Modul Neurovaskular

CEREBRAL ANEURYSM
Presenter : dr.Muhamad Ibnu Sina
Pembimbing: dr.Iskandar Nasution Sp.S FINS
Departemen Neurologi FK USU/RSUP H.Adam Malik

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INTRODUCTION
A cerebrovascular disorder in which weakness in the wall of a
cerebral artery or vein causes a localized dilation or
ballooning of the blood vessel.

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ANATOMY

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PATHOGENESIS

Risk Factors

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CLASSIFICATIONS
• Size

• The neck of the aneurysm plays also an important role to further separate aneurysms with small neck (less than
4mm) or with large neck (greater than 4mm)
• The ratio between aneurismal sac size and neck size is also an important parameter to be considered in planning
an endovascular approach

Boneville et al.Neuroimag Clin N Am 16 (2006) 371–382

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CLASSIFICATIONS
• Location

Boneville et al.Neuroimag Clin N Am 16 (2006) 371–382

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CLASSIFICATIONS
• Shape and site of origin

Boneville et al.Neuroimag Clin N Am 16 (2006) 371–382

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Saccular Aneurysm

• Most common
• have a neck that separates
the aneurysm from the parent
artery
• Lobulation was divided into
unilobular, multilobular,
daughter sac

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Saccular Aneurysm

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Fusiform Aneurysm

• as a circumferential arterial
dilatation resulting from
pathological involvement of
the entire artery
• fusiform aneurysms have
circumferential arterial
dilation without any ostium
or neck

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Giant Aneurysm

as aneurysms greater than 25

mm in diameter

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Dissecting Aneurysm

• A dissecting aneurysm
is when blood from the
vessel lumen tracks
between the two inner
layers, the intima and
the tunica media.
• This can cause
blockage of the flow

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• A pseudoaneurysm, also known as a false aneurysm,  collection of blood that forms
between the two outer layers of an artery, the tunica media and the tunica adventitia.
• It is usually caused by a penetrating injury to the vessel
• It may be pulsatile and can resemble a true aneurysm.

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SYMPTOMS
Only 10-15% of intracranial aneurysms are
symptomatic

The symptoms are primarily due to the mass effect

of a large aneurysm, or possibly from minimal
leakage of blood which irritates the meninges,

• Wagner M, Stenger K. Unruptured intracranial aneurysms: using evidence and outcomes to guide patient teaching. Crit Care Nurs Q 2005; 28: 341-54.

• Friedman JA, Piepgras DG, Pichelmann MA, et al. Small cerebral aneurysms presenting with symptoms other than rupture. Neurology 2001; 57: 1212-6 .

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Anterior communicating artery: Usually, ACoA aneurysms are silent until they
rupture. Suprachiasmatic pressure may cause altitudinal visual field deficits, aboulia or
akinetic mutism, amnestic syndromes and hypothalamic dysfunction

Anterior cerebral artery: Most are asymptomatic until they rupture, although frontal
lobe syndromes, anosmia and motor deficits may be noted.

Middle cerebral artery: This typically affects the first or second division in the sylvan
fissure. Aphasia, hemiparesis, hemisensory loss, anosognosia and visual field defects
may be noted.

Posterior communicating artery: These are directed laterally, posteriorly and

inferiorly. Pupillary dilatation, ophthalmoplegia, ptosis, mydriasis and hemiparesis may
result.

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Internal carotid artery: Supraclinoid aneurysms may cause ophthalmoplegia due to the compression of
the cranial nerve (CN) III or variable visual defects and optic atrophy due to the compression of the optic
nerve. Chiasmal compression may produce bilateral temporal hemianopsia. Hypopituitarism or anosmia
may be seen with giant aneurysms. Cavernous-carotid aneurysms exert mass effects within the
cavernous sinus, producing ophthalmoplegia and facial sensory loss.

Basilar artery: The clinical findings are usually those associated with SAH, although bitemporal
hemianopsia or an oculomotor palsy may occur. Dolichoectatic aneurysms may cause bulbar
dysfunction, respiratory difficulties and neurogenic pulmonary oedema.

Vertebral artery or posterior inferior cerebellar artery: Aneurysms at these arterial segments
typically result in ataxia, bulbar dysfunction or spinal involvement.

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DIAGNOSTIC
the gold-standard for diagnosis of cerebral aneurysms is DSA because it
remains the test with the highest spatial resolution

• Wagner M, Stenger K. Unruptured intracranial aneurysms: using evidence and outcomes to guide patient teaching. Crit Care Nurs Q 2005; 28: 341-54.

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ASPECT RATIO

Aneurysm size is a well-recognized risk factor in predicting

aneurysm rupture.

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 AR is a reliable predictor
of aneurysmal
pathophysiology,evolution,
and rupture.

the value of 1.6 as the

threshold value above
which aneurysms carry a
higher risk of rupture.

Ujiie H, Neurosurgery 48:495–503, 2001.

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• Pasien laki-laki , 45 tahun, dengan riwayat suka konsumsi alcohol, merasakan nyeri
kepala yang sangat hebat selama hidupnya. Pasien juga merasakan mual dan pandangan
kabur. Pada pemeriksaan didapatkan diplopia, ptosis pada mata kanan, dan pupil dilatasi.
Penyebab terjadinya kasus di atas adalah:

Aneurisma arteri komunikan anterior

Aneurisma arteri komunikan posterior

Aneurisma arteri serebri posterior

Aneurisma arteri serebeli superior

Aneurisma arteri serebri media

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• Laki-laki 43 tahun masuk ruang gawat darurat setelah mengalami gejala nyeri kepala dan
kelemahan tubuh sebelah kiri secara tiba-tiba. Pada penilaian NIHSS didapatkan 12 poin.
Pada pemeriksaan CT didapatkan gambaran hipodens sesuai teruitori MCA D. Pada
pemeriksaaan duplek didapatkan gambaran seperti di bawah, diagnosis:

Moya-moya

Fibrumuscular displasia

AVM

Diseksi carotis

Tromer carrotid body

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• Seorang laki-laki menderita nyeri kepala mendadak dan paling berat dirasakan sepanjang
hidupnya. Hasil CT scan normal dan LP 4 tabung didapatkan darah. Pemeriksaan
penunjang terbaik selanjutnya adalah: (MCQ UNDIP XXIII)

DSA.

MRI kepala dengan kontras.

MRI kepala tanpa kontras.

CT scan kepala dengan kontras.

MRA.

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