Percutaneous transhepatic coil embolization of a ruptured intrahepatic aneurysm in polyarteritis nodosa

Large visceral aneurysms in polyarteritis nodosa are relatively uncommon. We present a patient with polyarteritis nodosa who ruptured a large intrahepatic aneurysm which was treated by percutaneous transhepatic coil embolization.

Left ventricular outflow tract (LVOT) vegetations and spontaneous obliteration of a large ruptured intracranial mycotic aneurysm in a case of infective endocarditis

A 10-year-old girl with mild aortic regurgitation presented with cerebral infarction. Two-dimensional echocardiography showed vegetations on the septal wall of the left ventricular outflow tract without involvement of the aortic valve itself. After successful antibiotic treatment the patient developed an intra-cranial haemorrhage due to rupture of a large intracranial mycotic aneurysm. Consent for surgical treatment of the mycotic aneurysm was not obtained. Twelve months later repeat angiography showed that the aneurysm had undergone spontaneous obliteration.

[A case report of spontaneous rupture of bilateral lumbar artery in a patient with von Recklinghausen disease]

Vascular complications in von Recklinghausen disease are rare, especially spontaneous rupture of a major artery. A 50-year-old man with previously diagnosed neurofibromatosis was admitted because of spontaneous rt-sided lumbago, paresthesia in rt-lower limb and severe anemia. Angiographic studies, CT and MRI revealed pseudo-aneurysm of bilateral lumbar arteries, which ruptured into the psoas muscle. Both arteries were ligated and hematoma was removed. The pathogenesis of the spontaneous rupture is discussed.

[Endocarditis due to Candida albicans with peripheral arterial embolism and a cerebral mycotic aneurysm in an IV drug addict]

Endocarditis due to Candida albicans (EC) is a rare cause of endocarditis in IV drug addicts (IVDA). Its diagnostic is usually difficult and high peripheral embolization is characteristic, and could affect big vessels. The case of a female patients (IVDA) 21 years old is discussed, who showed bilateral iliofemoral embolism and cerebral hemorrhage due to mycotic aneurysm breakage in a EC. These two complications appeared during an EC episode are exceptional. We insist in the importance of the echographic images in the suspicion diagnosis of EC.

Ruptured mesenteric artery aneurysm in a patient with alpha 1-antitrypsin deficiency: etiologic implications

Clinical observations suggest that some aneurysms may be manifestations of intrinsic tissue abnormalities or systemic disease. Several investigators have reported reduced elastin content and increased elastase activity in infrarenal aortic aneurysms. Alpha 1-antitrypsin is the primary serum protease inhibitor modulating elastase activity. Elevated elastase activity caused by reduced alpha 1-antitrypsin inhibition, theoretically, could contribute to aneurysm formation. We report a case of ruptured middle colic artery aneurysm in a patient with multiple visceral artery aneurysms and profound alpha 1-antitrypsin deficiency. Reported middle colic artery aneurysms are reviewed, and etiologic implications are discussed.

Spontaneous rupture of the femoral arteries

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Dorsal internal carotid artery aneurysm: classification, pathogenesis, and surgical considerations

Despite the rarity of dorsal internal carotid artery (ICA) aneurysms they still offer surgical challenge to achieve a safe successful clipping due to their peculiar projection. In the past 13 years, 24 cases of dorsal ICA aneurysm were operated upon in our hospitals. Three separate groups of such aneurysms could be identified: group 1; where the aneurysms were located most proximally at the carotid-ophthalmic region, group 3; in which the aneurysms were present most distally just proximal to the ICA bifurcation, and group 2; where the aneurysms were located in between. All cases in this surgical series will be reviewed stressing upon the classification, pathogenesis, and surgical tactics of such a rare type of aneurysm.

Bacterial intracranial aneurysms

This is a retrospective study of 25 patients with bacterial intracranial aneurysms treated in a single department over a 20-year period. The clinical presentation, investigation and treatment of these patients is discussed. The outcome of the treatment is assessed and is thought to be not as poor as previously reported.

[Ruptured cerebral aneurysm associated with chronic renal failure: case report and evaluation of dialysis]

Two cases of ruptured cerebral aneurysm with chronic renal failure were successfully treated by selecting an appropriate dialysis during the pre- and postoperative period. Case 1; a 41-year-old male, who had been receiving hemodialysis for 4 years, complained of sudden onset of headache, and his consciousness deteriorated abruptly afterwards. A ruptured basilar-left superior cerebellar artery aneurysm was diagnosed, and an external ventricular drainage device was installed. The patient slowly recovered consciousness and was scheduled for delayed operation. During this period hemodialysis was suspended and continuous ambulatory peritoneal dialysis (CAPD) was performed instead. On the 24th day, the aneurysm was clipped, and CAPD switched to ordinary hemodialysis three days after the operation. However, consciousness deteriorated and CT scan showed diffuse cerebral swelling due to disequilibrium syndrome. The patient recovered consciousness 24 hours after hemodialysis. Frequent short-term dialysis eventually eliminated this syndrome. Case 2; a 60-year-old male, who had been receiving hemodialysis for 6 years, complained of a sudden severe headache, and a ruptured anterior communicating artery aneurysm was diagnosed. Emergency clipping of the aneurysm was performed and, except for mild vasospasm on the seventh day, the patient's recovery was uneventful postoperatively, with non-anticoagulative agent hemodialysis. These two cases demonstrate that chronic renal failure of a ruptured cerebral aneurysm patient can, with good prognosis, be treated by CAPD preoperatively, and non-anticoagulative agent hemodialysis postoperatively, followed by ordinary dialysis carefully avoiding the disequilibrium syndrome.

[A ruptured aneurysm of the distal posterior inferior cerebellar artery associated with basilar artery occlusion: a case report]

We presented a case of a distal posterior inferior cerebellar artery (PICA) aneurysm associated with basilar artery occlusion. A 66-year-old female was found unconscious at home and transferred to our hospital in a deep coma on February 9, 1991. Emergency CT scan revealed subarachnoid hemorrhage in the posterior fossa. She was treated conservatively because of her poor neurological status. The angiograms performed on February 13 showed occlusion of the basilar artery and a saccular aneurysm at the cortical branch of the PICA. The contrast material remained in the aneurysm for a long time throughout the venous phase. The left vertebral artery was markedly hypoplastic. The patient improved remarkably after admission and became almost alert late in February, although she still presented tetraparesis, dysfunction of lower cranial nerves and other neurological signs linked with the brain stem. The unusual angiographical findings in this case prompted us to perform the examination again, expecting some angiographical changes. The angiograms taken on March 15 revealed spontaneous disappearance of the aneurysm, although the basilar artery occlusion remained unchanged. The authors discussed some problems involved in this case, including the relation between the aneurysm and the arterial occlusion, and the mechanism of spontaneous disappearance of the aneurysm.

Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.

Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography

We present a case study of a 54-year-old patient with a perforated aneurysm of the anterior mitral valve leaflet, diagnosed 13 years after an episode of bacterial endocarditis by transesophageal echocardiography. This report illustrates the superiority of transesophageal echocardiography in the diagnosis and management of valvular endocarditis.

Risk of rupture of postangiographic femoral false aneurysm

The surgical management of 50 false aneurysms caused by transfemoral arterial catheterization was reviewed to document the incidence and effects of rupture before repair. Twelve false aneurysms ruptured, leading to shock in six patients, distal ischaemia in three and stroke in one. The mean(s.d.) time from catheterization to rupture was 2.8(1.7) (range 1-6) days. Postoperative complications occurred in seven patients with ruptured and eight with non-ruptured aneurysms (P < 0.04). The mean(s.d.) age of patients with ruptured aneurysms was 67.2(6.3) (95 per cent confidence interval 63.5-70.8) years and those without 58.5(9.1) (95 per cent confidence interval 55.3-61.7) years (P < 0.008). On multiple regression analysis, age, peripheral vascular disease and raised plasma liver enzyme levels on admission were found to be significant independent predictive variables for rupture (all P < 0.05). It is recommended that patients with these risk factors undergo urgent operative correction of femoral false aneurysm.

[Pitfalls of endovascular treatment for cerebral aneurysms]

Seventeen cases of unclippable aneurysms were treated by the endovascular balloon technique. Nine of them involved the anterior circulation, and eight involved the posterior circulation. Eleven of them were treated by parent artery occlusion with detachable balloons. Three were treated by endosaccular balloon embolization, and three cases combined with AVMs were occluded using ethylene vinyl alcohol copolymer (EVAL) including feeding arteries of the AVMs. Embolic complications occurred in one case of an IC bifurcation giant aneurysm treated by parent artery occlusion. Ischemic complications also appeared in two cases of aneurysms treated by endosaccular balloon embolization. In one case, the thrombus in the aneurysm propagated into the parent artery and occluded it later. In another case, the displaced balloon had obliterated the parent artery 6 hours after the embolization. Parent artery occlusion is a safe way to treat internal carotid giant aneurysms. However, endosaccular treatment still has some problems, i.e., 1) maintaining the balloon's position to preserve the parent artery, 2) balloon migration into the clot, 3) rupture of the aneurysm during or after treatment. Our studies indicate that endosaccular balloon embolization is still a high risk procedure and should be used only in selected cases, until new embolic agents, such as detachable coils, become available.

Implications for the pathogenesis of aneurysm formation: metastatic choriocarcinoma with spontaneous splenic rupture. Case report and a review

We report a case of ruptured intracranial aneurysm from metastatic choriocarcinoma in a patient presenting with intracerebral hemorrhage. Operative evacuation of the hematoma with clipping of a distal right middle cerebral artery aneurysm was performed. Postoperatively, the patient developed hypovolemic shock from spontaneous splenic rupture. Histopathologic examination of the cerebral aneurysm showed choriocarcinoma invading the vessel wall. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral or subarachnoid hemorrhage in women of child-bearing age.

[A ruptured aneurysm at the peripheral collateral circulation of the anterior choroidal artery in a patient with moyamoya disease: a case report]

This 42-year-old man experienced a sudden onset of occipital headache. Neurological examination revealed a moderately disturbed consciousness and a moderate left hemiparesis. CT scan disclosed a hugh hematoma in the right temporo parietal lobe without intraventricular hemorrhage. A cerebral angiography demonstrated typical findings of moyamoya disease and a small saccular aneurysm at the peripheral portion of the right anterior choroidal artery, which was dilated at the collateral circulation to the parietal lobe. The hematoma was removed at once by a craniotomy. He became alert but mild hemiparesis persisted. MRI disclosed a small signal-void lesion lateral to the trigone of the right lateral ventricle. The angiography repeated three weeks after the removal of the hematoma showed the unchanged size of the aneurysm. Direct surgery for the aneurysm was performed via the right parietal transcortical approach. The aneurysm was reached under the guidance of the intraoperative angiography. Trapping of the parent artery and the excision of the aneurysm were performed. On the basis of the presence of an internal elastic lamina at the neck of the aneurysm, the surgical specimen was histologically verified to be a true aneurysm. Since the collateral circulation was well preserved during surgery, no worsening of the neurological manifestation was observed. In view of the unfavorable prognosis for a moyamoya patient with this type of the aneurysm, which often results in a massive ventricular or intracerebral hemorrhage, surgery directed to the aneurysm itself should be considered.

Rupture of splenic artery aneurysm

Three cases of death from splenic artery aneurysm rupture were encountered from 1988 to 1991 at the Philadelphia Medical Examiner's Office. In two cases, cocaine was detected in the blood and was believed to have precipitated the rupture. Toxicologic testing for cocaine should be performed in all cases of splenic artery aneurysm rupture and its presence should be interpreted properly as contributory rather than incidental to death.

[Ruptured aneurysm at the peripheral branch of the posterior cerebral artery with systemic lupus erythematosus]

We report a 73-year-old woman with systemic lupus erythematosus (SLE) in whom intracerebral and intraventricular hemorrhage developed secondary to a ruptured aneurysm on the peripheral branch of the posterior cerebral artery. We reviewed data on 22 patients (43 aneurysms) in previous reports of ruptured cerebral aneurysms associated with SLE, including our case. Of these aneurysms, 34 (79.1%) were located on the major artery, and 9 (20.9%) were located on the peripheral small artery. Fusiform aneurysms accounted for 27.9% of the total. The prognosis was poor, and 14 patients (63.6%) died. Direct aneurysmal surgery was performed in 11 patients (50%), but 4 patients died of other diseases associated with SLE.

Smoking and subarachnoid haemorrhage: a case control study

Retrospective and epidemiological studies have suggested that smoking increases the risk of developing aneurysmal subarachnoid haemorrhage (SAH). During 1990, 217 patients presenting to the Mersey Regional Neurosurgical unit with spontaneous SAH were prospectively studied. Smoking habits of patients with SAH were compared with age, sex and occupation matched controls. The relative risk of spontaneous aneurysmal SAH for smokers was twice that of non-smokers (p < 0.001). Management outcome at 6 months following aneurysmal SAH was similar for smokers and non-smokers (p = 0.43) but smokers had more postoperative pulmonary complications requiring ventilation. Significance was tested with chi-square tests.