Léčba aneurysmat, AVM, kavernomů

Léčba aneurysmat, AVM, kavernomů
Sameš M., Hejčl A., Vachata P., Bartoš R.,
Pavlov V., Cihlář F., Derner M.
Neurosurgical Department, Department of Radiology,
Masaryk Hospital, Ústí nad Labem, Czech Republic
SAH Management
Coil
Clip
Higher age, ASA risk
Brain edema, HH 4-5
Younger age
Location-post circ (post inf BA)
Size 2-7 mm
Neck (5/2 = fundus/neck)
Location-ant circ (MCA)
Size > 7 mm
Wide, complex neck
ICH, hydrocephalus, Fisher
Kink, atherosklerosis
Symptomatol (CN III)
experience surg x endovasc
opinion of pts
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant (5%)
- small aneurysm (5%)
- wide neck (10%)
- MCA ( 25%)
- failure of EVT (10%)
Dept. Neurosurgery
Ústí nad Labem
Giant aneurysms
Dept. Neurosurgery
Ústí nad Labem
Case report – trap M2+bypass
Dept. Neurosurgery
Ústí nad Labem
Case report - postop
Dept. Neurosurgery
Ústí nad Labem
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant
- small aneurysm < 2 mm (5%)
- wide neck
- MCA
- failure of EVT
Dept. Neurosurgery
Ústí nad Labem
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant
- small aneurysm
- wide neck (5%)
- MCA
- failure of EVT
Dept. Neurosurgery
Ústí nad Labem
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant (5%)
- small aneurysm (5%)
- wide neck (5%)
- MCA ( 25%)
- failure of EVT (10%)
Dept. Neurosurgery
Ústí nad Labem
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant
- small aneurysm
- wide neck
- MCA
- failure of EVT (10%)
Dept. Neurosurgery
Ústí nad Labem
Carotid-opthalmic aneurysms
BOT, superior direction, TCD, suction blood from CCA
BOT
Opthalmic aneurysm-CT postop
MRA postop-no residual neck
Perimeter intact, no neurol deficit
Limit and Benefit
Endovascular vers. Mininvasive surgery
Uncoilable aneurysms:
- giant (5%)
- small aneurysm (5%)
- wide neck (10%)
- MCA ( 25%)
- failure of EVT (10%)
-
----------------------------------------------------
uncoilable 55%
Dept. Neurosurgery
Ústí nad Labem
Advances of surgery
Hernesniemi Prague 2007
1.
2.
3.
4.
5.
6.
CTA
Approaches – simple, fast
Killing the aneurysms
Navigation, 3D models
Intraoperative AG (ICG)
Prevention of vasospasms – Nicardipine – release
pellets
7. Bypass – surgery, selana, elana, strip
8. Subspecialization
9. Strong experience – video, courses, education
Intradural drilling of ant clin proc
carotid opthalmic aneurysm
Summary of isolated dissecting PICA
aneurysm: Location
Anterior medullary segment 38%
Lateral medulary segment
27%
Tonsilomedullary segment
9%
Telovelotonsilar - perfor to BG 9%
Cortical segment
13%
Korematsu K.et al., Acta neurochirurgica 150: 77-81, 2008
Postop DW MRI
Postop – approach, clip,
follow up 6 months
Follow up study
aneurysm a.basilaris - coil
recanalization after 6 months, recoil
clipping
75%
Dept. Neurosurgery
Ústí nad Labem
coiling
25%
Počet ošetřených aneurysmat
na vybraných pracovištích, 2010
MNUL
UVN
Homolka LBC
klip
63
33
35
24
coil
21
66
37
2
celkem
84
99
72
26
AVM
Léčba AVM
Léčba AVM - LGK
Spetzler- Martin
LGK Homolka
Gr 1
Gr.2
12%
49%
rok
% obliterace
1
2
3
4
20%
60%
70%
80%
Kavernózní angiom
1. Supratentoriální – epilepsie, krvácení
2. Kmen mozkový
- dotyk s pia mater
- recididivující krvácení
LGK neúčinný, pokud léčba - resekce
T.E., 45, kolapsové stavy, hemihypestézie
Pooper CT, bez komplikací
V.R., 59, recidivující krvácení z kavernomu,
LGK bez efektu
Po operaci bez okohybné poruchy
F.M, 85, bolesti hlavy, Parinaud, diplopie,
na CT/MR hematom v tectu, kavernom
Pooper kontrola 4/11
Pooper kontrola 4/11
j.o., 70, diplopie vertigo, v době termínu na operaci recidiv krvácení s
hemiparézou a plegií VII dx, oper 12/08
3/09 pooper kontrola
Neurochirurgická klinika MN UL
1968 - 2010
MNUL
Poruba
UVN
Homolka HK
Plzeň
LBC
2669
2642
2640
2433
1641
1568
2027