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Vascular Flashcards

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1
Q

What is the mortality of SAH?

A

Up to 50%

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2
Q

Which studies have looked into the natural history of unruptured aneurysms?

A

ISUIA

UCAS - unruptured intracranial aneurysms of Japan

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3
Q

What score helps to determine risk and whether to treat an unruptured incidental aneurysm?

A

UIATS - unruptured intracranial aneurysm treatment score

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4
Q

What is the rate of recannalisation for coiling?

A

10%

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5
Q

Which studies have looked into coiling vs clipping?

A

ISAT
BRAT
Finnish aneurysm study
All show significant improvement with coiling at one year but not by 2 years

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6
Q

Which aneurysms have highest incidence In the anterior circulation?

A

ACOM > PCOM > MCA

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7
Q

What is the most common approach for aneurysm clipping?

A

Pterional Approach

Lateral supra orbital approach (less invasive)

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8
Q

What approach is used for distal ACA / pericallosal artery aneurysm?

A

Anterior interhemispheric approach

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9
Q

What are the steps during aneurysm clipping after craniotomy?

A
  1. Arachnoid dissection
  2. Proximal control
  3. Distal control
  4. Aneurysm dissection - dissection of perforators, placement of clip, ICG angiography
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10
Q

What are the strategies to control aneurysm rupture?

A

Targeted tamponade
Suction
Proximal control with temporary clipping

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11
Q

What are the indirect treatment options for aneurysm treatment?

A 
Hunterian ligation (parent vessel sacrifice without bypass)
Aneurysm trapping with EC-IC bypass (radial artery, saphenous vein and STA)
In-situ bypass (2 close vessels are sutured side by side)
Aneurysm trapping with vessel re-implantation
Remodelling by flow reversal
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12
Q

When to clip vs bypass?

A

Fusiform aneurysm or previously coiling = bypass

Saccular aneurysm = clip

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13
Q

What are the goals of aneurysm treatment?

A

Complete occlusion with avoidance of recurrence

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14
Q

What proportion of aneurysms are found in children?

A

1% are

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15
Q

How do paediatric aneurysms present?

A

80% with haemorrhage - most are Fusiform > saccular

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16
Q

What is the risk of vasospasm in paediatric SAH?

A

10-20% - which is much lower than adults!

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17
Q

What are the % of complete long-term aneurysm occlusion with clip vs coil?

A

96 and 48% at 9 years from BRAT trial

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18
Q

What intraoperative test can be performed to ensure brain perfusion following bypass?

A

ICG and Laser speckle

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19
Q

What is the aneurysm rupture rate within 24 hours?

A

4% followed by 1% for every subsequent day

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20
Q

What is the concern with clipping with vasospasm?

A

Operating has a poorer outcome in patients with vasospasm

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21
Q

What is the role of bypass for ischaemia?

A

Flow augmentation of a chronically hypoperfused brain

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22
Q

What were the outcomes of the EC/IC bypass trial (NEJM 1985)

A

Surgery did not show any benefit over best medical treatment

But wrong patient selection and no stratification for haemodynamic compromise

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23
Q

What proportion of patients develop ischaemia due to vessel stenosis?

A

10%

80% are due to acute thrombus on a ruptured atherosclerotic plaque that are not helped by bypass!

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24
Q

How do you test cerebrovascular reserve capacity?

A

In patients with chronic haemodynamic insufficiency you measure brain perfusion pre and post DIAMOX iv which causes vessel vasodilation. In patients without reserve the blood flow remains the same or reduces due to steal phenomenon. These patients may be best treated with bypass (see JET and COSS studies no difference)

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25
What are the histological findings with Moyà Moyà
Intimal and media thickening causing vessel obliteration resulting in significant collateralisation
26
Who described the first cavernoma?
Luschka in 1854
27
What is the incidence of cavernoma?
0.5% No difference between M & F 90% are supratentorial
28
What proportion of cavernomas are associated with DVAs?
20%
29
What are the risk factors for cavernoma?
Previous radiotherapy | Familial mulitple cavernomas
30
What is the histology of cavernoma?
Mulberry appearance macroscopically | Sinusoid thin walled venous channels
31
What is the classical finding of cavernoma on MRI?
Pop-corn lesion | Haemosiderin ring
32
What is the bleeding rate of a cavernoma?
Previously thought to be higher but now 1% per year per cavernoma Bleeding risk is 2.5-5% if infratentorial and higher if there is an associated DVA 2% annual new seizure onset risk
33
What are the indications for brainstem cavernoma resection?
Repeat symptomatic haemorrhage (2 or more) | Superficial
34
What is the rupture rate of AVM (previously unruptured)?
2-3% per year | Higher if there is an associated nidal aneurysm
35
What are the treatment strategies for high grade AVMs?
Staged fractionated gamma knife to down stage the AVM followed by surgery if not completely obliterated
36
What is the CREST study?
Carotid revascularisation endarterectomy vs stenting trial Composite endpoint of stroke, MI and death showed no difference between the two overall, but stroke risk is higher with stenting (4%) compared to endarterectomy (2%) whilst MI risk is 1% stenting and 2% endarterectomy.
37
Which studies have compared surgery vs stenting for carotid disease?
``` CREST SPACE 3S ICSS SAPPHIRE Meta-analysis has shown endarterectomy is better: Symptomatic patients have double stroke rate with stenting vs surgery ```
38
What is the relationship of the hypoglossal nerve to the common facial vein with carotid endarterectomy?
Hypoglossal nerve lies under the common facial vein; | Hypoglossal nerve runs over the artery to SCM more superiorly
39
What nerve can lie over the carotid bifurcation?
Ansa cervicalis
40
What arteries are clipped / occluded in carotid endarterectomy?
Superior laryngeal artery ICA distal ECA Common carotid At the end take off the ECA, Common carotid then distal ICA
41
What is the outcome of the ISAT and BRAT trials at one year?
7.4% absolute risk reduction at 1 year which reduces to 5% by 2 years that is not significant
42
Which studies have shown the benefit of acute endovascular clot retrieval in stroke?
MR CLEAN ESCAPE EXTEND IA Etc
43
What proportion of strokes at ischaemic vs haemorrhagic?
85% vs 15%
44
What is the ischaemic threshold of brain?
18ml / 100g / min (normal is 50!)
45
What is the definition of the ischaemic penumbra?
Region of brain with decreased cerebral perfusion but not infarction (so salvageable brain)
46
What are the important velocities to know with TCDs?
Look this up
47
What is the prevalence of an unruptured intracranial aneurysm?
0.6-6% as per ISUIA (the majority do not rupture!)
48
Histologically thickened vessels without an internal elastic lamina. What are these?
Arterialised veins
49
What are internal elastic cushions?
Fibromuscular hyperplasia in AVMs
50
When is the highest risk of AVM haemorrhage in pregnancy?
15-20th week gestation
51
Histologically tightly packed vessels with hyalinised vascular channels (no elastic lamina). What is the diagnosis?
Cavernoma
52
What genes are involved with familial cavernoma syndrome?
CCM1 = KRIT1 (hispanic) | CCM2 & 3 (non-hispanic)
53
What is the main histological difference between AVM and cavernoma?
AVM has intervening brain and vessels have internal elastic lamina (arterial)
54
What are the 4 types of aneurysm?
Saccular Fusiform Myoctic Dissecting
55
What factors are associated with aneurysms?
``` Hypertension FHx AVM Collagen diseases (FMD / Ehler's danlos) Smoking ```
56
What type of aneurysms cause hypertensive haemorrhages?
Charcot-Buchard (occur of perforators)
57
What should be ruled out in a patient with mycotic aneurysms?
Bacterial endocarditis
58
What diseases affect large arteries?
Atherosclerosis Moya Moya Fibromuscular dysplasia Giant cell arteritis
59
Histologically what condition has fibro-muscular intimal hyperplasia?
Atherosclerosis
60
What cells are found within the intima in moya moya?
T-lymphocytes
61
What condition has granulomatous inflammation of arterial walls?
Giant cell arteritis
62
What are the causes of an arterial vasculitis?
``` Polyarteritis nodosa Wegeners granulomatosis Behcets Churg-strauss SLE ```
63
Look up the aneurysm clipping vs coiling meta-analysis!
Coiling has better clinical outcome than clipping | Coiling has a greater rebleed rate
64
What is Dolenc's triangle?
Anteromedial triangle
65
What is the meningo-orbital band?
Look up
66
Anterior clinoidectomy 3d anatomy
look up in Neurosurgery
67
How do you interpret TCD values
PI, EDV etc
68
What is the significance of a PCA infarct in a patient with low GCS after aneurysm rupture?
PCA infarct suggests poor outcome
69
What are the platelet function tests?
P2Y12 for clopidogrel | Arachidonic acid reaction units for Aspirin
70
What are the guidelines for reintroduction of anti-platelet agents in patients with drug eluting coronary stents?
Look it up
71
Where are the hypothalamic and Heubner perforators in relation to an ACom aneurysm?
Know the anatomy of this
72
What is the incidence of AVM?
10 x less common than aneurysms
73
What AVM classifications do you know?
Spetzler-martin Lawton Sekhar
74
What are the important consideration when assessing an AVM?
``` Nidus - compact / diffuse / shunts Feeding arteries - incl perforators Draining veins - deep supfl Pathological - aneurysms / venous stenosis Shape - usually connical ```
75
What is the rebleed rate of AVM?
6% in the first year and 2% every year after that
76
Are the findings of the ARUBA trial applicable to patient management?
Have a good answer to this
77
How would you investigate a young patient with recurrent atraumatic SDH?
DSA incl ECA for DAVF
78
What makes you treat a DAVF?
Cortical venous reflux or severe symptoms
79
What should be surgically occluded in DAVF?
The venous side of the fistula (venous leptomeningeal drainage)
80
What is the Aminoff-Logue grading?
??
81
What is the Denis grading in spinal DAVF?
??
82
What structure lies behind the common facial nerve?
The hypoglossal nerve

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