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Left facial numbness. Ann Schmidt Oct 2005. Patient Presentation. 54 yo female Left facial swelling, left leg swelling and left arm weakness Headache. Past Medical History. Hypothyroidism Hx of panic attacks Postmenopausal Surgeries - hysterectomy. Family history.
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Left facial numbness Ann Schmidt Oct 2005
Patient Presentation • 54 yo female • Left facial swelling, left leg swelling and left arm weakness • Headache
Past Medical History • Hypothyroidism • Hx of panic attacks • Postmenopausal • Surgeries - hysterectomy
Family history • Father with carcinoid, hypertension and dementia • Mother died of brain aneurysm, also had breast cancer
Social history • Owns a large business • Recent family stress • Loss of a friend to breast cancer
Exam • 148/94 Pulse 76 temp 97 resp 16 • No sign. Findings • Diag Panic attack
Future visits • 7/20 • Review of Urgent care visit. Question of panic attack vs. other etiology. • Set up MRI TIA?
Future visits • 7/29 patient presents to the ER with new drooping of left eye lid, numbness of her face No headache, fever or neck pain. Exam noted slight ptosis of right eyelid. • CT scan ordered • Diagnosis Bells palsy Start on Prednisone and Val acyclovir.
Future visits • 7/30 Clinic visit – review ER note and MRI.
Future visits • 7/30 Clinic visit- review clinic note and MRI • Order MRI/MRA
Future visits • MRA results • Neurosurgery consult • CT angio completed
Intracranial Aneurysms • Goals of this talk include • Review the prevalence of aneurysms • Review the etiology/ pathogenesis of aneurysms • Discuss the treatment of unruptured aneurysms.
Intracranial Aneurysms IA • Prevalence • Incidence • Pathogenesis • Heritable connective tissue disorders, autosomal dominant – Ehlers Danlos Syndrome, Neurofibromatosis, Marfans syndrome, Polycystic kidney • Familial
Familial aggregation • 1954 Chambers • 1995 reported in J Neurosurgery “Familial aneurismal subarchnoid hemorrhage : a community based study” • Did family members of patients with ruptured aneurysms have an increase risk of developing a SAH
Familial trends • 1970-1989 81 patients had SAH • Families contacted and fhx obtained • 76 had complete fhx • 15 had a 1st or 2nd degree relative with SAH • The number observed with a 1st degree was 11 – expected was 2.6 • 4 fold increase risk among 1st degree relatives
Study results • Risk may be highest among siblings in the index patient • Earlier age, may be smaller and recur. • Affected siblings are often the same decade of life.
Diagnosis • Clinical Presentation • Anterior communicating artery – 34% • Middle cerebral artery- 20% • Posterior communicating artery- 23% • Internal carotid artery 4% • Asymptomatic IC • Most aneurysms never rupture
Natural History of Aneurysms • The International Study of Unruptured Intracranial Aneurysms Investigators • In a group of 1449 patients the rate of rupture per year was eleven times higher if the patient had a history of previous rupture • Surgery did not decrease M and M if lesion was less than 10 mm and no previous history of rupture.
Neurology 1999 Johnston,Gress • Which unruptured cerebral aneurysms should be treated? A cost utility analysis • For aneurysms >10 mm those producing symptoms by compressing neighboring nerves and brain structures or in patients with a history of SAH from a different aneurysm treatment was cost effective.
Task force of the Stroke CouncilAHA 2000 • Recommendations • The treatment for small intracaverous ICA is not generally indicated. • Symptomatic intradural aneurysms of all sizes should be considered for treatment. • Coexisting or remaining aneurysms of all sizes in patients with SAH due to another treated aneurysm carry a higher risk for further hemorrhage. • <10 mm observe, >10 mm consider treatment
Management • Aneurysms <10 mm annual rupture .05-2% • Presence of smoking, Fhx Polycystic kidney disease or lupus elevates risk. • Considerable mortality/morbidity with treatment – 3.8%- 15.7% • Quality of life living with an aneurysm