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 Younger ageBrain edema, HH 4-5

Location-post circ (post inf BA) Location-ant circ (MCA)Size 2-7 mm Size > 7 mmNeck (5/2 = fundus/neck) Wide, complex neck

ICH, hydrocephalus, FisherKink, atherosklerosis

Symptomatol (CN III)

experience surg x endovascopinion of pts

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:

- giant (5%)- small aneurysm (5%)- wide neck (10%) - MCA ( 25%)- failure of EVT (10%)

Limit and Benefit Endovascular vers. Mininvasive surgery

Giant aneurysms

Dept. NeurosurgeryÚstí nad Labem

Case report – trap M2+bypass

Dept. NeurosurgeryÚstí nad Labem

Case report - postop

Dept. NeurosurgeryÚstí nad Labem

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:

- giant- small aneurysm < 2 mm (5%)- wide neck- MCA- failure of EVT

Limit and Benefit Endovascular vers. Mininvasive surgery

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:

- giant- small aneurysm- wide neck (5%)- MCA- failure of EVT

Limit and Benefit Endovascular vers. Mininvasive surgery

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:

- giant (5%)- small aneurysm (5%)- wide neck (5%) - MCA ( 25%)- failure of EVT (10%)

Limit and Benefit Endovascular vers. Mininvasive surgery

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:

- giant- small aneurysm - wide neck - MCA - failure of EVT (10%)

Limit and Benefit Endovascular vers. Mininvasive surgery

BOT

Carotid-opthalmic aneurysmsBOT, superior direction, TCD, suction blood from CCA

Opthalmic aneurysm-CT postop

MRA postop-no residual neckPerimeter intact, no neurol deficit

Dept. NeurosurgeryÚstí nad Labem

Uncoilable aneurysms:- giant (5%)- small aneurysm (5%)- wide neck (10%) - MCA ( 25%)- failure of EVT (10%)

- ----------------------------------------------------- uncoilable 55%

Limit and Benefit Endovascular vers. Mininvasive surgery

Advances of surgeryHernesniemi Prague 2007

1. CTA2. Approaches – simple, fast3. Killing the aneurysms4. Navigation, 3D models5. Intraoperative AG (ICG)6. Prevention of vasospasms – Nicardipine – release

pellets7. Bypass – surgery, selana, elana, strip8. Subspecialization9. 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 studyaneurysm a.basilaris - coil

recanalization after 6 months, recoil

clipping

Dept. NeurosurgeryÚstí nad Labem

coiling

75% 25%

MNUL UVN Homolka LBC

klip 63 33 35 24

coil 21 66 37 2

celkem 84 99 72 26

Počet ošetřených aneurysmat na vybraných pracovištích, 2010

AVM

Léčba AVM

Léčba AVM - LGK

rok % obliterace

1 20%2 60%3 70%4 80%

Spetzler- MartinLGK Homolka

Gr 1 12%Gr.2 49%

Kavernózní angiom

1. Supratentoriální – epilepsie, krvácení2. 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

MNUL Poruba UVN Homolka HK Plzeň LBC

2669 2642 2640 2433 2027 1641 1568

Neurochirurgická klinika MN UL 1968 - 2010