9/7/2013 Disclosures Neurointerventional Radiology: Minimally Invasive Treatments for Neurovascular • Chief Medical Officer: ChemoFilter • Diseases Scientific advisory: Medina • Consulting: Stryker, Silk Road • Data Safety and Monitoring Committee: DAWN trial UCSF Stroke and Aneurysm Update CME • Core Imaging Lab: MAPS trial, FRED trial Saturday September 7, 2013 1:00 PM • Grant support: NIBIB, ASNR Foundation • I will discuss off-label uses of drugs (tPA) and devices (stents, balloons, calcium channel blockers) Steven W. Hetts, MD • Videos from vendors will be shown Associate Professor of Radiology • I have borrowed liberally from my colleagues and acknowledge Interventional Neuroradiology their kind help: Christopher Dowd, MD, Joey English, MD, PhD, Daniel Cooke, MD, Peter Jun, MD, Van Halbach, MD, Randall University of California, San Francisco Higashida, MD Take Home Points Interventional Neuroradiology • A variety of endovascular techniques exist for • Use of imaging for the diagnosis and treating brain aneurysms treatment of disorders of the brain and spine • Cerebral vasospasm is the leading cause of • Imaging modalities include: – X-ray fluoroscopy mortality and morbidity in SAH patients and – CT can be treated endovascularly – MRI – Ultrasound 1
9/7/2013 What are Neurointerventional Procedures? • Image-guided: usually x-ray fluoroscopy • Transarterial, transvenous, percutaneous • Diagnostic and therapeutic • Multidisciplinary: Neurosurgery, Neurology Scope of Practice Scope of Practice • Cerebrovascular disease • Neuro-oncology • Cerebrovascular disease • Neuro-oncology – Brain aneurysms – Tumors of brain, head, – Brain aneurysms – Tumors of brain, head, – Subarachnoid hemorrhage – Subarachnoid hemorrhage neck, and spine neck, and spine • Peripheral vascular • Peripheral vascular (SAH) (SAH) – Cerebral vasospasm – Cerebral vasospasm malformations malformations – Arteriovenous – Arteriovenous – Venous and lymphatic – Venous and lymphatic malformations (AVMs) malformations (AVMs) malformations malformations – Arteriovenous fistulas – Arteriovenous fistulas • Neuro-endocrinology • Neuro-endocrinology (AVFs) (AVFs) – Hyperparathyroidism, – Hyperparathyroidism, – Atherosclerosis (intra/extra – Atherosclerosis (intra/extra Cushing’s disease Cushing’s disease cranial) cranial) – Vertebral osteoporosis – Vertebral osteoporosis – Acute ischemic stroke – Acute ischemic stroke • Neuroangiography • Neuroangiography 2
9/7/2013 Outline Outline • Aneurysm treatment: background and history • Aneurysm treatment: background and history • Aneurysm treatment: techniques • Aneurysm treatment: techniques – Surgical clipping – Surgical clipping – Endovascular coiling – Endovascular coiling – Balloon-assisted coiling – Balloon-assisted coiling – Stent-supported coiling – Stent-supported coiling – Vessel takedown – Vessel takedown – Flow diversion – Flow diversion • Treatment of cerebral vasospasm • Treatment of cerebral vasospasm Brain Aneurysms Location of Aneurysms • Abnormal thin-walled swelling or outpouching of an artery • 1 to 12 million Americans have potentially detectable aneurysms • Shape and location of aneurysm influence optimal method of treatment Schievink, NEJM 1997 3
9/7/2013 CT X-Ray Angiography Subarachnoid Hemorrhage Schievink, NEJM 1997 Aneurysmal SAH Outline • 5% of all strokes • Aneurysm treatment: background and history • 30,000 in USA annually • Aneurysm treatment: techniques • Population-based mortality 45% – Surgical clipping – Endovascular coiling • Significant morbidity among survivors – Balloon-assisted coiling • High risk of rebleeding – Stent-supported coiling – 4% day 1, 30+% first month, 3%/yr long term – Vessel takedown • 70% mortality from rebleeding – Flow diversion • Goal: occlude aneurysm ASAP • Treatment of cerebral vasospasm Bederson et al. Stroke 2009;40:994-1025. 4
9/7/2013 Treatment of Cerebral Aneurysms Outline • Aneurysm treatment: background and history • Aneurysm treatment: techniques – Surgical clipping – Endovascular coiling – Balloon-assisted coiling – Stent-supported coiling – Vessel takedown – Flow diversion • Treatment of cerebral vasospasm Surgical Clipping Endovascular Coiling Endovascular Timeline • 1974: first report of balloon embolization of aneurysm (Serbenenko) • 1982: further Soviet balloon experience reported (Romodanov, Shcheglov) - detachable and nondetachable • 1980s: experience with silicone (Hieshima) and latex balloons; became standard endovascular alternative to surgical clipping • 1990: limited experience with pushable fibered coils • 1991: Guglielmi Detachable Coil (GDC) developed 5
9/7/2013 36F, SAH (I) Aneurysm Coiling coil R PcomA aneurysm ISAT (Lancet 360: 1267-1274, 2002) International Subarachnoid Aneurysm Trial Endovascular Timeline • 1997: Balloon-assist ( “ remodeling ” ) technique for wide • 1995: GDC approved by FDA (high-risk aneurysms) • Coil vs. clip of ruptured aneurysms in 2143 pts. • Pts. appropriate for both therapies randomized 1:1 • Trial stopped early: “ disability-free survival ” at 1 yr. f/u • At 1 yr. f/u: 23.7% coil pts., 30.6% clip pts. dependent/dead necked aneurysms (Moret) • 1997: Stent-supported coiling (Higashida and others) • 1998: Detachable Silicone Balloon approved by FDA better in coiled pts. • 1998: ISUIA study (retrospective) • Study criticisms: – no long-term f/u • 2002: Other detachable aneurysm coils – many aneurysms excluded from randomization – rebleed rate: coil (2/1276); clip (0/1081) 6
9/7/2013 ISAT Long Term Follow Up U.S. Trends in Aneurysm Treatment Lancet Neurol 8:427-433, 2009 Lin et al, JNIS 4:182-189, 2012 • 2143 ruptured aneurysm pts enrolled 1994-2002 at 43 centers • Random assignment to clipping or coiling • Annual follow-up of 2004 patients for 6 to 14 years (mean 9 y) • 24 rebleeds at 1 or more years after index aneurysm rx – 13 rebleeds from index aneurysm (10 coiled, 3 clipped, p=0.06) – 4 rebleeds from non-index aneurysm identified at time of index rx – 6 rebleeds from new aneurysms • Risk of death at 5 years: lower in coiling group (RR 0.77) – 11% coiled pts dead, 14% clipped pts dead (p=0.03) • Proportion of survivors independent at 5 years: equivalent – 83% coiled pts independent, 82% clipped pts independent Effect of ISAT and ISUIA Lin et al, JNIS 4:182-189, 2012 Endovascular Timeline • 2002: ISAT study • 2002: Neuroform Self-Expanding Stent • 2002: Bioactive Coils Available • 2003: ISUIA study (prospective) • 2003: Detachable Silicone Balloons off market • 2003: GDC approved for all aneurysm indications • 2005: Enterprise Self-Expanding Stent • 2011: Pipeline Flow Diverter (limited indications) 7
9/7/2013 Endovascular or Surgical Treatment of Outline Ruptured Aneurysms • Aneurysm treatment: background and history • Admit or transfer to hospital experienced in • Aneurysm treatment: techniques treatment of SAH • Diagnose source of SAH as soon as possible – Surgical clipping • Treat aneurysm (surgical clipping or endovascular – Endovascular coiling coiling) within first 5 days of initial rupture – Balloon-assisted coiling • Manage vasospasm 5 days to 2 weeks post bleed – Stent-supported coiling – Vasospasm is major source of morbidity and mortality – Vessel takedown – HHH therapy – Flow diversion – Endovascular therapy • Treatment of cerebral vasospasm Endovascular Treatment of Outline Unruptured Aneurysms • Informed consent • Aneurysm treatment: background and history • Premedication • Aneurysm treatment: techniques – ASA 81 mg PO qd x 5 days – Surgical clipping – Clopidogrel 75 mg PO qd x 5 days (for stents) – Endovascular coiling • Anesthesia support: MAC for dx, GA for rx – Balloon-assisted coiling • ICU overnight after procedure – Stent-supported coiling • Hospital floor bed for second night – Vessel takedown • Home by 48 hours post procedure (now often – Flow diversion • Treatment of cerebral vasospasm within 36 hours) 8
9/7/2013 45F, SAH (I) R MCA Factors Favoring Craniotomy aneurysm poor coil • Accessible location (e.g., MCA bifurcation) candidate • Ability to inspect aneurysm • Hematoma requiring evacuation • Experienced surgeon Outline Factors Favoring Endovascular Treatment • Anatomical • Aneurysm treatment: background and history – size • Aneurysm treatment: techniques – aneurysm neck – Surgical clipping • Deep location – Endovascular coiling – for example: basilar tip, low ICA, AcomA – fusiform dissecting vertebral aneurysms – Balloon-assisted coiling • Concurrent vasospasm – Stent-supported coiling • Older patient age – Vessel takedown • Experienced neurointerventionalist – Flow diversion • Treatment of cerebral vasospasm 9
9/7/2013 Left ICA Planar Angiograms Unsubtracted Rotational Angiogram AP Lateral Subtracted Rotational Angiogram 3D Angiogram Manipulation 10
9/7/2013 Mid Coiling Angiogram Pre and Post Coiling Angiograms 54 yo M, GCS 15, with the second-worst R ICA Catheter Angiogram headache of his life NECT NECT 11
Recommend
More recommend
