Scene A: Patient Evaluation

1. Neuroendovascular Surgeon consulted by ER physician for a patient who presented with severe headaches and left eye drooping:Procede to evaluate the patien in the ED

2. Scene A: Patient Evaluation • 52 year old female with acute onset of the worst headache in her life, neck stiffness and double vision. She could not tolerate the pain and called the EMR. No preceding history of trauma. • PMH: Mother had brain aneurysm treated 15 years ago. • Social: Smoker for 15 years, 1 pack per day. • Medication: Multivitamin • Allergies: None

3. Physical Exmination: Activity • Gets Vitals: BP 160/95 Elevated • Neurologic evalution : Alert and orientated. Left eye drooping. Light aversion. Face symmetric. Normal speech. Moving all limbs with good strength. • Orders labs and a Head CT without iodinated contrast.

4. DOCTOR NOTE • Strokes are either hemorraghic or ischemic • Hemorrhagic strokes can occur within the tissues of the brain or within the linings. • A hemorrhage in the surface lingins of the brain is called a SAH • A non contrast CT head scan is used to identify a SAH

5. EMR • What is a stroke • What is an ischemic stroke • What is a hemorhagic stroke. • What is a rapid way of diagnosing a stroke • What is the NIH stroke scale • What is the Hunt and hess grading

6. Conclusion • Dr-------- • Your clinical assesment is complete. Procede to the CT room where Mrs Jones has been placed on the CT scanner.

7. Scene B: Diagnosis Dr. _______,Mrs. Jones is awaiting your arrival in the CT room where you will perform a CT scan to differentiate between a hemorrhagic and ischemic stroke. Be sure to follow the protocol for the procedure carefully and refer to your EMR if you have any questions. Keep up the good work!

8. CT Scan Activity • Neuroendovascular surgeon assists technologist in acquiring non contrast head CT. • Adjust height of gurney so bottom of gurney bed is level with inner CT circle. • Adjust patient’s gurney forward until the base of his skull is on the other side of the CT machine (scan runs anteriorly from base of skull). • Go into the CT control room. • Select the “Head CT without contrast” option on the monitor.

9. CT Scan Activity cont’d… • Push “run scan”. • Interpret scan with neuroradiologist. • Subarachnoid hemhorage identified. • Order a CTA with 3D images.

10. Dr. _______’s Notes (Scene B) • . • There are many causes of SAH. Most commonly they occur from truama or aneusyms. • Non invasive CT angiogram with 3D images with iodinated contrast may identify an aneurysm Return to ER Bleeding

11. CTA:Activity • Select Head CT angiography with 3D study on screen. • Identify aneurysm on 3D study.

12. EMR (Scene B) • How are Xrays used to create images of the body • How does CT use Xray beams to create images of structures inside the skull • What is iodinated contrast • How is blood identified on a non contrast head CT scan. • What is CT angiography. • What is 3D CT angiography • What is the subarachnoid space. • What are the causes of SAH • What is an aneurysm • Where do they occur • Why does an aneurysm rupture • Return to ER

13. Scene B Conclusion Dr. _______,Great job! Mr. Jones is certainly benefiting from your expertise and hard work. Your accurate and rapid diagnosis of a brain aneurysm will be critical selecting the appropriate treatment.

14. Scene C: Digital subtraction Angiography Dr. _______,Now that you have determined that Mr. Jones’ brain hemorrhage is caused by an aneurysm, you discuss the findings with the patient and her family. You inform them that that a ruptured aneurys has to be treated right away. You present them the options of surgical clipping the aneurysm versus endovascular coiling. Mrs. Jones and is agreeable to coiling and is transported to the catheter angiography suite. Please remember to consult the hospital protocol and EMR as necessary.

15. The patient is appropriately draped has been anesthetised for the procedure and is pain free.

16. Scene D 1 – Groin artery access before DSA Protocol: 1. Select needle and insert into the right common femoral artery. 2. Select the appropriate guidewire and insert into needle. 3. To secure access to the vessel xelect a sheath and thread it over guidewire. Dr.’s Notes EMR Patient History Protocol Trash

17. DSA: Activity • Select the left internal carotid artery with a guide catheter • Push “inject contrast dye”. • Push “run scan”. • Locate the aneurysm on the scan results. • Highlight the area of the aneurysm • Determine the morpholgy of the aneurysm. ( aspect ratio, aneurysm and neck size) • Determine a working projection

18. Dr. _______’s Notes (Scene C) • Catheter Angiogram shows a PCOM aneurysm with favourable morphology for aneurysm coiling. • Aneurysm in Anterior Communicating Artery • .Wide neck aneurysm need additional steps to prevent coils from slipping into the brain vessels. Return to ER

19. EMR (Scene C) • What is flouroscopy • What is digital subtraction angiography • What is a catheter • How is a catheter used • What is 3D rotational angiography • What are the treatment options for a ruptued aneurysm • What is surgical clipping • What is endovascular coiling embolization • Why is the aspect ratio important • Why are aneurysm treated right away • What is an intracranial stent. Return to ER

20. Scene C Conclusion Dr. _______,Congratulations! You have confirmed the Mrs. Jones’ posterior communicating artery aneurysm with DSA. You have identified a favourable morphology for coiling and will procede to do so In order to do this, you must first advance a microcatheter into the aneurysm .

21. Scene D: Microcatheter insertion Dr. _______,Now that you have located Mr. Jones’ aneurysm in the postior communicating artery, you need to advance the microcatheter into the aneurysm. Be sure to consult the protocol manual and EMR if you are in need of assistance with the procedure.

22. Scene D 2 – Catheter Angiogram Procedure Protocol: 4. Select microcatheter and microguide wire. 5. Select appropriate shape. Use road mapping to advance the catheter into the aneurysm. Confirm microcatheter position in aneruysm Choose shape of microcatheter Hospital Announcements Tool Tray Dr.’s Notes EMR Patient History Protocol Trash

23. Dr. _______’s Notes (Scene D) • Aneurysm is ready to be coiled Aneurysm in Anterior Communicating Artery Middle Cerebral Artery Internal Carotid Artery

24. EMR (Scene D) • What is a microcatheter • Why are tips shaped to different configurations • What is a roadmap • How is this used Return to ER

25. Scene D: Coil Embolization Dr. _______,Congratulations! You successfully navigated the microcatheter and microguidewire up to the posterior communicating artery. You are now ready to coil embolyze the aneurysm.

26. Scene E Introduction Dr. _______,Mr. Jones’ aneurysm is now ready to be embolyzed. You will need to select the correct coil size to commence embolization. Be sure to consult the protocol manual and EMR if you are in need of assistance. Good luck!

27. Coiling Procedure Activity • Select coil type and select the number desired. • Click & drag coils from tray to aneurysm. • Inject dye and check image for aneurysm occlusion • ?Create your own coil

28. EMR • What is a coil • What is it made of • Who invented it • How is it delivered • How is it detached • Risks of coiling • What is vasospasm

29. Dr. _______’s Notes (Scene E) • Aneurysm successfully coiled. No vessel injury • Sent patient to ICU for recovery. Ordered HHH therapy and monitoring for vasospasms. Aneurysm in Anterior Communicating Artery now embolyzed Middle Cerebral Artery Internal Carotid Artery

30. Scene E Conclusion You have successfully treated Mr. Jones within If you have scored a ___ or higher, you are still in the running to become Chief of Staff – great job! If you have scored lower than a ___, perhaps the next stroke patient to come through the doors of St. Normal Hospital will have better results. Also, please realize that Mr. Jones’ journey is not over. He will have a 10-14 day stay in the ICU (where the rate of mortality from strokes is very high 2-12 days following the initial stroke) and then undergo physical therapy.