Acute aortic dissection presenting as rupture of the femoral artery

A 44-year-old male with Marfan's disease presented acutely with severe chest and left groin pain. A pulsatile mass was present in the left groin and the left leg was pale and pulseless. CT imaging demonstrated the presence of a distal thoracic aortic dissection (AD) involving the left iliofemoral segment with extravasation of contrast into the left groin. The patient was treated with an urgent femoral-femoral bypass, which repaired the femoral artery and restored perfusion to the left lower extremity. Whereas rupture of the aorta into the chest or pericardium is common, femoral artery rupture complicating AD has not been previously reported. This case illustrates the need for peripheral branch intervention when compromised by the dissection process including isolated iliofemoral segments, which are typically benign. Given frank femoral artery rupture, urgent surgical repair was required and resulted in a satisfactory outcome.

Dexamethasone in the treatment of subarachnoid hemorrhage revisited: a comparative analysis of the effect of the total dose on complications and outcome

The benefit of dexamethasone in aneurysmal subarachnoid hemorrhage (SAH) is unproven. This actual study re-examined the impact on complications and outcome. Two hundred and forty-two patient records were analyzed. Dexamethasone had been prescribed individually. Group A consisted of patients in WFNS-grade I to III that were given at least 12mg/day dexamethasone for at least five days. All other patients in WFNS-grade I to III were assigned to group B. Groups C and D resulted from WFNS-grades IV and V, subdivided according to dexamethasone medication as groups A and B. Hydrocephalus and re-hemorrhage were significantly less frequent in group A than B (19% vs. 37%, P=0.011, and 3% vs. 13%, P=0.037, respectively). Favorable outcomes (Glasgow Outcome Scale, GOS 4 and 5) were more frequent in group A than B (99% vs. 85%; P=0.003). Frequencies of vasospasm and infections did not differ. In groups C and D significant differences were demonstrated for frequencies of hydrocephalus (C: 16%, D: 57%; P=0.006) and complications other than infection (C: 33%, D: 79%; P=0.002). Favorable outcomes were more frequent in group C than D (79% vs. 47%; P=0.046). Frequencies of vasospasm and infections did not differ.

Multiple basilar artery trunk aneurysms associated with fibromuscular dysplasia

An association between fibromuscular dysplasia (FMD) and intracranial aneurysms has been proposed but the occurrence of multiple aneurysms on the trunk of basilar artery (BA) associated with FMD has not been previously reported.

[Surgery of the ruptured distal anterior cerebral artery aneurysms]

INTRODUCTION

Distal anterior cerebral artery aneurysms (DACAA) are the particular group of the aneurysms of anterior circle of Willis. The characteristic factors are: different location on the distal anterior cerebral artery, specific surgical approach and rare occurrence.

AIM

Retrospective analysis of the outcome and attempt to find risk factors in DACAA surgical treatment were goals of this report.

MATERIAL AND METHOD

The authors report a series of 49 cases with DACAA who were operated on in the Department of Neurosurgery, Jagiellonian University in Kraków, in the period of 16 years. There were 29 women (59.2%) and 20 men (40.8%) with a mean age of 49 years. Multiple aneurysm were in 12 cases (24.5%), in which ruptured DACAA were always the cause of the haemorrhage. We investigated age, sex, Hunt and Hess grade, arterial hypertension, timing of operation, coexistence of intracerebral haematoma (ICH), intraventricular haemorrhage (IVH), cerebral ischaemia, hydrocephalus, multiple aneurysms, intraoperative aneurysmal rupture, use of temporary parent vessel clipping, significant brain oedema during surgery, anatomical variability of anterior cerebral artery as a potential risk factors.

RESULTS

There were 29 patients (59.2%) in good and very good clinical state and 11 (22.4%) in poor clinical state on discharge. Nine (18.4%) patients died. Statistically significant factors such as age (p<0.035), arterial hypertension (p<0.0035), Hunt and Hess grade (p<0.0073), IVH (p<0.0054), cerebral ischaemia (p<0.036) affected the direct outcome of patients.

CONCLUSIONS

There are typical risk factors in surgically treated DACAA: age, arterial hypertension, clinical status, intraventricular haemorrhage, cerebral ischemia. Most of treated cases remain in good and very good condition. Haemorrhagic and ischaemic complications were most frequent causes of operating losses in DACAA patients.

[Rupture of a jejunal artery pseudo-aneurysm after a cephalic duodenopancreatectomy]

Arterial pseudo-aneurysms complicating pancreaticoduodenectomy are rare but have a poor prognosis. They usually result from arterial erosion due to pancreatic fistula. The authors report a pseudo-aneurysm with an uncommon localization (first jejunal artery), diagnosed after a negative first arteriography, and successfully treated by radiological embolization. Special features of pseudo-aneurysms complicating pancreaticoduodenectomy are reviewed.

Ruptured Intercostal Artery Pseudoaneurysm after Blunt Thoracic Trauma

Here, we present the case of ruptured intercostal artery pseudoaneurysm two months after blunt thoracic trauma. Ruptured aneurysm hemorrhaged into the retroperitoneal space due to adhesion in the intrathoracic space. We unsuccessfully embolized the aneurysm during an angiographic procedure and performed the aneurysmectomy, removing the hematoma, using a retroperitoneal approach. Ruptured intercostal artery pseudoaneurysm after blunt thoracic trauma may have caused the delayed life-threatening hemorrhage.

Investigation of the surgically treated and untreated unruptured cerebral aneurysms of the anterior circulation

BACKGROUND

The natural history of unruptured cerebral aneurysms and the surgical risks are modified by several factors including size, location, and presence of subarachnoid hemorrhage (SAH). The main confusion arises because the backgrounds of the past reports describing the natural history or the surgical complication of unruptured cerebral aneurysms were different. The present study aimed to adjust the backgrounds and investigate the surgical indication with close monitoring of both surgically treated and untreated unruptured cerebral aneurysms.

METHODS

In the past 9 years, 201 patients who had unruptured anterior circulation aneurysms were monitored. The decision of the operation was not randomized. The patients were divided into three subgroups by the size of the aneurysms (small group: below 5 mm, medium group: between 5 and 15 mm, large group: over 15 mm). In both surgically untreated and treated patients, overall mortality and morbidity corresponding to Rankin score II or worse was counted as unruptured aneurysm related event. The ratio of event free was compared between surgically treated and untreated patients using Log-rank test.

RESULTS

In untreated patients, SAH was noted in 1 in the small group and 4 in the medium group. The annual rupture rate of the medium group was 12 times higher than that of the small group. In surgically treated patients, overall mortality and morbidity of the surgery was 2.3% in the small group, 3.6% in the medium group, and 20% in the large group. One surgically treated patient had SAH because of regrowth of aneurysm. When ratio of event free was compared, no significant advantage of surgery was noted in the small group and in all of the patients. However, the benefit of surgery was significant in the medium group (Log-rank p = 0.0189).

CONCLUSIONS

The present results indicated that prophylactic surgery has a benefit for the medium-size aneurysms (5-15 mm) of the anterior circulation. For large aneurysms, individual investigation is necessary because of the variety of surgical difficulties, and the complex symptoms because of rupture and the mass effect as well as cerebral embolism. In small aneurysms, careful observation may be a reasonable choice unless the aneurysm is at a specially high risk of rupture.

Malignant hypertension and cerebral haemorrhage in Seckel syndrome

Seckel syndrome is an autosomal recessive condition with severe short stature and facial and neurological anomalies. Intracranial haemorrhage, due to rupture of a cerebral aneurysm, is a very rare complication of this syndrome. Malignant hypertension may play an important role in the aetiology of the aneurysm and early detection is essential in order to prevent organ damage.

CONCLUSION

we report a new case of Seckel syndrome associated with malignant hypertension and cerebral haemorrhage.

A case of a ruptured pheochromocytoma with an intratumoral aneurysm managed by coil embolization

Although the spontaneous rupture of adrenal pheochromocytoma is rare, it can be lethal because it can induce serious changes in the circulation. We describe a 32 year old man with bilateral pheochromocyroma presenting as abdominal pain. In the emergency room, an abdominal MRI showed an aneurysmal vessel in the right adrenal mass and accompanying hemorrhage around the tumor capsule. The bleeding site was found by transfemoral abdominal angiography. Coil embolization was done in the bleeding vessels, specifically branches of the right adrenal artery. The hemorrhage was successfully controlled and vital signs of the patient were restored. Following emergency care, biochemical and imaging studies showed compatible findings of a bilateral adrenal pheochromocytoma. Postoperative histologic findings confirmed these observations. A ruptured pheochromocytoma should be considered as a cause of acute abdomen in cases of a concomitant adrenal mass. Intratumoral aneurysmal bleeding may be a cause of ruptured tumor, and careful angiographic intervention will help to ensure safe control of bleeding in such an emergency situation, even in cases of bilateral tumor.

Unruptured intracranial aneurysms

Between 3.6 and 6% of the population harbour an unruptured intracranial aneurysm. Risk of rupture is related to aneurysm site and size and whether or not the patient has already had a subarachnoid haemorrhage (SAH) from another aneurysm. In ISUIA 2, the rupture rate for anterior circulation aneurysms<7mm was 0% per year in patients with no prior SAH, and 0.3% per year in patients with previous SAH; 7-12mm aneurysms, 0.5% per year (both groups); 13-24mm aneurysms, 3% per year; and giant aneurysms 8% per year. Rupture rate for posterior circulation aneurysms is higher at all sizes:<7mm was 0.5% per year in subjects with no prior SAH, 0.7% in those with prior SAH; 7-12mm, 3% per year; 13-24mm, 3.7% per year; and giant aneurysms, 10% per year. Non-invasive tests like contrast enhanced magnetic resonance angiography (MRA) and multislice computed tomographic angiography (CTA) are alternatives to intra-arterial digital subtraction angiography (IADSA) to detect aneurysms. Although these are promising techniques, the quality of data testing their accuracy remains limited and single slice CTA and time-of-flight MRA are poorer at detecting aneurysms<5mm diameter, which account for up to 1/3 of unruptured aneurysms. For ruptured aneurysms, the only large scale randomised controlled trial comparing surgical and endovascular treatment (ISAT) by coiling, resulted in an absolute 8.8% reduction (updated figure as of June 2003 for 1888 patients) in death or dependency at 1 year compared with surgical clipping. For unruptured aneurysms, the best available data so far comparing coiling and clipping is from the prospective (but non-randomised) arm of ISUIA. Elective surgical clipping had combined morbidity and mortality at 1 year of 12.2% versus 9.5% for coiling, although the groups were not matched with more high risk patients in the endovascular treatment cohort. Nevertheless these data are encouraging for future randomised trials of elective coiling versus clipping for asymptomatic aneurysms, in particular as the unproven long-term durability of coiling treatment and the fact that complete aneurysm occlusion is not always achieved remain obstacles to its wider use in unruptured aneurysms. There is an increased risk of SAH in relatives of patients with SAH (highest in those with two or more first degree relatives affected), but most SAH is sporadic and therefore the balance of available evidence indicates that mass screening for aneurysms is not cost effective. There may be a limited role for investigation of high-risk subgroups and ideally such screening should be tested in a randomised trial. The avoidance and active management of vascular risk factors should also be part of the management of at risk subjects.

Pseudoaneurysm formation at the rupture site of a middle cerebral artery aneurysm--case report

A 42-year-old man suffered subarachnoid hemorrhage manifesting as sudden severe headache one month before admission. On admission, his headache had subsided and he had no neurological deficits. Cerebral angiography demonstrated an aneurysm originating from the bifurcation of the right middle cerebral artery. The aneurysm was irregular, with a snowman-like shape. Neck clipping of the aneurysm was carried out through a right pterional approach. Intraoperatively, a red, pulsating sac mimicking a blood clot (the snowman's "head") was located over the yellowish, thick-walled portion of the aneurysm. Exploration around the aneurysm detached the red sac from the thick-walled portion of the aneurysm. There was a small tear in the apex of the thick-walled aneurysm sac. A Sugita clip was applied to the neck of the true aneurysm. The postoperative course was uneventful and he was discharged one month later without neurological deficits. Histological examination of the red-colored sac showed the features of pseudoaneurysm. The red sac may have been a pseudoaneurysm covering the rupture site of the true aneurysm.

Intraarterial administration of Abciximab for thromboembolic events occurring during aneurysm coil placement

BACKGROUND AND PURPOSE

Platelet-derived thrombi may occur during intracranial aneurysm coiling. We report a series of 13 patients treated with intraarterial Abciximab for thrombus formation complicating aneurysm coiling.

METHODS

Four patients were treated for acutely ruptured aneurysms. Three procedures consisted of the retreatment of previously coiled aneurysms. Six patients had asymptomatic untreated aneurysms. Abciximab was administered intraarterially through a microcatheter as a bolus of 4-10 mg over a period of 10-20 minutes. All patients underwent postthrombolysis control angiography. They also underwent immediate pre- and postoperative cranial CT.

RESULTS

In 10/13 cases, the thrombi developed without coil protrusion into the parent artery. In one case, the thrombus was generated from the guiding catheter and embolized remote from the aneurysm site. In one case, the thrombus developed before any coil placement. In another patient, a coil loop protruded into the parent artery favoring a heightened thrombotic state. Arterial thrombi were totally occlusive in two patients, whereas in the remaining 11 cases, the thrombi were not totally obstructive. Complete recanalization was achieved in 92% (12/13) of cases within 20-30 minutes. Incomplete arterial reopening was noted in one case, in which a thrombus fragment embolized distally, causing cerebral infarction. There were no Abciximab-related intracranial hemorrhages.

CONCLUSION

Intraarterial Abciximab was effective in this series for the treatment of thrombotic complications occurring during aneurysm coiling.

Clip wrapping for partial avulsion of the aneurysm neck

✓ An intraoperative aneurysm rupture due to a tear at the aneurysm neck can be a tricky complication to manage. The authors describe a simple technique found to be useful in such a case.

Ruptured renal artery stump aneurysm in a renal autotransplanted Behçet's disease patient

A recurrent aneurysm at the anastomosis site or the remaining artery frequently occurs after the operative treatment of an aneurysm in Behçet's disease despite anti-inflammatory medication. Herein, a ruptured left renal artery stump aneurysm in a patient with Behçet's disease, who received a left nephrectomy, aorto-biiliac bypass and heterotopic autotransplantation of the right kidney for the treatment of an abdominal aortic aneurysm and renal hypertension one year prior to this admission, is reported. An aneurysm and rupture occurred despite the administration of anti-inflammatory medications while monitoring of the clinical findings, such as skin manifestations, erythrocyte segmentation rate (ESR) and C-reactive protein (CRP). Although there is no definite proven treatment modality to prevent recurrent aneurysms at the anastomosis site or a remote artery, close follow-up with anti-inflammatory medications, and surveillance with regular intervals are the only current methods for the prevention and/or to treatment of an arterial complication in patients with Behçet's disease.

Rare, late complications in a patient with Hodgkin's disease

We report a unique case of a cured Hodgkin's disease patient who developed several complications decades after mantle and neck radiation therapy. First on the right, then years later on the left side of the neck a pharyngocutaneous fistula developed complicated by rupture of the carotid arteries on both sides necessitating their ligation. The fistula on the right side was successfully closed by plastic surgery, but the one on the left side is still a problem as severe hypoperfusion of the brain limits therapeutic possibilities. We discuss the relationships between the treatment for Hodgkin's disease and subsequent complications as well as treatment of these complications.

Rupture of an internal carotid artery aneurysm during angiography with leakage of contrast medium via an external ventricular drain

With a ruptured intracranial aneurysm producing subarachnoid haemorrhage (SAH) cerebral angiography is currently used for identification of the affected vessel. Aneurysm rerupturing is one of the more serious complications of cerebral angiography and has been frequently described. We report a 61-year-old man who presented with SAH who had rerupture of a large aneurysm of the internal carotid artery during angiography. A substantial amount of contrast medium escaped via a ventricular drain. The three main risk factors for rerupture of an aneurysm are: angiography performed within 6 h of the primary SAH, an aneurysm on the internal carotid artery and an unfavourable Glasgow coma score.

Aneurysm Rupture during Endovascular Coiling: Effects on Cerebral Transit Time and Neurophysiologic Monitoring and the Benefits of Early Ventriculostomy: Case Report

OBJECTIVE AND IMPORTANCE

We report a case of intra-operative aneurysm rupture during endovascular therapy and document the effects of rupture on cerebral transit times and neurophysiologic monitoring. The effects of early ventriculostomy are clearly documented.

CLINICAL PRESENTATION

A 42-year-old man with Hunt and Hess grade 1, Fisher grade 3 subarachnoid hemorrhage secondary to a 5 mm anterior communicating artery aneurysm underwent coil embolization.

INTERVENTION

Endovascular therapy was complicated by intraprocedural aneurysm rupture. Changes in cerebral transit time and electroencephalography along with somatosensory evoked potentials were documented as were improvement in these parameters following aneurysm obliteration and ventriculostomy placement. The patient awoke without deficit and was discharged 2 weeks later with a grossly normal examination.

CONCLUSION

Early recognition of aneurysm rupture during coil embolization and prompt aneurysm obliteration and reduction in intracranial hypertension can lead to acceptable patient outcomes. Use of neurophysiologic monitoring in the intubated patient can help the neurosurgeon determine the need for cerebrospinal fluid drainage in such situations.

Risk of death in pregnancy achieved through oocyte donation in patients with Turner syndrome: a national survey

To determine the risk of death in pregnant women with Turner syndrome who were treated with oocyte donation, and to ascertain the prevalence of preconception cardiac screening in these patients.

DESIGN

Survey and literature review.

SETTING

Academic infertility center.

PARTICIPANT(S)

All 258 donor-egg programs in the 1997 Assisted Reproductive Technology Success Rates publication from the Society for Artificial Reproductive Technology were surveyed by fax or telephone.

MAIN OUTCOME MEASURE(S)

Death in pregnancy conceived through oocyte donation and proportion of patients prescreened with echocardiography.

RESULTS

One hundred thirty-four (52%) programs reported 146 Turner patients treated, resulting in 101 pregnancies. One patient died from aortic rupture while awaiting treatment; 72 (49.3%) patients were pre- screened with echocardiography. No deaths in pregnancy were reported. A literature review identified four case reports of Turner patients who died during pregnancy in the United States during the same time period.

CONCLUSION(S)

The maternal risk of death from rupture or dissection of the aorta in pregnancy may be 2% or higher. Patients with Turner syndrome have not been adequately screened with echocardiography before treatment. Specialists who treat patients with Turner syndrome need to be aware of their cardiac risk and its potential exacerbation from the increased cardiac demands of pregnancy.

Review: spontaneous rupture of splenic artery aneurysm in pregnancy

Splenic artery aneurysms (SAA) occur predominantly in women and a majority of the aneurysms are asymptomatic until rupture. Over half of those that rupture occur during pregnancy or in women who have had children. Rupture during pregnancy is associated with a very high maternal and fetal mortality rate. Although this condition is uncommon, good materno-fetal outcome can only be achieved by early diagnosis and prompt treatment. It is therefore important to increase awareness of this condition so that obstetricians and other frontline staff can entertain the diagnosis of a ruptured splenic artery aneurysm in any pregnant woman who presents with severe upper abdominal pain. This article reviews the aetiology, clinical features, diagnosis and treatment of this potentially lethal condition.

Massive epistaxis related to petrous carotid artery pseudoaneurysm after radiation therapy: emergency treatment with covered stent in two cases

Two patients had acute left carotid rupture from radiation therapy-induced pseudoaneurysms, resulting in hemodynamic collapse. Because the patients were semicomatose and in shock, an immediate salvage procedure was needed. Location of the pseudoaneurysm at the skull base made surgical treatment less possible. Endovascular therapy was the treatment of choice. Preserving patency of the carotid artery was a desirable option. The successful use of a covered stent in the emergency treatment of massive epistaxis due to active bleeding from pseudoaneurysm in the petrous internal carotid artery (ICA) is described.

Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States

BACKGROUND

The hypothesis of this study was that differences exist among patients with private insurance compared with patients with Medicaid or no insurance, regarding access to the timely treatment of abdominal aortic aneurysms (AAAs) and the outcomes of AAA repair.

METHODS

The study comprised 5363 patients aged less than 65 years (mean age, 59 years) with a diagnostic code for intact or ruptured AAA and a procedure code for AAA repair in the National Inpatient Sample for 1995 to 2000. Dependent variables included ruptured AAA, intact AAA, and in-hospital postoperative mortality rates. Independent variables included payer status, median income, race, gender, age, and comorbid disease. Risk-adjusted analyses were performed with the use of binary logistic regression.

RESULTS

AAA rupture was most likely (P <.001) to affect patients with no insurance (36%) or Medicaid (18%), compared with patients with private insurance (13%). After an adjustment for case-mix had been made, data showed that patients without insurance had an increased risk of rupture compared with patients with private insurance (odds ratio, 2.3; 95% CI, 1.5-3.5; P <.001). Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%).

CONCLUSIONS

Uninsured patients more often seek treatment of ruptured AAAs compared with patients with private insurance. Operative mortality rates in uninsured patients are greater for elective and emergent AAA repair. These data support the tenet that payer status is associated with mortality rates after AAA repair.