-1

81
Q

nervi vasorum

A

⬆️ vasoconstriction tone
Loss vasodilation
Sympathetic hyper activity due to ⬆️ ICP and hypothalamic injury

82
Q

obligatory role in vasodilatation factor

A

endothelial derived relaxant factor (EDRF):

83
Q

Other cause of ⬇️⬇️ LOC 7

A

Low o
Infection
Low na
Seizure
Hydrocephalus
Edema
Rebleeding

84
Q

Dx criteria vasospams

A
85
Q

EEG change on vasospasm

A

Declaims percent of alpha ➡️ Relative alpha ( 6-14 hz)
⬇️ amplitude
Can predict vasospasm

86
Q

TCD in vasospasm

A

Detect vasospasm be for clinical by 24-48 hr
Increase 50cm/ sec predict vasospasm

87
Q

Prevention of vasospasm

A

Reduce risk of rebleeding by early treatment and remove blood clots

88
Q

transluminal balloon angioplasty (TBA)

A

Complication ➡️ artery occlusion, dissection , rupture , displacement of clipping
Criteria ( indication )
1- failure triple H
2- ruptured aneurysm is repaired
3- within 12 hr form sx onset
CI 🚫🚫 Strok t/ o first by CT or MRI

89
Q

Triple H

A

CI unsecured anurysum
Start If anurysum secure

Start pressure to ⬆️ SBP by 15% or improve neurologically or SBP reach 220

Dopamine ,
Levophed

phenylephrine ( use N HR )

dobutamine: positive inotrope

90
Q

MCC 📍 Saccular aneurysm

A

80-90 ICA; 🥇 ➡️ 30% ACoA ➡️ 🥈 25% PCOM ➡️ 🥉 20% MCA
4-15% VBA ➡️ basillar tip ➡️ BA- SCA ➡️ BA-VA ➡️ AICA
5% VA- PICA

91
Q

pathophysiology of cerebral aneurysms

A

⬇️ tunica media and adventitia at site of bifurcation with internal elastic lamina prominent

92
Q

Fusiform aneurysms mc 📍

A

VBA

93
Q

IVH with anurysum location

A

Distal PICS ➡️ 4th ventricle
ACOM ➡️ lamina terminals ➡️ 3 rd V
Distal BA , carotid terminus➡️ floor 3 rd V

94
Q

Presentation of cerebral aneurysms

A

SAH , ICH ,IVH , SDH , intravacular ➡️ arteriovenous fistula

95
Q

CN palsy aneurysmal

A

3rd 🥉 CN ➡️ PCOM 🚨in non aSAH ➡️ impending or enlarge aneurysm
Optic CN2
➡️ ophthalmic , ACOm, Basil’s apex ➡️ chism compression

Trigminal ( facial pain syndrom) c4 , c6

96
Q

ADPKD and anurysum location and secrning

A

Mc location MCA
Screening cerbral angio
Q2-3 y in 1 Hx of aneurysm or 2- relative ADPKD+ anurysum
Q5-20 y patient with ADPKD with relative ADPKD 🚫 Hx of anurysum

97
Q

Endovascular techniques to treat the aneurysm

A

Thrombosis ➡️ colling or Onyx( wide- giant ICA anurysum) , flow diversion
Traping, ligation

98
Q

Surgical treatment options for aneurysms

A

Clipping gold stander ⭐️
Warping ➡️ fusiform or branch from dome best by plastic resin

99
Q

Ultra ear
Y anurysum secure by

A

< 24 hr

100
Q

Early vs late secure aneurysm

A

Early 25-96 hr

Late 10- 14 d
Late associated with high mortality and poor outcomes in high grade aSAH

101
Q

Favor late ⏰ surgery day 10-14

A

Inflammation of brain , solid clot , intra operative rupture ⬆️ early , vasospasm ⬆️ early
H&H >4
Poor medical conditions
Difficult location BA , giant

102
Q

Favorable factor for early surgery

A

Good medical 🏥 condition
H&H < 3
Large amount of SAH / large clot
Condition ( 🔺. BP or seizure ) complicate mangment if un secure anurysum
Early rebleeding , imminent rebleeding

103
Q

Imminent aneurysm rupture sign

A

1- progressing cranial nerve palsy
2-increase in aneurysm size on repeat angiography
3-beating aneurysm sign ➡️ pulsatile changes in aneurysm size between cuts or slices on imaging

104
Q

Aneurysmal rest 🐶 ear

A

When a portion of the aneurysm neck is not occluded by a surgical clip,

105
Q

🧠 relaxation during surgery

A

Hyperventilating
CSF after dura opening ➡️ EVD , LP , cinsternostomy

106
Q

Cerebral protection by increasing the ischemic tolerance of the CNS

A

1- drug ⬇️ ischmic effect 🚫 ⬇️ CMRO➡️ CC. Nimodipine , mannitol
2- ⬇️ CMRO2 ➡️ long action barbiturates vs isoflurane and Propofol short acting
Hypothermias safe 33
< 33 moderate hypothermia TBI
Deep hypothermia < 18
Profound hypothermia < 10

107
Q

Prevention of intraoperative rupture aneurysm

A

Prevent HTn due to pain ➡️ local anesthesia
⬇️ transmural pressure by ⬇️ MAP before dura opening
3- reduce shearing force by ⬇️ brain retraction ➡️ wide exposure remove sphenoid wing 🪽
⬇️ 🧠 volume by CSF drain or mannitol
4 ⬇️ tear aneurysm fundus or neck by sharp dissection

108
Q

Intra operative rupture MC occurs during which step

A

Dissection blunt dissection laceration by sharp dissection

109
Q

Risk of recurrence after clipping anurysum

A

1.5/y at 4 years

110
Q

⭐️ follow up aneurysm after treatment

A
111
Q

Anomalies of ACA are common

A

Azygous ACA, the “unpaired ACA” (type I anomaly) is rare.

Type II anomaly is “bihemispheric ACA” as an A2 segment of the ACA that

sends branches across the midline to both hemispheres, usually in the

presence of a contralateral A2 segment that is either hypoplastic or that terminates early

most common (type III anomaly) is the “accessory ACA,” defined as a third artery originating from the Acom, in addition to the paired A2, usually in the midline and with branches to one or both hemispheres.

112
Q

Familial aneurysms most syndroms associated

A

polycystic kidney disease, and connective tissue disorders such as Ehlers-Danlos type IV, Marfan syndrome, and pseudoxanthoma elasticum

113
Q

Risk for rupture Familial aneurysms

A

familial IAs tend to rupture at a smaller size and at a younger

114
Q

Genetics with Familial aneurysms

A

Ch 9 CDKN2B; antisense inhibitor gene)
Ch8 SOX17; transcription regulator gene),
Ch4 EDNRA gene).

115
Q

Cortical subarachnoid hemorrhage cSAH cause

A

Trauma ⭐️ MC
AVM pial
DAVF
Dissection
CVST
CAA
Coagulation
Tumors
vasculitis

posterior reversible encephalopathy syndrome (PRES)

reversible cerebral vasoconstriction syndrome (RCVS),

116
Q

reversible cerebral vasoconstriction syndrome (RCVS),AKA Call-Fleming syndrome,

A

Groups of disorder shrink sx of reversible segmental multifocal cerebral vasoconstriction➡️ sever H/A focal ischmic and seizure
RF postpartum, certain drugs,female
DSA , CTA ➡️ beading of vessels

117
Q

MCA clippings artery need to preserved

A

distal MCA branches, recurrent perforators

118
Q

superior hypophyseal artery aneurysm sx depend on location

A

paraclinoid variant ➡️ 🚫 👀 visual sx

suprasellar variant ➡️ when giant, may mimic pituitary tumor on CT

Vascula Lesion (23 decks)

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