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CEREBRAL ANEURYSMS . why do we need mathematical models? edoardo boccardi Neuroradiologia Ospedale Niguarda-Ca’Granda Milano. the answer is obvious and very simple we (medical doctors) are very ignorant. the answer is obvious and very simple we (medical doctors) are very ignorant

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cerebral aneurysms

CEREBRAL ANEURYSMS

why do we need

mathematical models?

edoardo boccardi

Neuroradiologia

Ospedale Niguarda-Ca’Granda Milano

slide2

the answer is obvious and very simple

we (medical doctors) are very ignorant

slide3

the answer is obvious and very simple

we (medical doctors) are very ignorant

we know very little about vascular diseases and their causes

slide4

the answer is obvious and very simple

we (medical doctors) are very ignorant

we know very little about vascular diseases and their causes

we hope to find answers in modelization

slide5

why cerebral aneurysms?

because cerebral aneurysms represent a possible and not uncommon cause of death. When they rupture in the brain they cause a very severe disease:

subarachnoid hemorrhage (SAH)

slide6

SAH

subarachnoid hemorrhage is a very severe disease:

slide7

SAH

  • subarachnoid hemorrhage is a very severe disease:
  • one third of patients dies before arriving to the hospital
slide8

SAH

  • subarachnoid hemorrhage is a very severe disease:
  • one third of patients dies before arriving to the hospital
  • one third of those who are hospitalized will die later on
slide9

SAH

  • subarachnoid hemorrhage is a very severe disease:
  • one third of patients dies before arriving to the hospital
  • one third of those who are hospitalized will die later on
  • less than half of the survivors will go back to normal (around 20% of the initial population)
slide10

AIMS

the goal of modern medicine is to cure in the best possible way SAH patients, but more than that it would be better

to prevent

the occurence of SAH

slide11

aneurysm:

localized dilatation of an artery

slide12

aneurysm:

localized dilatation of an artery

artery:

blood vessel (tube) where blood flows in a centrifugal direction (i.e. from the heart towards the tissues)

slide13

aneurysm:

localized dilatation of an artery

artery:

blood vessel (tube) where blood flows in a centrifugal direction (i.e. from the heart towards the tissues)

the vessels which bring blood back to the heart are the veins

slide15

angiography (arteriography)

is the technique we use in order to visualize cerebral vessels and to find the aneurysm(s)

slide16

catheter

arteriography

slide19

anterior

circulation

slide21

posterior

circulation

slide22

when a vessel ruptures there is a hemorrhage

when an artery ruptures the hemorrhage is more rapid and more intense

slide23

when a vessel ruptures there is a hemorrhage

when an artery ruptures the hemorrhage is more rapid and more intense

a hemorrhage in the subarachnoid space is a SAH

slide26

a SAH is (almost) always due to the rupture of a cerebral aneurysm :

because these arterial dilatation of the cerebral arteries are usually to be found in the subarachnoid space

slide28

a person with an acute SAH must be immediately taken care of

to help him/her overcome this terrible trauma

and to avoid possible complications

slide29

one of the most dreaded complication is a second rupture of the aneurysm or

rebleeding

often more severe than the first, with less chances of survival

to avoid the rebleeding we must exclude the aneurysm from the circulation. This is what we call aneurysm treatment

slide30

the aim of the treatment is

to prevent a new rupture of the aneurysm

options:

surgical clip

endovascular coils

slide31

clip

open surgery

slide35

before

after

slide37

coils

endovascular treatment

slide41

SAH

rupture of an aneurysm at the tip of the basilar artery

slide45

before

after

slide47

is it possibile to recognize an aneurysm before it ruptures?

. symptoms due to compression of nervous structures

slide48

is it possibile to recognize an aneurysm before it ruptures?

. symptoms due to compression of nervous structures

. incidental finding in exams for other reasons

slide49

is it possibile to recognize an aneurysm before it ruptures?

. symptoms due to compression of nervous structures

. incidental finding in exams for other reasons

. in cases where a ruptured aneurysm is also present

slide50

biology

  • unruptured aneurysms
  • may not be all the same
  • incidental (discovered by chance)
  • coincidental (with a ruptured aneurysm)
  • large mass effect
slide52

biology

not all ruptured aneurysms will rupture

on the contrary, most of them won’t

slide53

unruptured aneurysms

is it possible to recognize those that will rupture?

slide54

geometry

study of shapes

slide55

geometry

study of shapes

the human vascular tree has a reproducible morphology more or less constant in everybody

slide56

two carotids anteriorly (right and left)

two vertebrals posteriorly (right and left)

slide58

two carotids anteriorly (right and left)

two vertebrals posteriorly (right and left)

inside the head these arteries will divide in a series of branches

slide60

two carotids anteriorly (right and left)

two vertebrals posteriorly (right and left)

inside the head these arteries will divide in a series of branches

there are many connections between these branches, for the most part barely visible and not very effective, except .....

slide63

on angiograms the circle of Willis is not visualized in its whole extension, but only a segment at a time

slide67

it is not unusual to find aneurysms within an anomalous (?), unfrequent, original morphology of the circle of Willis

or associated to other anatomic variants (duplications, fenestrations, etc.)

slide69

it is not unusual to find aneurysms within an anomalous (?), unfrequent, original morphology of the circle of Willis

or associated to other anatomic variants (duplications, fenestrations, etc.)

why? and why not always?

is it a direct relation between shape and shear stress on the arterial walls or is it something less obvious, more hidden?

slide74

what is the origin of an aneurysm?

  • congenital
  • . already present at birth
  • . focal “weakness” of the wall
  • .
slide78

what is the origin of an aneurysm?

  • congenital
  • . already present at birth
  • . focal “weakness” of the wall
  • .
  • acquired: local “stress” (abuse)
  • . progressive
  • . acute
  • .
slide79

what is the origin of an aneurysm?

what is the cause of the local “stress” ?

. constitutional factors (wall quality)

slide80

what is the origin of an aneurysm?

what is the cause of the local “stress” ?

. constitutional factors (wall quality)

. dynamic factors (flow, velocity, pression)

slide81

what is the origin of an aneurysm?

what is the cause of the local “stress” ?

. constitutional factors (wall quality)

. dynamic factors (flow, velocity, pression)

. morphology (curves, countercurves, bifurcations)

slide82

what is the origin of an aneurysm?

what is the cause of the local “stress” ?

. constitutional factors (wall quality)

. dynamic factors (flow, velocity, pression)

. morphology (curves, countercurves, bifurcations)

slide83

we hope that the study of shapes and structures may lead to the understanding of the processes of aneurysm birth, growth and eventual rupture

slide90

we have many questions and very few answers

we do not know what to tell people who have a cerebral aneurysm

slide91

we have many questions and very few answers

we do not know what to tell people who have a cerebral aneurysm

with your help we hope to better understand, because it could mean a major advance in a fight for life

thank you.