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Surgery for Cerebrovascular
Diseases(CVDs)
Jian-min Zhang
Dept. of Neurosurgery
2nd Affiliated Hospital
Zhejiang University College of Medicine
introduction
• Cerebral vascular diseases (CVDs) are
series of diseases with high mortality,
which have loaded a heavy burden to
the society.
• Classification ： Hemorrhagic and
Occlusive
• Treatment：medicine and surgery
• With the development of basic science,
microneurosurgery and endovascular
techniques, more and more CVDs can
be treated by means of surgery.
1. Hemorrhagic CVDs
intracranial aneurysm
cerebral vascular malformation
hypertensive hemorrhage
(1). intracranial aneurysm
general knowledge
• incidence: 0.2-7.9% in autopsy; 6-8/105/year for
ruptured aneurysms. It is the third common CVDs and
the incidence is increasing.
• Most common in 40-60 years old
• Morphology: abnormal dilation of intracraniaarteries---saccular, fusiform and dissecting
• Often diagnosed when ruptured and cause
subarachnoid hemorrhage(SAH).
• Mortality decreased with the improvement of
diagnose and management.
Etiology
•Congenital
•Acquired:
Infectious
Traumatic
Caused by angiosclerosis
Caused by disecting of blood vessels
Common Location
•anterior circulation: 85%～95%
anterior a. -30%
posterior communicating a. -25%
middle cerebral a. -20%；
•Posterior circulation: 5% ～ 15%
basilar a. -10%；
vertebrate a. -5%，
Risk factors
•age
•Genetic background
•Homodynamic factors
•Defects in medial layer of blood vessels
•Hypertension
Natural history
•Ruptured :7% die on the spot,7%
misdiagnosed
•Re-bleeding: peak at 7-10th days
Pathology
•SAH
•Intracranial hemorrhage
•hydrocephalus
•Cerebral vasospasm
Symptoms
•bleeding：headache, nausea
and consciousness disturbance
•Local neurological symptoms
•Systematic symptoms
动脉瘤破裂出血.avi
Hunt-Hess scale
I Asymptomatic or minimal headache and slight
nuchal rigidity
II Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy
III Drowsiness, confusion, or mild focal deficit
IV Stupor, moderate to severe hemiparesis, possible
early decerebrate rigidity and vegetative
disturbances
V Deep coma, decerebrate rigidity, moribund
appearance
diagnosis
•Lumbar pucture
•CT/MRI
•DSA ,CTA , MRA
radiology
（ＣＴ）
CT could not directly detect the body
of aneurysms unless it is very large
managements
•medical
•surgical
•endovascular
１.medical
•Lying in bed for more than 4 weeks
•Avoiding agitation or excertion
•haemostatic
•Dehydration to reduce intracranial pressure
•Anti-vasospasm
•external ventricular drainage
•Controlling the blood pressure
•Symptomatic treatment
２.surgical
•history：1885,Horsley ligation of internal carotid a.
1927 cerebral angiography
1931 encapsulate the aneurysms with muscles
1937 aneurysm clipping ( by Dandy) and trapping
1942 ligation of the neck of the aneurysms
•Purpose of the operation：avoiding re-rupture and rebleeding, keep the aneurysm-bearing arteries open and
controlling vasospasm
•Operation: direct—clipping, ligation or trapping
Indirect: ligation of carotid artery or blocking
the aneurysm-bearing atery
Trapping (preoperative tests)
indication
• age＜75；
• Hunt-Hess scale: I－ III
• Hunt-Hess scale IV-V should be operated when the
patients recover to I-III
• In acute phase: with intracerebral hemorrhage or large
volume of SAH
• Infectious aneurysm
Operation time
• Immediate operation for Hunt-Hess I -II ；
• Patients with recurrent bleeding；
• Patients with vasospasm should be operated on
after 14-21 days from the initial bleeding;
• Patient >50 years should avoid operation with in
1 week from the last bleeding；
• Patients with giant aneurysms, wide base
aneurysms should wait for the retraction of the
brain edema, for the operations are difficult.
Open surgery for aneurysm clipping
•approach
•By microsurgery and special instruments
•Endoscope-assisting operation
•Close the neck of the aneurysms keep the
aneurysms-bearing artery open and protect the
nearby blood vessels and nerves
Pros of the aneurysm clipping
•For the reconstruction of endomembrane of the
blood vessels, which is the most important against
the pressure of the blood flow.
•Anatomically “cure”: better durance, less incidence
of recurrence
•Can remove the haematoma in the subarachnoid
space and in the cerebral tissue, reduce the
intracranial pressure and alleviate the vasospasm.
Cons of the aneurysm clipping
•Require skilled neurosurgeons
•Invasive, with many complications: retracting the
brain tissues and cranial nerves, poor tolerance by
severe, aged patients or patients with systematic
co-morbidities
•High risk for posterior circulation aneurysms
３.endovascular treatment
history
1974: Self made latex balloon
1988: mechanic detachable coil system
1991: Guglielmi detachable coil, GDC
recent development：Trufill DCS Orbit；Hydrocoil
Matrix coil
stent assisted coil
Onyx glue emblization
Endovascular treatment is best suitable for the
aneurysms located between posterior cerebral
artery and anterior inferior cerebelar artery on the
basilar artery.
•Stent assisted coiling
broad neck aneurysms are difficult to treat by endovascular
techniques. Endovascular stent could be placed inside the
aneurysm-bearing arteries to constrain the coil. The stent
assisted coiling is broadly applied in intracranial broad
neck aneurysm, giant aneurysm, dissecting aneurysm,
pseudoaneurysm, fusiform aneurysm.
The intracranial stent is necessary for the re-construction of
the arteries, and for reducing the pressure to the artery
wall. It is also helpful to the embolization inside the
aneurysms and to the formation of the endomembrane of
the arteries to closed the neck of the aneurysms。
Indication
of endovascular treatment
endovascular treatment is suitable for
more than 90% aneurysms, except for the
infectious aneurysms or aneurysms with
large haematoma.
Pros of endovascular
treatment
• Avoid open surgery, less invasive, no
retraction of the brain, less
complications；
• Do not limited by the operation
approaches；
• Less in-hospital time, faster recovery
Cons of endovascular treatment
• Not suitable for the reconstruction of the
endomenbrane of the arteries.
• More cases with incomplete embolization,
higher rate of re-rupture and need for further
treatment;
• Higher rate
vasospasm.
of
cerebral
infarction
and
• Higher cost in China (but more inexpensive in
some countries).
(2).Vascular malformation
Classification
•Arteriovenou malformation
•cavernous hemangioma
•telangiectasis
•Venous maformation
（1）Arteriovenous malformation,AVM
• AVM is the direct communication of arteries
and veins in the brain. The blood in the
arteries directly goes in to veins without
passing through capillaries
• this pathophysiology cause a series of
homodynamic disturbance.
Clinical manifestation
1. bleeding: 68% of the AVM patients
2. Epilepsy seizures: 17%-47% of the patients
begin with epilepsy seizures, which is caused
by the lack of blood supply resulting from the
steal phenomenon, the incidence of the
seizures is associated with the size, locations
and the type of AVM
3. headaches (not a specific symptoms) 15%24% of the patients begin with headache
diagnosis
•Clinical manifestations
•CT、MRI/MRA、DSA
Treatment
•Surgical
•endovascular
•Stereotaxic radial therapy
•Combined therapies
Operation
Remove the AVM, improve the blood
supply, control the seizures
Endovascular therapy
•Only simple AVM can be controlled
by endovascular therapy, any
residual will lead to recurrence
•The improvement of endovascular
therapy will reduce the rate of
incomplete embolization and
recurrence
Stereotaxic radial therapy
•Gamma knife and x-knife
•Indicated for minor AVM (<3cm in diameter, high risk for
operation, small residual after operation or embolization,
lesions in functional areas or patients that can not tolerant
open surgery.
•It often take 2-3 years for the closure of the AVM. About
20% cases failed. Less than 25% cases are suitable for
stereotaxic RT.
Combined therapy
•For most of the AVM patients, combined therapies
of the 3 treatments are the optimal therapies.
•Open surgery, endovascular embolization and
stereotaxic radial therapy will not replace each other.
（2）Cavernous angioma
20-40 years old
epilepsy seizures, repeated bleeding or
neurological deficit
treatment:
operation (microsurgery, with navigation)
stereotaxic
observe
(3).Hypertensive hemorrhage
高血压脑出血
•Open procedure to reduce
intracranial pressure
•Stereotaxic respiration combine
with urokinase
2.Occlusive cerebral vascular
diseases
• Stenosis of carotid artery or
vertebral-basilar artery
• Acute embolization
(1).Carotid Artery Stenosis
•Ischemic stroke claims for 85% of the stroke patients. The world
wide incidence is 200/105. the most common cause of ischemic
stroke is the carotid stenosis caused by Atherosclerotic thrombosis.
The narrower the carotid artery, the more incidence of the stroke.
•The plaque in carotid artery is composed of cholesterol cellulose
and platelets. In severe narrowed
carotid artery, the microthrombi are flushed by the unsteady blood flow and detach from
the endomembrane, causing transient ischemic attack (TIA) or
cerebral infarction. Timely intervention of the sclerotic stenosis
of the carotid artery is crucial for the prevention of the
transformation of TIA or reversible ischemic neurological deficit
(RIND) to complete infarction.
Treatment
•Carotid endarterectomy
•Endovascular therapy
Surgical treatment of carotid stenosis
• Firstly performed in 1954, Carotid
endarterectomy CEA have become an
effective method to alleviate carotid stenosis.
According to a study, 9% patients with
carotid stenosis about 70%-90% that receive
CEA have ipsilateral ischemic stroke, while
26% patients that received optimal medical
treatment have ipsilateral stroke.
CEA剪辑.mpg
Interventional therapy
• PTAS have become one of the most commonly used
methods to treat carotid stenosis. This method restored
the diameter of the narrowed carotid artery, improve the
blood flow to the brain by placing a stent in the locus of
the stenosis. The stent also help to avoid the detachment
of the atherosclerotic plaque. Effect rate of PTAS is
89.7-100%, restenosis incidence is 4%.
• Main purpose of stenting is to improve the blood flow
to the brain.
• In recent 5 years, better catheter, sheath and stent and
better protection of the distal arteries make the
interventional therapy become more and more
interested by neurological doctors.
(2) Moyamoya Dieases
Moyamoya:
“Puff of smoke” term coined by
Suzuki and Takaku in
1969 and now
accepted worldwide
Trends
•With the development of microsurgical devices,
interventional materials and clinical techniques,
the surgery treatment of cerebral vascular diseases
will be more widely applied
•Time is brain, time is important in both
hemorrhagic and ischemic CVDs. Early transport
to clinical center of CVDs, early diagnosis and
early treatment will bring about good recovery .