PICA Stroke, Brainstem strokes|ASA,Plavix|45|Male
PICA Stroke, Brainstem strokes|ASA,Plavix|45|Male
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switch gears here and talk about

hemorrhagic stroke. Hemorrhagic stroke just like ischemic stroke comes in different flavors. So I'm going to talk about 2 key ones here today and they're all non-traumatic. The one shown here is a intraparenchymal hemorrhage. Meaning the hemorrhage is in the

substance of the brain. This starshaped hemorrhage is pretty classic for a subarachnoid hemorrhage which is within the folds of the brain not inside the brain but within the folds of the brain. And they both have a very high mortality

rate. Half the patients don't make it to the hospital. So let's start with the aneurysms. You've heard some about aneurysms today. An aneurysm is like a blister on a blood vessel wall that develops over time due to various

risk factors such as uncontrolled hypertension smoking binge-drinking recreational drug use...just a few of them that are known to be influential in their formation and growth. Back in the day you would have to have

an open brain surgery where they'd have to shave your hair make an incision peel the scalp back drill a hole in the bone and then go ahead and put this clip across the neck of the aneurysm excluded from

filling with blood. But since the advent of endovascular treatment you can do this transfemorally by taking a catheter parking it...microcatheter... into the aneurysm and deploying coils which are like miniature metal

slinkies so that you replaced the majority of the volume of the aneurysm with coils which prevents....which minimizes greatly entry of blood. And if you diminish pulsatile flow into the aneurysm you decrease the risk of


patients who come in with ruptured aneurysms.

They come in in very bad shape they're easy to recognize at least by how severe they are. There are patients who may have aneurysms that have not yet ruptured but still are having symptoms and these symptoms show an impending

rupture of an aneurysm. This and the next example show you exactly that. This is a 51-year old lady with two weeks of headaches double vision droopy eyelid. And she came in. Her CT scan looked okay.

However a CTA showed this PCOM aneurysm... this bubble right here. And that bubble was pushing on the nerve that's passing right onto it. That's why she was having her symptoms. That's actually a hallmark of an

impending aneurysm rupture. Because with each pulsation that's pushing on the nerves and that's telling you that the vessel wall around the aneurysm is getting weaker and could rupture any minute. So it's important to recognize this and she

was recognized in a timely fashion. Here's the aneurysm on the angiogram AP view and here's the lateral view...looks like a boot shape. And we went ahead and coiled this. So here are some...a magnified view of how the coils look within the

aneurysm. Here's the microcatheter that goes up and around into the aneurysm fundus and coils are deployed that way. This is the final result which shows you that the coil volume has replaced the blood

volume within the aneurysm with very little filling within the aneurysm itself. How did she do with her double vision. Well this is what you look like. There's a difference between eyelid sizes on

the left side compared to the right side. Two weeks later he already had significant improvement in the degree of the droopiness of the eyelid and the double-vision. Six months later the double-vision fully gone and she

actually had full movement of eyes. So again another success story that you see. We can offer endovascularly these patients who come in with aneurysms which had ruptured which had not ruptured and those that were discovered incidentally. You

all heard Dr. Gaughen talk about the pipeline device as a treatment option for aneurysms that are certain shape size and location. Well this lady here had almost eight weeks of double vision. Couldn't move her

eyes and the problem with her was that this eye couldn't look to the left. You can see that in this picture. She thought it would go away and waited several weeks before saying "okay it's not going away I

need to seek attention". So when she came she had a CT angiogram and the subsequently a diagnostic angiogram which shows this huge aneurysm here. This is the lateral view of the same thing. And I will play you a video and I think the video illustrates

how blood flows into the aneurysm. Contrast flows this way. It enters the aneurysm swirls in comes out goes wherever it's supposed to go. So this aneurysm would be a good aneurysm for this paitent to have the pipeline embolization device

placement. However she came in with not enough time to put her on two antiplatelet agents so that you couldn't get her therapeutic to tolerate the pipeline stent. Remember what Dr. Gaughen had said that they need to be able to tolerate Aspirin Plavix or two

antiplatelet agents in order for this to actually work. So we went ahead and said let's take the risk of rupture from the this aneurysm by putting in some coils so that it doesn't fill with as much blood and doesn't keep pulsating against the

DI that controls the eye muscles. Then we brought her back in after he became therapeutic. And what you see here is you won't be able to appreciate the stent itself... the pipeline devices itself because the

coils are there and that makes it very difficult for you to see where the pipeline device was place...but this is the outline of how the pipeline device was laid across the neck of the aneurysm that courses along the blood vessels. And the

idea of pipeline as Dr. Gaughen had said... if you want to put a seive that looks like it's jailing fence rolled around to make a stent and use that kind of a seive to interrupt the flow of water you would get dribble on the other side. And that

slows down the blood flow and you would form a clot. The tighter that mesh the more effective that will be. So pipeline embolization device is a much tighter mesh and that's what's shown down here. So that's the kind of

thing that she got put. And now time that's passed between here and here is about six months. So I had no expectation that this lady double vision would have improved but she came back after this procedure three weeks later and now she not only has...is

able to look all the way to the left she does not have double vision anymore. So again a very impressive result that we were able to see in this patient. The

we...one of the things that I found with this device is that when you have finished putting the

device in about 25 to 50 percent of the time there's something else you need to do to make that device look better. We know that devices that don't oppose the perforator branches are going to

cause perforator strokes. We know that the vessel is going to look like the stent and six months. So if you have narrowing of the stent you need to get it to open so that there isn't flow limitation and that and also so that you

don't have blockage of perforated branches. I've seen a couple cases of people who didn't heed that advice and left the stent not well opposed at the level of the anterior choroidal artery and had anterior choroidal artery infarcts.

So the wall opposition is a very important component of this and so touch-up becomes an important part of our procedure. As you can see here...here's a patient we put overlapping stents in for a giant cavernous aneurysm and

immediately after deployment of the second stent you see this little area of filling defect...so this is thrombus forming in the stent immediately post procedure. And we went back up with the microcatheter gave intra-arterial

Integrellin and started them on Integrity drip and you can see the clot dissolves right away. Here's that same patient at four months. Aneurysm's almost completely gone with a little tiny bit of the aneurysm

still feeling from the infralateral trunk. So here's another example of poor opposition. So here's your cavernous aneurysm...ophthalmic segment here...the you can see a wasting deformity at the level of the ophthalmic artery with poor filling

of this segment. And you can see this big sac pseudoaneurysm that the ophthalmic is coming off. So you don't want to leave that because if you leave it one of two things is going to happen. Either the aneurysm is gonna stay open because it's

going to continue to shunt through that vessel or that ophthalmic artery's going to shut down you can potentially have an ophthalmic artery stroke. And you can see why that was. So here here we do a CT...a Dyna CT which is this a CAT scan that we can

actually do on the interventional table. We do it with dilute contrast so we can see the vessels very well. And you can see this lays out the opposition of the device very well. So here we have one device and you can see

the inside the second device and there is a step off between the two. So there's significant overlap there. And you can see that again here. So we went back up with a balloon at that level inflated a compliant balloon which is a very safe

way to open up these devices...the devices aren't stiff devices and they open up very well even with compliant balloons and then we're done. You can see the lumen of the stent looks much better and we take the run. You can see that that

pseudoaneurysm outside of the vessel is not there in the ophthalmic arteries is connected or opposed to the stent and open. So then...so those are the technical

everything we talked about. Flow diversion I do think...I use it I get to watch a lot of people use it...I think that is a very promising technology. I think that it is the first device that's

been put in my hands that's allowed me to offer a cure for endovascular aneurysms which is the major selling point for open surgeons to continue to be able to clip aneurysms. I think that in the current iteration of

these devices there are still significant pitfalls...technical pitfalls that we have to learn that we have to overcome and certainly technical pitfalls related to the device and the aneurysm disease process itself that

still make the complication rate something that we need to pay attention to in our decision making. So for right now coil technology is still a very strong technology still very commonly used and they're obviously aneurysms that

coil technology is still ideal for use. I think as our technologies grow we're going to see this application used more and more. Flow diversion is also now....so the next generation of flow diversion is looking

at limiting some of these complications. But there's also flow diversion technology that we call intra-sacular flow diversion which is taking this sort of technology and instead of putting it intraluminally...which is inside the blood

vessel...you actually put mesh inside the aneurysm. So it's for aneurysms that can't tolerate intraluminal flow diversion like ruptured aneurysms bifurcation aneurysms aneurysms that we see that we just don't

want....aren't effectively treated with flow diversion right now. So questions for me about any

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