Peripheral pseudoaneurysm in active Behçet's disease: surgical and perioperative therapeutic strategies

Since aneurysms in patients with Behçet's disease are often pseudoaneurysmal and adjacent arteries are highly inflammatory, there is not only a risk of rupture but also a high incidence of late surgical complications at anastomotic sites. Furthermore, there is no consensus on perioperative medical therapeutic strategy in patients with active vasculo-Behçet's disease who require surgery. Herein, we present two cases of active Behçet's disease, a 51-year-old male with rupture of the left internal iliac artery who required emergent operation and a 31-year-old male with a rapidly developed pseudoaneurysm in the right superficial femoral artery. Surgical and perioperative therapeutic strategies are also discussed.

Transformation of a ruptured giant pulmonary artery aneurysm into an air cavity after transcatheter embolization in a Behçet's patient

Pulmonary artery aneurysms due to Behçet's disease are mainly seen in young males and very rarely in females. To our knowledge there are only 10 cases reported in the related literature. Emergent transcatheter embolization was performed in a female patient with a known history of Behçet's disease in whom massive hemoptysis developed because of rupture of a giant pulmonary artery aneurysm. At 6-month follow-up, transformation of the aneurysm sac into an air cavity was detected. To our knowledge, such a transformation has never been reported in the literature before. Embolization of the pulmonary artery aneurysm and the mechanism of cavity transformation are reviewed and discussed.

Clinical experience of 153 patients with posterior circulation aneurysms

OBJECTIVE

To study the morbidity and mortality of patients with aneurysms of the posterior circulation (basilar-vertebral system) and investigate the natural history of these aneurysms without surgical intervention.

METHODS

Of 1232 patients with intracranial aneurysms admitted to Tiantan Hospital from January 1990 to October 2001, 153 (12.4%) had aneurysms of the posterior circulation. Their clinical and angiographic data were reviewed retrospectively. Additionally, to June 2002, 38 of the cases managed without surgery have been followed by telephone and correspondence. For these patients, the annual aneurysm rupture rate was estimated in "person-years".

RESULTS

Patients were aged 4-69 years (mean 40.8). The peak incidence was in the 5th decade. There were 88 males and 65 females. One hundred and two patients (66.7%) were treated surgically, and of these, 60 (58.8%) had an excellent outcome, 10 (9.8%) a good outcome, 29 (28.4%) a fair outcome and 3 (2.9%) died. The other 51 (33.3%) patients were treated conservatively for various reasons. Of these, 13 died of ruptured aneurysm in hospital. Ten of these patients had had a previous subarachnoid haemorrhage and 3 had not. The other 38 surviving, conservatively managed patients were followed for 5-95 months (mean 23). Of them, 3 (17.6%) died of aneurysmal rupture, giving an annual rupture rate of 9.2%, or 3/32.47 patient years.

CONCLUSIONS

To prevent death and disability due to aneurysmal rupture, posterior circulation aneurysms should be treated aggressively.

[Cerebral aneurysms in patients with the occlusion of the brachiocephalic vessels]

Cerebral aneurysms coexistent with iatrogenic (after surgical ligation or occlusion) or idiopathic (due to atheromatosis) occlusion of an extracranial cerebral artery are very rare. The occlusion of the brachiocephalic vessels leads to the formation of a collateral circulation at two levels: the circle of Willis and the connections between collaterals of the extracranial cerebral arteries. The authors discuss different types of collateral arterial pathways as well as hemodynamic abnormalities in the case of the occlusion of the brachiocephalic vessels, particularly internal carotid artery or the innominate artery occlusion. The paper analyses the etiopathogenesis of cerebral aneurysms in view of the hemodynamic theory of cerebral aneurysms formation. The article is illustrated with own three cases of ruptured cerebral aneurysms coexistent with the occlusion of the innominate artery.

Perforated Periaortic Valve Abscess Presents as Acute Pericarditis and Patient Died in Transesophageal Echocardiographic Study

Rupture of infective endocarditis-associated perivalvular abscess of left ventricular outlet leading to death is a rare complication of transesophageal echocardiography. We report a case of impending rupture periaortic valve abscess of left ventricular outlet that was initially diagnosed as acute pericarditis at the emergency department in which the patient suddenly collapsed during the ongoing procedure of transesophageal echocardiography. Emergency surgical intervention was performed, but in vain. Destructive aortic valve and rupture of the periaortic valve abscess were found.

Aneurysm re-rupture during computed tomography angiography

Re-rupture of cerebral aneurysms during conventional angiography, demonstrated by contrast leakage into the extravascular space, is well known and well documented. However, the occurrence of this complication during computed tomography (CT) angiographic examinations has rarely been published despite its extensive use. We present the clinical and radiological features of a rebleeding event during a CT angiographic study. No hemodynamic or contrast-related factors can be evoked predisposing to he occurrence of this complication during this imaging technique. This, along with the short study time, may explain the rarity of this coincidence.

Endovascular management of unruptured intracranial aneurysms

Endovascular coil embolisation is increasingly used to treat unruptured intracranial aneurysms (UIA). Endovascular coil embolisation of UIA is associated with a 5-10% risk of morbidity and nearly zero mortality from the procedure. Complete or near complete occlusion is usually achieved in >90% of cases, and endovascular therapy seems to reduce the risk of future rupture significantly. Specific selection criteria for endovascular embolisation and novel approaches to endovascular treatment of aneurysms are discussed. Endovascular therapy appears to be a safe and effective treatment for selected UIA. Treatment failure rates will probably decrease with greater experience and advances in techniques and devices. Further study with long term follow up, however, is still necessary to characterise the efficacy, durability, and cost efficiency of endovascular treatment of UIA.

Subarachnoid hemorrhage not due to ruptured aneurysm in moyamoya disease

A patient with moyamoya disease presenting with subarachnoid hemorrhage (SAH) is reported. A 38-year-old Japanese woman developed a sudden onset headache and nausea during hospitalization for a cerebral infarct in the right frontal lobe. CT scan showed SAH in the left frontal sulci. Cerebral angiogram showed stenosis of the distal bilateral internal carotid arteries with moyamoya vessels, and significant transdural anastamoses from the left external carotid artery to cortical arteries on the left frontal cortex. The patient was kept normotensive and underwent a right-sided surgical revascularization procedure, remaining well for three years. SAH not due to ruptured aneurysm in moyamoya disease is rare. The cause of the SAH was thought to be disruption of the transdural anastomotic vessels. Recognition of these fragile vessels in moyamoya disease is essential.

Vascular complications of pancreatitis

Vascular complications of pancreatitis are a major cause of morbidity and mortality. Arterial complications include haemorrhage from direct arterial erosion or pseudoaneurysm formation, and visceral ischaemia. Venous complications predominantly are related to splanchnic vein thrombosis. This review, with illustrative cases, describes the main manifestations of these complications and emphasizes the importance of early radiological diagnosis and intervention.

Rupture of splenic artery aneurysm with portal hypertension during pregnancy: a case report

BACKGROUND

Spontaneous rupture of a splenic artery aneurysm (SAA) during pregnancy is a rare event with catastrophic consequences. This report presents a case of SAA associated with portal hypertension that ruptured during pregnancy with maternal survival.

CASE

A 27-year-old primigravid woman at 31 weeks of gestation presented to the Emergency Department at Pars Hospital in Tehran, Iran with sudden onset of severe abdominal pain. She was in obvious distress with blood pressure of 90/50 mm Hg and a pulse rate of 110 beats per minute. Abdominal ultrasound confirmed free fluid in the peritoneal cavity. The patient was immediately transferred to the operating room. An infant delivered by Caesarean section died shortly thereafter. There was no evidence of placental abruption, but about 2 L of blood was noted in the abdominal cavity. A ruptured SAA was found. Proximal ligation of the splenic artery was performed followed by splenectomy. The patient did well and was discharged on the eighth postoperative day.

CONCLUSION

This case illustrates the need to consider ruptured SAA as part of differential diagnosis of hemoperitoneum in pregnant women. Immediate surgical intervention is needed to ensure survival of mother and fetus.

Timing of endovascular repair of blunt traumatic thoracic aortic transections

BACKGROUND

Patients with blunt traumatic thoracic aortic transection (BTTAT) just distal to the takeoff of the left subclavian artery typically have concomitant injuries that make open emergent surgical repair highly risky. Over the past decade, endovascular repair of the injured thoracic aorta with commercially available and custom-made covered stents has developed as a viable option, with reported decreases in short-term morbidity and mortality. If active extravasation of contrast from the injured thoracic aorta is not appreciated on chest computed tomography scan, other concurrent injuries of the head, abdomen, and extremities can often be repaired with careful control of blood pressure. The timing of endovascular repair of the traumatic thoracic aortic transection, however, often comes into question, particularly with the presence of fever, pneumonia, or bacteremia. We sought to identify a time frame during which endovascular repair of BTTAT could safely be performed.

METHODS

Age, concomitant injuries, time from trauma to repair, type of device, and major outcomes were recorded.

RESULTS

Over a 5-year period (January 2000 to March 2005), 51 patients presented with BTTAT. Twenty-seven (52.9%) patients with BTTAT died shortly after arrival. Of the remaining 24, 9 underwent emergent open repair, with 1 intraoperative death. Two delayed open repairs were performed. Thirteen patients with BTTAT underwent delayed endovascular repair. Successful endovascular repair of BTTAT was performed in all 13 patients, with no intraoperative deaths. Seven patients were treated with commercial devices and six with custom-made covered stents. None of the repairs was performed emergently. The timing of repair ranged from 1 day to 7 months (median, 6 days), and all patients were treated aggressively with beta-blockade before surgery. One patient was discharged from the hospital and underwent elective repair at a later date. Three patients died in the postoperative period (30 days): two from multisystem organ failure and one from iliac artery complications encountered at the time of device deployment. The remaining 10 patients were successfully discharged to a rehabilitation facility.

CONCLUSIONS

The opportunity to successfully perform endovascular repair of BTTAT may be possible many days after the initial injury in the hemodynamically stable trauma patient.

The development and clinical features of splenic aneurysm associated with liver cirrhosis

OBJECTIVES

Splenic artery aneurysm (SAA) is usually asymptomatic, but can be fatal if it ruptures. Portal hypertensive patients with varix or splenomegaly are sometimes complicated by SAA. However, there have been no large-scale clinical studies regarding whether liver cirrhosis itself is associated with splenic aneurysm regardless of varix or splenomegaly.

METHODS

In the present study, we retrospectively analyzed 303 cirrhotic patients examined with arteriography. The diagnosis and characteristics of SAAs were determined, and the relation with splenic artery diameter was evaluated.

RESULTS

Nine patients (2.97%) had 12 complicated SAAs. The aneurysms, which measured 4-22 mm in diameter, were all saccular, and occurred commonly in the splenic hilum (50.0%). A correlation was noted between splenic artery diameter and aneurysm diameter (R(2)=0.706). Aneurysm growth was strongly associated with an increase in diameter of the splenic artery trunk (R(2)=0.705), which is closely related to arterial flow.

CONCLUSIONS

SAA is considered a complication of cirrhosis. The increase in splenic artery diameter may result in SAA enlargement and rupture. Elective procedures should be considered based on the follow-up of main trunk or diameter of the splenic artery in addition to SAA size, a known risk factor of aneurysmal rupture.

Aneurysm of the internal carotid artery in a female patient of Behcet's disease: a rare presentation

Behcet's disease is a systemic inflammatory disease characterized commonly by oral and genital ulcerations, with skin and eye involvement. Unlike other manifestations, involvement of the central nervous system and vascular manifestations can be late in the course and are the leading causes of death. Aneurysms are relatively common in visceral vessels but extremely rare in intracranial arteries, being limited to few case reports. Moreover, vascular involvement is significantly less common in female than in male patients. In this paper, we report a case of aneurysm of internal carotid artery in a female patient of Behcet's disease who had presented with subarachnoid hemorrhage and was treated successfully by a brief course of corticosteroids followed by endovascular treatment.

Ruptured intracranial aneurysm associated with von Hippel-Lindau syndrome: a molecular link?

OBJECT

Research into the etiopathogenesis of intracranial aneurysms has failed to demonstrate molecular markers or pathognomonic genetic sequences. The authors describe the case of aneurysmal rupture in a patient with von Hippel-Lindau (VHL) syndrome and explore a possible molecular link.

METHODS

A 17-year-old girl underwent endovascular coiling for an aneurysmal subarachnoid hemorrhage. Six years later, she developed spinocerebellar hemangioblastomas. Gene sequencing revealed a heterozygous, germline point mutation at nucleotide 469 in the VHL locus on chromosome 3. The mutation changed a codon for proline (CCC) to one for serine (TCC) at amino acid position 86.

CONCLUSIONS

The VHL tumor suppressor gene may be causally related to aneurysm formation through the effects of transcription factors, growth factors, and matrix metalloproteinases. Although a single point mutation is unlikely to be responsible for the complex phenotype of intracranial aneurysm, further research on aneurysmal domes and VHL gene expression may help validate the theory that extracellular matrix destruction is the final common pathway to aneurysm formation.

The perianeurysmal environment: influence on saccular aneurysm shape and rupture

PURPOSE

The purpose of this study was to evaluate whether interactions between intracranial cerebral saccular aneurysms and the perianeurysmal environment (PAE), in the form of contact constraints, influence aneurysm shape and risk of rupture.

METHODS

A total of 190 consecutive aneurysms during a 34-month period were retrospectively analyzed. Of these, 124 were ruptured (group 1) and 66 were unruptured (group 2). Pretreatment high-resolution CT angiography was available for each aneurysm and was the determinant inclusion criterion. Aneurysm size and location, type of hemorrhage, initial Glasgow Coma Scale rating, World Federation of Neurological Societies grade, Fisher grade, and presence of concomitant aneurysms were recorded. Contact constraints between aneurysms and anatomical structures of the PAE were identified for each aneurysm and further subdivided into balanced or unbalanced depending on whether contact constraints occurred symmetrically on the aneurysm wall. Regular or irregular shape was recorded and correlated to contact constraints.

RESULTS

Compared with unruptured aneurysms, ruptured aneurysms were found to be larger and more irregular, to develop more contact constraints with the PAE, and to show higher rates of unbalanced contact constraints. Ruptured aneurysms had a tendency to be found in locations of a constraining PAE. Irregular shape was positively correlated with the presence of an unbalanced contact constraint, even in the absence of obvious contour deformations from an imprint of an adjacent structure.

CONCLUSION

The existence of contact constraints between intracranial saccular aneurysms and the PAE were shown to influence shape and risk of aneurysm rupture. Modifications of wall shear stress by contact constraints are discussed. Analysis of contact constraints between aneurysm and the PAE could be considered additional parameters in the assessment of risk of aneurysm rupture.

[Spontaneous peri-pancreatic hematoma associated with celiac trunk stenosis: diagnostic difficulties and therapeutic management]

We report a case of spontaneous peri-pancreatic hematoma which was associated with a celiac trunk stenosis. Hematoma was probably due to the rupture of a pancreaticoduodenal artery aneurysm. This diagnosis of pancreatic carcinoma, initially retained, illustrates the difficult diagnostic process. Therapeutic modalities for preventing recurrence are discussed.

Surgical management of popliteal artery aneurysms: Which factors affect outcomes?

OBJECTIVE

Popliteal artery aneurysm (PAA) is uncommon. The clinical presentation of PAA includes rupture, embolism, and thrombosis. In this article, we evaluate the results of our 20-year experience with surgical management of PAAs, analyzing the role of anatomic, clinical, and surgical factors that potentially affect early and long-term results.

METHODS

From January 1984 to December 2004, 159 PAAs in 137 patients were operated on at our department. Data from all the patients were retrospectively collected in a database. PAAs were asymptomatic in 67 cases (42%); 5 (3%) PAAs were ruptured. In 51 cases (32%), PAA caused intermittent claudication. The remaining 36 limbs (23%) had threatening ischemia due in 30 cases to acute PAA thrombosis, in 4 cases to chronic PAA thrombosis, and in 2 cases to distal embolization. In selected patients with acute ischemia, preoperative intra-arterial thrombolysis with urokinase was performed. Early results in terms of mortality, graft thrombosis, and limb salvage were assessed. Follow-up consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Long-term survival, patency, and limb salvage rates were analyzed.

RESULTS

Forty cases were treated with aneurysmectomy and prosthetic graft interposition; in 39 cases, the aneurysm was opened, and a graft was placed inside the aneurysm. Four patients had aneurysmectomy with end-to-end anastomosis. In 73 cases, ligation of the aneurysm with bypass grafting (39 with a prosthetic graft and 34 with an autologous vein) was performed. The remaining three patients underwent endovascular exclusion of their PAAs. A medial approach was used in 97 patients (61%), and a posterior approach was used in 59 patients (37.1%). The outflow vessel was in most cases (93.7%) the below-knee popliteal artery. Thirty-day amputation and death rates were 4.4% (7/159 limbs) and 2.1% (3/137 patients), respectively. The amputation rate was significantly higher in symptomatic limbs than in asymptomatic ones (6.5% and 1.4%, respectively; P = .05). Eight limbs (5%) had an early graft thrombosis that required a reintervention. Follow-up was available in 116 patients (84.7%) and 138 limbs (86%) with a mean follow-up time of 40 months (range, 1-205 months). The cumulative estimated 60-month survival, limb salvage, and primary and secondary patency rates were 84.2%, 86.7%, 66.3%, and 83.6%, respectively. Asymptomatic limbs had significantly better results than symptomatic ones in terms of limb salvage (93.4% and 80.4%, respectively; P = .03; log-rank, 4.2) and primary patency (86.5% and 51.6%, respectively; P = .001; log-rank, 10.3). Among symptomatic patients, results were better in claudicant limbs than in acutely ischemic ones in terms of limb salvage (90.5% and 58.7%, respectively; P = .001; log-rank, 17.5). Univariate analysis showed the absence of symptoms, the presence of two or three tibial vessels, the use of a posterior approach, the kind of intervention, and the site of distal anastomosis to significantly affect long-term patency. Cox regression for factors affecting 60-month primary patency showed that clinical presentation, runoff status, and the site of distal anastomosis significantly influenced long-term results.

CONCLUSIONS

Results of surgery on asymptomatic PAAs are good-significantly better than those for symptomatic ones. Elective surgical intervention should be performed in patients with a low surgical risk and a long life expectancy when the correct indication exists. In thrombosed aneurysms, intra-arterial thrombolysis may represent an alternative to emergent surgical management. Our data demonstrated that results are similarly good in claudicants, and this fact confirms that only acute ischemia due to PAA thrombosis represents a real surgical challenge. In selected patients with focal lesions, a posterior approach seems to offer better long-term results. The runoff status and the site of distal anastomosis affect long-term patency as well.

Percutaneous treatment of a ruptured superior mesenteric artery aneurysm in a child

Splanchnic artery aneurysms are very rare in children. We report a 10-year-old girl with a large atraumatic ruptured superior mesenteric artery aneurysm that was considered inoperable. She was ultimately treated with two percutaneous US-guided thrombin injections, which led to complete occlusion of the aneurysm. The aetiology of the aneurysm remained unclear, but a family history was suggestive of a congenital connective tissue disease such as Ehlers-Danlos syndrome subtype IV.

Subarachnoid hemorrhage and inflammation: bench to bedside and back

Subarachnoid hemorrhage (SAH) is a devastating and complicated disease. The development of therapeutic interventions has been hampered by a poor understanding of the three components of the disease pathology in SAH: aneurysm rupture, cerebral edema, and vasospasm. The role of inflammation in the pathology of subarachnoid hemorrhage will be reviewed. The events leading up to aneurysm rupture are heralded by degradation of the endothelial cell layer integrity and inflammatory cell infiltration into the wall of the aneurysm. This is associated with release of active agents that can digest the basement membrane and may cause rupture. After rupture, cytokine release by mononuclear leukocytes is associated with early edema. Vasospasm is a complicated process that includes arterial wall thickening and vasoconstriction. Evidence supports the role of inflammation in free radical formation and in perturbations in nitric oxide and endothelin-1 levels that are important mediators of the vasoconstriction in vasospasm. Targeting the inflammatory mediators associated with the three prominent events in SAH is a promising strategy for reducing the mortality and morbidity in these patients. More study is needed to determine which specific effectors in the inflammatory cascade may serve as targets for intervention.

A mathematical model of the natural history of intracranial aneurysms: quantification of the benefit of prophylactic treatment

Object

The International Study of Unruptured Intracranial Aneurysms (ISUIA) data raised new controversy regarding the threshold size that requires treatment. In particular, this study has been criticized for disagreeing with previous epidemiological data.

Methods

The author first used a Markov model to simulate the natural history of intracranial aneurysms, making three key assumptions based on prospective ISUIA data and other recent reports: that the rate of de novo aneurysm formation is constant after the age of 20 years; that unruptured aneurysms gain volume at a constant rate; and that unruptured aneurysms rupture at a volume-dependent rate. Next, he expressed outcomes for patients with unruptured aneurysms in terms of expected number of quality-adjusted life years (QALY) and compared two hypothetical cohorts, one receiving treatment and the other not being treated. These assumptions enabled the construction of a mathematical model with epidemiologically compatible findings. The benefits of treatment for unruptured aneurysms were highly influenced by aneurysm size and were calculated as −0.28, 0.25, and 1.07 QALY for patients having unruptured aneurysms with diameters of 7, 10, and 13 mm, respectively.

Conclusions

Under the author’s assumptions, the prospective ISUIA data may be consistent with epidemiological findings. Prophylactic treatment for unruptured aneurysms may produce some benefits in large aneurysms if acceptable treatment risks can be assured, but it is not likely to offer improvement over the natural history for patients with small aneurysms.

A fatal case of ruptured giant coronary artery aneurysm

A 5-year-old Japanese boy died because of a ruptured left coronary artery aneurysm (CAA). He was diagnosed as having Kawasaki disease (KD) on the 5th day from onset, with all of the principal signs. On the 7th day of illness, bilateral CAAs were already found via echocardiography, and he was treated with intravenous (IV) gamma globulin and oral ASA. However, the fever persisted and the CAA progressed rapidly. Echocardiography on the 12th illness day showed a giant (18-mm) left anterior descending (LAD) artery aneurysm. Oral propranolol and nifedipine were administered, in conjunction with warfarin/aspirin anti-coagulation therapy. On the 13th day of illness, cardiac arrest developed abruptly, and, despite cardiopulmonary resuscitation (CPR), the patient remained unresponsive and died one hour later. The final pathological diagnosis was a ruptured LAD artery aneurysm and cardiac tamponade. Microscopic investigation of the ruptured vascular wall revealed marked neutrophilic infiltration, with fewer macrophages and lymphocytes. CAA ruptures are a very rare, but fatal, complication of KD. Based on a review of previous reports on CAA ruptures, we consider it useful to distinguish aneurysms which rapidly dilate and continue to expand beyond a diameter of 10 mm with ongoing vasculitis (these CAAs can be termed "super-giant") from the more common giant CAAs limited to a diameter of 8 or 9 mm, because a decision must be made as to whether to start intensive care or to intervene surgically, in order to ensure the survival of patients with such a potentially critical complication.

Simulation of the natural history of cerebral aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms

Object

Despite recent publications of large-scale study data, controversy over the management of unruptured cerebral aneurysms continues. The low rupture rates in the International Study of Unruptured Intracranial Aneurysms (ISUIA) apparently contradicted surgeons’ experiences with ruptured aneurysms. In the present study, based on data from the ISUIA, a mathematical model describing the natural history of cerebral aneurysms was developed. With this model, the author aimed to examine the validity of data from the ISUIA and to provide a better treatment guideline for unruptured aneurysms.

Methods

The author made a computer simulation of the natural history of cerebral aneurysms that was used to calculate such figures as the prevalence of unruptured aneurysms, incidence of subarachnoid hemorrhage (SAH), and age and size distribution of both unruptured and ruptured aneurysms. The lifetime lesion rupture probability for individual patients with various ages and aneurysm sizes was also computed, thereby providing a useful index to help patients in the medical decision-making process.

The computer model produced a sample of unruptured aneurysms in the general population with a prevalence of 4.2% and a median diameter of 5.8 mm. These unruptured aneurysms—affected by the rupture rate reported in the ISUIA—had a yearly SAH incidence of 19.6 per 100,000 persons. The median diameter of these aneurysms was 9.4 mm.

Conclusions

Findings in the present study validated the results of the ISUIA by showing that the seemingly low rupture rates could explain the statistical data for ruptured aneurysms. With the featured model, the author calculated the lifetime probability of lesion rupture—a useful measure for deciding on the optimal treatment for unruptured aneurysms.

Distal-End Aneurysm of the Frontopolar Artery with an Atypical Postoperative Complication: Case Report

OBJECTIVE

We present a unique case of a saccular aneurysm originating from the distal end of the right frontopolar artery (FPA).

METHODS

This previously healthy, 54-year-old man had sustained a mild head trauma. On admission, he was lethargic, but his neurological examination results were otherwise normal. Neuroradiological studies (including brain computed tomography, magnetic resonance imaging, and cerebral angiography) demonstrated a distal-end aneurysm of the right FPA. The aneurysm was clipped and resected via a right frontal craniotomy.

RESULTS

The postoperative course was uneventful. Pathological examination of the resected specimen confirmed rupture of the wall of a true aneurysm. The patient's medical history was also negative for trauma in the past, previous neurological disease, and vascular collagen disorders. Routine angiography performed 30 days postoperatively demonstrated complete occlusion of the right FPA. The patient was free of focal neurological deficits.

CONCLUSION

This case demonstrates that not all distally located aneurysms are necessarily mycotic or traumatic.

Surgical treatment of complicated abdominal aortic aneurysms

The clinical data presented in the given work are based on the treatment of 166 patients with complicated abdominal aortic aneurysms, operated on during 20 years, namely between 1984 and 2004. Of these, aneurysmal rupture was identified in 51 (30.7%) and the risk of rupture in 115 (69.2%) cases. Coexistent pathology was present in 150 (90.4%) patients. Coronary artery disease was prevalent - 105 (63.3%) cases. The lethal outcome was recorded in 21.6% of cases (36 pts.). The basic cause of patients' death in the short-term postoperative period was acute cardiovascular insufficiency (9.6%).