Fusiform superior cerebellar artery aneurysm presenting with contralateral abducens nerve paresis--case report

A 25-year-old female suddenly developed headache and diplopia. On admission, neurological examination revealed neck stiffness and left abducens nerve paresis. A computed tomographic scan suggested subarachnoid hemorrhage. Left vertebral angiogram showed an aneurysm on the anterior pontine segment of the right superior cerebellar artery (SCA) and marked flexion and meandering of the basilar artery to the left. At surgery, an atherosclerotic, fusiform aneurysm was found through the right subtemporal transtentorial approach, and the right SCA was clipped just proximal to the aneurysm. Thirteen cases of SCA aneurysm have been described in the literature, but none was a fusiform aneurysm.

Infarction of the conus medullaris

We encountered a patient with acute cauda equina syndrome. The clinical course, laboratory data and imaging study, including magnetic resonance imaging (MRI) strongly suggested that this episode was caused by a vascular disorder of the conus medullaris. We emphasized the diagnostic usefulness of MRI in the vascular disease of the conus medullaris as well as the clinical importance of this disease in the differential diagnosis of acute cauda equina syndrome.

Extracranial vertebral artery aneurysm with neurofibromatosis. Endovascular treatment by detachable balloon

An extracranial vertebral artery aneurysm in a patient with neurofibromatosis is described. The aneurysm was treated by endovascular balloon occlusion of the proximal vertebral artery. The details of the therapeutic management are discussed, and the vascular manifestations of neurofibromatosis are reviewed.

Aneurysms of the intracavernous carotid artery: clinical presentation, radiographic features, and pathogenesis

Thirty-seven patients with 44 intracavernous carotid artery aneurysms (ICCAAns) were seen at one institution from 1976 through 1988. Fifteen patients had multiple intracranial aneurysms and 7 had bilateral ICCAAns. Age at diagnosis ranged from 15 to 80 (median 61). Thirty patients were women. Sixteen had a history of hypertension. In 34% of patients the ICCAAns were asymptomatic at diagnosis, 36% were associated with headache, and 57% had associated signs or symptoms of mass effect including sixth nerve paresis (43%), trigeminal pain or sensory loss (32%), third nerve paresis (20%), decreased vision or visual field cut (18%), fourth nerve paresis (16%), and Horner's syndrome (7%). In 4 patients the ICCAAns ruptured, leading to subarachnoid hemorrhage in 3 and epistaxis in 1. Two patients with ICCAAns were seen with spontaneous thrombosis of the ipsilateral internal carotid artery leading to distal ischemic symptoms in 1. More than 90% of the ICCAAns were saccular. Thirty-four percent were small (less than 1 cm), 48% were large (1 to 2.5 cm), and 16% were giant (greater than 2.5 cm). The majority arose from the anterior genu of the intracavernous internal carotid artery, followed in frequency by the horizontal segment, and then the posterior genu. Magnetic resonance imaging is superior to computed tomography for diagnosing ICCAAns and is the screening procedure of choice. Angiography remains the "gold standard" for diagnosis and determining specific anatomic details necessary to plan therapy. Analyzing the radiographic anatomy of 44 ICCAAns. we conclude that theories attributing the origin of aneurysms to arterial bifurcations may be inadequate to explain the point of origin and direction of take off of up to one-fourth of ICCAAns.

Control of renovascular hypertension by renal embolization

Two cases with medically well-controlled renovascular hypertension due to unilateral contracted kidney were treated by percutaneous renal embolization. One of the patients had two aneurysms of the renal artery in addition to the stenosis. Both patients remained normotensive without medication after follow-ups of 6 and 24 months, respectively.

Multiple aneurysms in a seven-year-old child

Arterial aneurysms, rarely encountered in childhood, pose difficult etiologic and therapeutic problems. We report the case of a seven-year-old Algerian girl with aortoiliac, visceral, and limb aneurysms revealed by a tumefaction in the left popliteal fossa. Aortic rupture subsequently occurred. The aneurysms were resected with subsequent prosthetic or vein graft replacement. Three years later, clinical and functional results of the grafts were satisfactory. Possible etiologies include inflammatory arteritis, dysplasia, or idiopathic primary aneurysms.

Renal infarction secondary to fibrous dysplasia and aneurysm formation of renal artery

We report a case of a previously healthy forty-year-old man with bilateral renal artery stenosis secondary to bilateral medial fibrous dysplasia. He was additionally found to have a dissecting aneurysm of the left upper renal artery branch with resultant infarction of the upper and middle pole renal segments. We believe renal infarction secondary to medial fibrous dysplasia with occlusion of the renal artery associated with a dissecting aneurysm has not been reported, and we report the first such case. A multimodality treatment approach was utilized.

Type IV Ehlers-Danlos syndrome with isolated arterial involvement

Ehlers-Danlos syndrome is a connective tissue disorder characterized by skin hyperelasticity and friability, hyperextensible small articulations, vascular fragility, and ocular and visceral symptoms. Ten types of Ehlers-Danlos syndrome have been described to date. Type IV is characterized by isolated arterial involvement with the risk of rupture, making diagnosis difficult. A 25-year-old man was operated on for a ruptured left and then right iliac artery and once again for a hepatic artery aneurysm within a nine month period. The diagnosis of Ehlers-Danlos syndrome was based on clinical and histopathologic findings. An asymptomatic iliac artery aneurysm was found in the patient's 23-year-old brother.

Hypertension and renal artery aneurysm: spontaneous cure

An 18-year-old man is described with an aneurysm of the left renal artery diagnosed during study for hypertension. Medical treatment achieved control of the blood pressure. The patient voluntarily interrupted treatment 1 1/2 years after initial diagnosis but the blood pressure remained normal. Angiography at that time revealed almost complete thrombosis of the aneurysm and peripheral plasma renin activity returned to normal in contrast to the high figures registered initially (15 ng. per ml., normal values 0.51 to 2.64). The patient had normal blood pressure, received no medication and was on only a salt-free diet 1 year after this event.

Cirsoid aneurysms of the jejunum. An unrecognized cause of massive gastrointestinal bleeding

Cirsoid aneurysms (exulceratio simplex Dieulafoy) as a cause of massive gastrointestinal hemorrhage have been known to occur in the stomach. Endoscopy plays an important role in the diagnosis of and therapy for these lesions. We report two cases of a cirsoid aneurysm in the proximal jejunum; two cases have been previously reported in the literature. These lesions have the same pathologic features as gastric cirsoid lesions and cause massive gastrointestinal hemorrhage. Because these lesions are beyond the reach of current endoscopy, surgery was necessary to diagnose and treat the lesions in three of four patients. The fourth patient died after unsuccessful surgical exploration, and the lesion was found post mortem. Jejunal cirsoid aneurysms may be an unrecognized rather than a rare cause of gastrointestinal bleeding. They should be considered in the patient with massive proximal gastrointestinal bleeding in whom the source is not known, especially if angiography suggests a small-bowel site. With the advent of newer forms of endoscopy that can examine the small bowel, the management of these lesions may change; at present, surgery is lifesaving.

Retinal macroaneurysms: the natural history in four patients

Macroaneurysms of the retinal arterioles are a clinical entity distinct from the aneurysmal dilations associated with Coats' disease, Leber's disease, Eales' disease, and angiomatosis retinae. The pathogenesis is not completely understood, but they are closely associated with systemic hypertension, generalized atherosclerosis, and age. Macroaneurysms have been classified into three major groups: exudative, hemorrhagic, and quiescent. Four examples of macroaneurysms are presented with photographic documentation. The clinical appearance, natural history, complications, and management of this retinal entity are discussed.

The relationship of retinal microaneurysm counts to the 4-year progression of diabetic retinopathy

The relationship of retinal microaneurysms to the progression of diabetic retinopathy over a 4-year period was examined in a population-based sample of diabetic persons. The number of microaneurysms in color stereoscopic fundus photographs of seven standard fields was counted in the eyes of diabetic persons (n = 236) who had only microaneurysms in photographs at the baseline examination. If only one eye was involved (n = 121), the mean number of microaneurysms was 2.3; with bilateral involvement (n = 115), the mean was 9.3 in the more involved eye. The number of microaneurysms at the baseline examination was positively associated with significant progression of retinopathy. This relationship remained after controlling for the level of glycosylated hemoglobin. These data suggest that the number of microaneurysms at baseline is an important predictor of progression of diabetic retinopathy. Microaneurysm counts may prove to be a useful early end point in clinical trials.

[Hemosuccus pancreaticus following rupture of a hepatic artery aneurysm]

We describe the rare case of a hemosuccus pancreaticus as the cause of an upper gastrointestinal bleeding. A perforated common hepatic artery aneurysm caused a bleeding into the pancreas and the pancreatic duct. Besides the hepatic artery-aneurysm aneurysms of the coeliac trunc and the splenic artery were found. After the bleeding had been localised by pancreoscopy and angiography, the coeliac trunc, the tail of the pancreas and the spleen were resected without any complication.

Bilateral ruptured isolated internal iliac artery aneurysms--report of a case and review of the literature

We present herein, a rare case of a 78-year-old man who experienced rupture of an isolated internal iliac artery aneurysm on 2 separate occasions. He underwent successful embolization with ligation of the right aneurysm at our institution, where only 2 such cases have ever been seen. Embolization with ligation proved very effective in clotting the intraaneurysmal blood in this case and would appear to be the treatment of choice for very large aneurysms. A review of the English and Japanese literature follows this case report.

[Aneurysm of the deep veins of the legs. Apropos of a case involving a vein in the calf]

A fusiform venous aneurysm of a deep calf vein was discovered following pulmonary embolism occurring during laparotomy in a 59 year old woman. This lesion has especially been described at popliteal vein level and 25 cases were found in the literature. Analysis shows that the principal clinical manifestation is pulmonary embolism due to clot migration from the thrombosed aneurysmal pocket. Local signs are much rarer. Diagnosis depends on venography. Subsequent management of a venous aneurysm, discovered incidentally, remains unclear since the incidence of complications is unknown. Anticoagulant therapy is required in the presence of thrombotic complications. The general tendency is to combine a caval filter with resection of the aneurysm. The necessity for venous reconstruction following the latter remains debatable.

[Aneurysm of the renal artery in youngsters: presentation of a case and review of the literature]

The case of a young man with an aneurysm of the renal artery, causing vasculorenal hypertension, and surgically treated, is presented. The present concepts of incidence, etiology, renal aneurysm-hypertension association, surgical indications and rupture risk, are exposed.

[Asymptomatic calcified aneurysm of the inferior pancreaticoduodenal artery--differential diagnostic considerations]

A calcified aneurysm of the inferior pancreaticoduodenal artery with simultaneous occlusion of the celiac axis but without any local symptoms is presented. In the description of the diagnostic procedure, the considerations relating to differential diagnosis against solitary circumferentially calcified masses in the right upper quadrant of the abdomen are discussed. As a result of increasingly sophisticated examination techniques, especially digital subtraction angiography, computed tomography and ultrasonography, these aneurysms, which were formerly thought to be rare, are now discovered surprisingly often. Knowledge of this vascular malformation and its differential diagnoses helps to avoid risky methods of examination.

Aneurysm of the left subclavian artery associated with Turner's syndrome. Successful surgical treatment

An unusual case of a 38-year-old woman with Turner's syndrome associated with aneurysmal dilation of the left subclavian artery is presented. Aortography revealed a fusiform aneurysm in the proximal segment of the left subclavian artery, which was as long as 6 cm. The diagnosis of Turner's syndrome was postoperatively confirmed by chromosomal study, which showed 45X0. The aneurysm was successfully removed and reconstruction was done by interposition of a woven Dacron graft, 8 mm in diameter and 6 cm in length, between the thoracic aorta and subclavian artery just proximal to the thoracic outlet. Microscopic findings of the resected tissue of the subclavian artery revealed deposition of acid mucopolysaccharide in the intima and media.

Computed tomography of bronchial artery aneurysm with erosion into the esophagus

Bronchial artery aneurysms are rare lesions. A case report is presented in which CT demonstrated a 7 cm enhancing mass that proved to be a mediastinal bronchial artery aneurysm. The aneurysm subsequently eroded into the esophagus, resulting in fatal exsanguination.