Heather L.

Hinds Gillian Lieberman, MD

August 2001

Cerebral aneurysms
A case study Heather L. Hinds, Harvard Medical School Year III Gillian Lieberman, MD

Heather L. Hinds Gillian Lieberman, MD

Our Patient
57yr old woman History of migraines Presents with persistent headache
several months duration different from her usual headache

Need to rule out intracranial abnormality

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Heather L. Hinds Gillian Lieberman, MD

Menu of tests for initial cerebral imaging

Computed tomography (CT)
Fast and readily available Excellent for detection of acute hemorrhage

Magnetic resonance imaging (MR)

Higher soft tissue resolution/contrast Multiplanar capability

(Plain film
Shows the skull, but reveals few brain abnormalities)
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Heather L. Hinds Gillian Lieberman, MD

Our Patient
57yr old woman History of migraines Presents with persistent headache
several months duration different from her usual headache

Test of choice: HEAD CT

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Heather L. Hinds Gillian Lieberman, MD

Normal Head CT
Check: Blood, acute
High attenuation (bright)
RIGHT LEFT

Midline
Is symmetry preserved?

R Frontal lobe L Lateral Ventricle Gr W

Ventricles Cisterns Sulci Grey/white matter Soft tissues Bones Sinuses

R Occipital lobe

W = white matter Gr = grey matter

BIDMC PACS system

Heather L. Hinds Gillian Lieberman, MD

Our Patients Head CT (no contrast)

Film Findings: Spherical mass Smooth margined High attenuation Slight mass effect Located just anterior to the Circle of Willis
No acute hemorrhage, edema, infarct
BIDMC PACS system RIGHT LEFT Frontal lobe

Midbrain Cerebellum

Heather L. Hinds Gillian Lieberman, MD

DDx: Cerebral mass

Tumor Hematoma Abscess Arterio-venous malformation (AVM) Aneurysm

Heather L. Hinds Gillian Lieberman, MD

Work-up: Cerebral mass

Computed tomography (CT) + IV contrast Magnetic resonance imaging (MRI)

Heather L. Hinds Gillian Lieberman, MD

Our Patients Head CT (with contrast)

RIGHT Frontal lobe LEFT RIGHT Frontal lobe LEFT

cerebellum cerebellum BIDMC PACS system

BIDMC PACS system

2 brightly enhancing round lesions suggestive of cerebral aneurysms

Heather L. Hinds Gillian Lieberman, MD

Lets review the anatomy of the Circle of Willis

Communicating system of vessels that supplies blood to the brain Anterior portion fed by the internal carotid arteries Posterior portion fed by the vertebral arteries
http://www.strokecenter.org/education/ais_vessels/ais048.html

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Heather L. Hinds Gillian Lieberman, MD

Circle of Willis in our Patient

RIGHT LEFT RIGHT Frontal lobe ACA LEFT

MCA

basilar tail

PCA

cerebellum BIDMC PACS system

BIDMC PACS system

Film findings: C/W cerebral aneurysms.

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Heather L. Hinds Gillian Lieberman, MD

Menu of tests for evaluating suspected: Cerebral aneurysms

Computed tomography (CT) + contrast Magnetic resonance imaging (MRI) Magnetic resonance angiograpy (MRA) Cerebral angiography
Patient Plan: Come to the ER for immediate MR imaging!
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Heather L. Hinds Gillian Lieberman, MD

Our Patients sagittal MR (T1 sequence)

T1 sequence
Fat is bright (high signal) CSF is dark (low signal)
Sagittal section corpus callosum midbrain

Mass characteristics
Low signal emission
flow void moving blood is dark

Position adjacent to ICA

cerebellum internal carotid artery BIDMC PACS system

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Heather L. Hinds Gillian Lieberman, MD

Our Patients Axial MR (T2 sequence)

T2 sequence: CSF is bright (high signal)
RIGHT LEFT RIGHT LEFT

BIDMC PACS system

BIDMC PACS system

Round lesions with flow void confirmed

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Heather L. Hinds Gillian Lieberman, MD

Menu of tests for evaluating suspected: Cerebral aneurysm

Computed tomography (CT) + contrast Magnetic resonance imaging (MRI) Magnetic resonance angiograpy (MRA) Cerebral angiography

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Heather L. Hinds Gillian Lieberman, MD

Magnetic Resonance Angiography (MRA)

MR technique for imaging vessels
Uses MR pulse sequences (Time of Flight) that can turn flowing blood into a strong signal (white blood)

Does not require contrast; non-invasive Can convert a stack of contiguous MR slices into a 3D angiographic model
Excellent visualization of the Circle of Willis and aneurysm characterization

Note: Traditional angiography is the Gold Standard

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Heather L. Hinds Gillian Lieberman, MD

MRA - Circle of Willis

Our Patient
Anatomic Diagram
RIGHT LEFT ACA

MCA b a s i PCA

a r internal carotid vertebral arteries BIDMC PACS system

http://www.strokecenter.org/education/ais_vessels/ais048.html

internal carotid

Internal carotid artery aneurysms

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Heather L. Hinds Gillian Lieberman, MD

Our patients diagnosis

Right giant suprasellar internal carotid artery (ICA) aneurysm (2.6cm) Left supraclinoid internal carotid artery aneurysm (13mm)
Patient was booked for definitive treatment in 5 days
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Treatment options
Broadly include; 1. Surgical clipping 2. Angiographic embolization

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Heather L. Hinds Gillian Lieberman, MD

Lets review a little on Cerebral aneurysms

Dilatations or outpouchings of the arterial wall
Saccular (berry) or fusiform (dilated and elongated) Mycotic, neoplastic, traumatic

Saccular aneurysms form secondary to a weakness in the media and elastica of the arterial wall
typically occur at vessel bifurcations/branchings

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Heather L. Hinds Gillian Lieberman, MD

Saccular aneurysms
Frequency: 3.6-6% of the population
15-20% multiple aneurysms

Most common locations: Circle of Willis

Anterior communicating artery Posterior communicating artery Bifurcation of the middle cerebral artery Basilar tip 30-35% 30-35% 20% 5%

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Heather L. Hinds Gillian Lieberman, MD

Saccular aneurysm
Risk factors
Female gender Family history Polycystic kidney disease (ADPKD) Connective tissues disorders Smoking (cardiovascular risk factors?)

Treatment options: Conservative or aggressive?

> 5-9mm increased risk of rupture

Treatment options
Surgical clipping of the neck of the aneurysm Aneurysm occlusion (angiography) Choice for this patient Proximal vessel occlusion

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Heather L. Hinds Gillian Lieberman, MD

Unfortunately, our Patient returned.

4 days later, patient complained of headache and vomiting Arrived at the ER unresponsive
Concern: Subarachnoid Hemorrhage (SAH) 80% of SAH are due to rupture of saccular aneurysms

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Heather L. Hinds Gillian Lieberman, MD

Our patients CT without contrast

Acute blood is bright (high attenuation)
RIGHT LEFT RIGHT LEFT

4th ventricle

BIDMC PACS system

BIDMC PACS system

High attenuation blood is present in dilated ventricles

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Heather L. Hinds Gillian Lieberman, MD

Our patients CT without contrast

BIDMC PACS system

BIDMC PACS system

Blood again seen in dilated ventricles Enlarged aneurysm with surrounding edema causing mass effect

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Heather L. Hinds Gillian Lieberman, MD

Impression
Subarachnoid hemorrhage following rupture of a right internal carotid artery aneurysm
Acute blood in cisterns and ventricles Dilatation of ventricles (hydrocephalus) Mass effect on right lateral ventricle Midline shift

Interventional radiological treatment was pursued.

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Lets review anatomy to understand how a ruptured aneurysm bleeds into the subarachnoid space

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Heather L. Hinds Gillian Lieberman, MD

http://www.csuchico.edu/ pmccaff/syllabi/sppa362/362unit3.html

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Heather L. Hinds Gillian Lieberman, MD

Brain ventricles
Cavities in the brain filled with CSF Open to subarachnoid space via foramen in the 4th ventricle
Foramina of Luschka Foramen of Magendie
http://www.epub.org.br/cm/n02/fundamentos/ventriculos_i.htm

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Heather L. Hinds Gillian Lieberman, MD

Plan: Transcatheter embolization Guglielmi Coiling

Method
Wall off the aneurysm from the circulation by filling it with platinum wire coils.

Benefits
Utilizes standard angiography techniques Less invasive than surgical clipping (craniotomy) Can reach distal/inaccessible aneurysms

Risks
Occlusion of parent artery by renegade coils Perforation of aneurysm Little information available on long term outcomes

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Heather L. Hinds Gillian Lieberman, MD

Our patients Cerebral artery angiogram during embolization

Femoral artery catheterization route to the internal carotid Inject contrast Continue moving catheter through the internal carotid towards the Circle of Willis
External carotid artery

Internal carotid artery

Right common carotid

BIDMC PACS system

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Heather L. Hinds Gillian Lieberman, MD

Our Patients Cerebral artery angiogram during embolization

Locate aneurysm Estimate volume Thread a microcatheter through the main catheter to the aneurysm site Deliver fine, wound platinum coils through the microcatheter via a guide wire Release coils into aneurysm Pack until full

Internal carotid artery

BIDMC PACS system

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Heather L. Hinds Gillian Lieberman, MD

Our patients cerebral angiogram during embolization

Internal carotid artery

BIDMC PACS system

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Aneurysm partially filled with coils

Heather L. Hinds Gillian Lieberman, MD

Projected outcomes
Guglielmi coil treated cerebral aneurysm
Best for aneurysms 4-10mm, narrow necks Best for aneurysms difficult to access using surgical approaches Best for patients for whom surgery is contraindicated Problems: incomplete occlusion (rebleeding), potential complications (rupture, artery occlusion/coil migration) Long term outcomes still unclear

Surgically treated cerebral aneurysm

Classic approach - surgical clipping of aneurysm neck Better occlusion of aneurysm Carefully controlled randomized trials need to be done.
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Our Patient was already unresponsive at the time of the angiographic embolization and died shortly thereafter

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Heather L. Hinds Gillian Lieberman, MD

Take home message

Rule out intracranial abnormality?
Exam of choice: typically CT ALWAYS do non-contrast CT to identify acute blood Follow with contrast study, if indicated

Cerebral mass?
MR to characterize further

Putative aneurysm?
Cerebral artery angiography is the Gold Standard MRA offers a convenient alternative; also CTA

Treatment of aneurysm?
Surgical clipping or thrombosis Considerations: Aneurysm location, size and neck shape Patient stability
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Heather L. Hinds Gillian Lieberman, MD

References
Dovey, Z., Misra, M., Thornton, J., Fady, T., Charbel, M.D., Debrun, G.M., Ausman, J.I. Guglielmi detachable coiling for intracranial aneurysms. Arch Neurol 2001; 58:559-564. Grossman, R.I., Yousem, D.M. Neuroradiology: The requisites. St. Louis: Mosby; 1994. Naidich, T.P., Righi, A.M. Neurovascular imaging. Radiol Clin North Am 1995; 115-66. Reeder, M.M., Felson, B. Gamuts in radiology: Comprehensive lists of roentgen differenetial diagnosis. Cincinnati: Audiovisual Radiology of Cincinnati, Inc.; 1975. Schnitzlein, H.N., Murtagh, F.R. Imaging Anatomy of the Head and Spine. Baltimore: Urban & Schwarzenberg; 1985. Van Gijn, J., Rinkel, G.J.E. Subarachnoid haemorrhage: diagnosis, causes and management. Brain 2001; 124: 249-278. Wardlaw, J.M., White, P.M. The detection and management of unruptured intracranial aneurysms. Brain 2000; 123: 205-221.
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Heather L. Hinds Gillian Lieberman, MD

Acknowledgements
Dr. Gillian Lieberman Dr. Chad Brecher Dr. Nicole Thobe Dr. Steven Reddy Pamela Lepkowski Larry Barbaras and Cara Lyn Damour

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