A 4-year-old girl with autosomal dominant polycystic kidney disease complicated by a ruptured intracranial aneurysm

In patients with autosomal dominant polycystic kidney disease (ADPKD), intracranial aneurysms (ICAs) are extrarenal manifestations and may result in serious and potentially fatal outcome following rupture. Although ICAs are a well-known complication of ADPKD, nearly all cases of ICA occurring in the context of ADPKD are adults. Here, we report the case of a Japanese girl with ADPKD who developed a subarachnoid haemorrhage (SAH) due to a ruptured ICA at the age of 4 years.

CONCLUSION

This report is intended to raise awareness that the use of noninvasive screening techniques such as three-dimensional CT angiography or magnetic resonance angiography to detect intracranial aneurysms should also be performed in paediatric patients with autosomal dominant polycystic kidney disease.

Fenestration of the Lamina Terminalis as a Valuable Adjunct in Aneurysm Surgery

OBJECTIVE:

Hydrocephalus, vasospasm, and frontobasal injury are common complications after aneurysmal subarachnoid hemorrhage (SAH) from anterior communicating artery aneurysms. Previous studies have suggested that fenestration of the lamina terminalis (FLT) during surgery may be associated with reduced rates of shunt-dependent hydrocephalus and vasospasm. We report 106 patients affected by anterior communicating artery aneurysms and Fisher Grade 3 aneurysmal SAH and the affect of FLT on shunt-dependent hydrocephalus, vasospasm, and frontobasal injury.

METHODS:

During a 3-year period, 53 patients underwent FLT and 53 did not. We prospectively evaluated admission and discharge clinical grades, hydrocephalus at admission, occurrence of clinical vasospasm, need for interventional vasospasm therapy, frontobasal hypodensity incidence, and permanent ventriculoperitoneal shunting requirement. Follow-up ranged from 3 to 35 months (mean, 17.9 mo).

RESULTS:

Shunting incidence after aneurysmal SAH with hydrocephalus was 4.25% in patients who underwent FLT and 13.9% in patients who did not (P< 0.001). Clinical cerebral vasospasm occurred in 29.6% of patients who underwent FLT and in 54.7% of patients who did not (P< 0.001). Frontobasal hypodensity was identified postoperatively in 0% of patients who underwent FLT and in 5% of patients who did not. Good outcome was reported in 69.81% of patients who underwent FLT and in 33.96% of patients who did not (P< 0.001). Poor outcome was associated with higher Hunt and Hess grades, need for ventricular drainage, elevated intracranial pressure, and multiple interventional vasospasm therapies. No complications were linked to FLT.

CONCLUSION:

FLT was associated with statistically significant decreases in shunting rates, incidence of vasospasm, and better outcomes. We recommend its routine use in patients with Fisher Grade 3 anterior communicating artery aneurysmal SAH.

Repeat imaging for intracranial aneurysms in patients with autosomal dominant polycystic kidney disease with initially negative studies: a prospective ten-year follow-up

Patients with autosomal dominant polycystic kidney disease (ADPKD) have a higher incidence of intracranial aneurysms (ICA) than the general population. These ICA also rupture at an earlier age in patients with ADPKD and are associated with high morbidity and mortality. In a recent study, 25% of patients with ADPKD with a documented ICA demonstrated a new ICA on follow-up. It is not known, however, whether patients with ADPKD who have had a negative ICA imaging study would demonstrate an ICA on a repeat imaging study. Only 2 (2.6%) of 76 patients with ADPKD with an initially negative study demonstrated an ICA on follow-up, despite the high frequency of risk factors such as hypertension, smoking, and a family history of ruptured ICA. The mean length of follow-up was 9.8 yr (median, 9.7 yr). These findings have important health care and economic implications in following patients with ADPKD.

Progression of a posterior communicating artery infundibulum into an aneurysm in a patient with Alagille syndrome

✓ The authors present a case in which a posterior communicating artery (PCoA) infundibulum progressed into an aneurysm in a patient with Alagille syndrome (arteriohepatic dysplasia). The 3-mm PCoA infundibulum had been noted on angiography studies obtained 5 years earlier, prior to clip occlusion of a basilar tip aneurysm. Recently, the patient presented to the emergency department with the sudden onset of headache and decreased mental status. A computerized tomography scan of the head with three-dimensional angiography revealed no gross subarachnoid hemorrhage, but did demonstrate a 5-mm PCoA aneurysm. Lumbar puncture demonstrated xanthochromia and a large quantity of red blood cells. The patient underwent open surgery for aneurysm clip occlusion and obtained a good recovery.

This case illustrates the small but growing number of examples of infundibulum progression. It also indicates the need for a close follow up in patients with congenital abnormalities that may pose an increased risk for what has traditionally been considered a benign lesion.

Pulmonary Artery Dissection and Rupture Associated With Aortopulmonary Window

A 31-year-old man with uncorrected aortopulmonary window and fixed pulmonary hypertension experienced dissection of the pulmonary artery, rapidly complicated by a fatal spontaneous rupture into the pericardium. In the setting of pulmonary hypertension, the diagnosis of dissection and rupture of the pulmonary artery should be considered in cases of thoracic pain or cardiogenic shock.

Coronary artery dissection and perforation complicating percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is widely utilized in the treatment of symptomatic coronary artery disease. Despite its numerous benefits, serious and potentially life-threatening complications of PCI can occur, including iatrogenic coronary artery dissection and perforation. The incidence of these complications has been augmented by the development of coronary interventional devices intended to remove or ablate tissue. We herein review the classification, incidence, pathogenesis, clinical sequelae and management of coronary artery dissection and perforation in the current era. Specifically, the current angiographic classifications of coronary artery dissections and perforations are reviewed. The findings of several recent, large registries of PCI-related coronary artery perforations are summarized. The management of coronary artery dissection and perforation is discussed at length, including the application of newer modalities such as covered stents.

Homicidal cerebral artery aneurysm rupture

When a normally natural mechanism of death is induced by physical injury or intense emotional stress, it is appropriate to rule the manner of death as something other than natural. When the case-specific circumstances are such that the death occurs as a result of the criminal activity of another person, it is acceptable to rule such deaths as homicides. Presented herein is a case of homicidal cerebral artery aneurysm rupture occuring in an intoxicated, 46-year-old man who was punched in the face by another individual. The details of the case are presented, followed by a discussion of the controversies that exist when dealing with such cases. Guidelines for investigating similar deaths are presented, with emphasis on the timing of the trauma in relation to onset of symptoms due to aneurysm rupture.

Coronary Artery Rupture Associated With Amphetamine Abuse

We report a case of spontaneous coronary artery rupture associated with amphetamine abuse in a 31-year-old woman. The patient presented to the emergency department with sudden onset of central chest pain and a normal electrocardiogram. Cardiac enzymes were consistent with acute myocardial infarction. Drug screening was positive for amphetamines. Coronary angiography revealed an aneurysmal lesion with 99% occlusion of the proximal left circumflex coronary artery and extravasation of contrast material. Percutaneous coronary intervention was performed with stent placement. Antegrade flow was achieved without residual stenosis. This is the first reported case of coronary artery rupture related to amphetamine abuse.

Les ruptures anévrismales intracrâniennes per-embolisation

OBJECTIVE

The purpose of this study is to determinate the frequency, causes, management and outcome of aneurysmal rupture occurring during embolization. We present our experience with this severe and feared complication.

METHODS

We retrospectively reviewed 314 acute cerebral aneurysms that were treated with endovascular coiling. These patients were identified and the management and outcomes were recorded. The literature was reviewed.

RESULTS

Six patients had an intraprocedural aneurysmal rupture. This complication occurred sporadically. Prevalence was 1.9%. Of these six, four were women and two were men. The mean age was 68 years (range: 43-74 years). Four aneurysms were located in the anterior circulation and two in the posterior circulation. Perforation occurred during microcatheterization of the aneurysm in one case and during coil deposition in five cases. In these five patients, aneurysmal rupture resulted from detachment of the first coil in three patients and detachment of the third and last coil in two patients. Hemodynamic changes were noted for one patient. The Glasgow Outcome Scale score at last follow-up examination was 1 in three patients and 3 in one patient (fair recovery). Mortality was 33% and morbidity was 16.7%.

CONCLUSION

Aneurysmal perforation during embolization is a rare event (1.8 to 4.4%). When perforation is recognized, embolization can be completed immediately with further coil deposition and reversal of anticoagulation therapy.

Ruptured cerebral aneurysm in the early stage of life--a congenital origin?

We report the case of a large fusiform aneurysm of the anterior cerebral artery in a 3-month-old girl presenting with generalized seizures and complicated by a cardiorespiratory arrest needing resuscitation. The native cerebral CT scan revealed a diffuse subarachnoid hemorrhage (Fischer III grade); CT angiography showed an aneurysm of the distal A1 segment of the anterior cerebral artery (ACA). Successful treatment was achieved through surgical trapping of the aneurysm and sacrifice of the distal A1 segment. A histological study of the aneurysmal wall revealed the absence of elastic fibers in an otherwise fibromuscular media and showed no signs of previous hemorrhage. Intracranial aneurysms of the ACA are very rare in the early stage of life and their pathogenesis is not clear. This case is of interest as the location and shape of the aneurysm, the absence of relevant familial and medical history, and the histopathological findings raise the hypothesis of a congenital origin. It further describes the value of CT angiography for studying aneurysms in the very young.

Ruptured Giant Syphilitic Aneurysm of the Descending Aorta in an Octogenarian*

Syphilis can lead to saccular aneurysms of the thoracic aorta. Today syphilitic aortic aneurysms are rare. The average time from primary infections to the development of aortic aneurysms is 10 to 15 years. An 83-year-old man was admitted with a giant aneurysm of the descending thoracic aorta. The patient had first experienced subacute pain in the left hemithorax some weeks previously. Computer tomography scan detected an 11 x 11 cm aneurysm of the descending aorta. Serodiagnostic tests for syphilis were highly positive. Femoro-femoral bypass was initiated and a tube graft was interposed. The postoperative course was uneventful, the patient was discharged at the twentieth postoperative day. Histological examination of the aneurysmal wall showed typical syphilitic changes. Postoperatively, Penicillin G was given for 6 months. Three years later the patient remains asymptomatic. Although extremely rare today, tertiary syphilis should be considered in the differential diagnosis of thoracic aneurysms. In selected octogenarians replacement of the descending aorta is possible.

[A surgical repair of ruptured atherosclerotic coronary artery aneurysm; report of a case]

We reported a successful surgery for the huge ruptured coronary aneurysm resulting in cardiac shock. The rupture of atherosclerotic coronary aneurysm is extremely rare except congenital cardiac disease and as a coronary artery-pulmonary artery fistula or a coronary arterio-venous fistula. Excision of the aneurysm, closure of the coronary ostium and coronary artery bypass using saphenous vein graft was performed. The post operative course was uneventful. The histological findings revealed atherosclerotic coronary aneurysm.

Autosomal dominant polycystic kidney disease presenting as subarachnoid hemorrhage

Intracranial aneurysms occur in patients with autosomal dominant polycystic kidney disease (ADPKD) approximately five times more often than in the general population, and in the same patient group, subarachnoid hemorrhage from rupture of aneurysms occurs about a decade earlier than in the general population. We present a case of unsuspected ADPKD presenting as spontaneous subarachnoid hemorrhage from a ruptured intracranial aneurysm.

EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM RUPTURED INTO THE THORACIC CAVITY WITH NEUROFIBROMATOSIS TYPE 1: CASE REPORT

OBJECTIVE AND IMPORTANCE

We are sometimes involved in the care of patients with neurofibromatosis Type 1 because of the associated disorders of cervicocerebral vessels. However, extracranial vertebral artery aneurysm in neurofibromatosis Type 1 is very rare. We present the first reported case of a rupture of an extracranial vertebral artery aneurysm into the thoracic cavity in a patient with neurofibromatosis Type 1.

CLINICAL PRESENTATION

A 52-year-old woman who presented with a decrease in left-sided grip and numbness of the left upper limb was admitted. During history taking, she developed shock. Radiological examination revealed that a left extracranial vertebral artery aneurysm had ruptured into the thoracic cavity. With consciousness decreasing gradually because of hemorrhagic shock, the patient became comatose.

INTERVENTION

Balloon occlusion of the vertebral artery proximal to the aneurysm was performed and surgical ligation was attempted, but cardiac arrest occurred immediately after the beginning of surgery, and the patient died. The vertebral artery proximal to the aneurysm was removed for pathological examination.

CONCLUSION

In this case, the changes noted were interpreted as changes showing fragility of the vascular wall secondary to neurofibromatosis Type 1. Patients with neurofibromatosis Type 1 exhibit disorders of cervicocerebral vessels, and in some cases progression may follow a violent course. Periodic follow-up of such patients and early diagnosis are important.

IS ASPECT RATIO A RELIABLE PREDICTOR OF INTRACRANIAL ANEURYSM RUPTURE?

OBJECTIVE

This study was undertaken to assess the reliability of the aspect ratio (AR) (i.e., aneurysm depth to aneurysm neck) in predicting aneurysm rupture. It has been shown that the AR is a key factor in predicting intraaneurysmal blood flow and aneurysm rupture.

METHODS

Seventy-five patients with subarachnoid hemorrhage and multiple aneurysms were studied. The sizes of the aneurysms and their ARs were determined by examining the angiographic films. By comparing the difference between ruptured and unruptured aneurysms in the same individual, each patient in effect served as his or her own control. Each ruptured aneurysm was confirmed during surgery.

RESULTS

There were 75 ruptured and 107 unruptured aneurysms. The mean AR was 2.70 for ruptured aneurysms, compared with 1.8 for unruptured aneurysms. This difference between the ARs was statistically significant (P < 0.001). The difference in aneurysm sizes in the two groups also was significant (P < 0.001).

CONCLUSION

AR on its own is as reliable a variable as the size of the aneurysm for predicting aneurysm rupture.

Carotid rupture during stent-assisted aneurysm treatment

We report the case of a supraclinoid carotid rupture during the delivery of a balloon-expandable stent in a 59-year-old patient with incidental paraclinoid berry aneurysms for whom stent-assisted coiling was planned. The deployment of the stent resulted in immediate rupture of the artery. We describe the emergent management of this complication with prolonged balloon inflation to occlude the site of rupture, a treatment that led to the discharge of the patient 2 weeks later without any sequelae.

Fatal and life threatening rupture of splenic artery aneurysms in children with portal hypertension

Aneurysms of the splenic artery (SAAs) are a rare complication of portal hypertension in adults. Although the risk of rupture is small, associated mortality is high. Furthermore, circulatory changes that occur following liver transplantation (OLT) may increase the risk of SAA rupture. The incidence in children with portal hypertension is unknown and thus we present our experience with two children who had ruptured SAA, one of whom died. Although there are no accepted methods for routine screening, hepatic angiography should be considered in children with long-standing portal hypertension (more than 10 yr), in order to detect and consider resection of the aneurysms, either before or at the time of liver transplantation.

Increased Carotid Wall Stress in Vascular Ehlers-Danlos Syndrome

Background— Vascular Ehlers-Danlos syndrome (vEDS), also known as EDS type IV, an inherited disorder of connective tissue, results from mutations in the gene encoding type III procollagen ( COL3A1 ). Affected patients are at risk for arterial dissection or rupture, the main cause of death. To understand the pathogenesis of the vascular lesions, we used a biomechanical approach and determined steady and pulsatile wall stress.

Methods and Results— Sixteen patients with vEDS and 16 age-, gender-, and blood pressure–matched control subjects were included in this cross-sectional noninvasive study. Circumferential wall stress was determined under steady and pulsatile conditions at the site of an elastic (common carotid) and a muscular (radial) artery from the measurements of intima-media thickness and internal diameter with high-resolution echo-tracking systems and either mean blood pressure or pulse pressure, respectively. At the site of the carotid artery, steady circumferential wall stress was 43% higher in vEDS patients than in control subjects (68.9±14.3 versus 48.2±12.1 kPa, P <0.001), and pulsatile circumferential wall stress was 22% higher (28.2±7.7 versus 23.1±5.7 kPa, P <0.001). Carotid intima-media thickness was 32% lower (408±56 versus 598±171 μm, P <0.001) in vEDS patients, and internal diameter was not different between groups. Radial artery parameters were not significantly different between groups.

Conclusions— In vEDS patients, an abnormally low intima-media thickness generates a higher wall stress than in control subjects at the site of an elastic artery, which may increase the risk of arterial dissection and rupture.

Complication analysis of intracranial aneurysm embolization with controllable coils

OBJECTIVE

To explore the causes, prevention, and management of the complications during intracranial aneurysm embolization with controllable coils (mechanical detachable spiral, MDS; and Guglielmi detachable coil, GDC).

METHODS

Retrospective review of 120 cases with 125 intracranial aneurysms embolized with controllable coils from March 1995 to July 1999 was conducted. The 20 accidents (in 18 cases) including aneurysm rupture, over-embolization, protrusion of coil end into the parent artery, and thrombosis of the parent artery were analyzed.

RESULTS

Among the 20 accidents, there were 6 aneurysm ruptures, 6 over-embolizations (in 5 cases), 6 coil protrusions, and 2 thromboses (one was secondary to coil protrusion). The embolization-related mortality was 3.33% (4/120), the permanent neurological deficit was 1.67% (2/120), and the transitory neurological deficit was 3.33% (4/120). The occurrence and outcome of the complications were related to the embolizing technique, the pattern of aneurysm and its parent artery, the imperfection of embolic materials, and the observation and management during embolization.

CONCLUSION

Skilled embolizing technique, better understanding of the angio-anatomy of an aneurysm and its parent artery, correct judgement and management during embolization, and improvement of embolic materials are beneficial to the reduction of complications and to the melioration of the outcome of complications.