Aneurysm of the left aortic sinus causing acute myocardial infarction

This report describes the findings and management of a young male who presented with an acute ST-segment elevation myocardial infarction due to compression of the circumflex coronary artery by a large aneurysm of left sinus of Valsalva.

Recurrent true brachial artery aneurysm

True aneurysm of the brachial artery is a rare disease entity. The mechanism of aneurysm formation is considered to be compression of the arterial wall, producing contusion of the media and subsequent weakness of the wall and fusiform dilatation. It can be caused by arteriosclerotic, congenital, and metabolic disorders, and can be associated with diseases such as Kawasaki's disease. Doppler ultrasonography, computed tomography, arteriography, and selective upper extremity angiography may be performed for establishing the diagnosis of aneurysm. The best therapeutic option is operative repair, and it should be performed without any delay, in order to prevent upper extremity ischemic or thrombotic sequelae. Here, we report a case of recurrent brachial artery aneurysm with review of the literature.

"Real-world" comparison of non-invasive imaging to conventional catheter angiography in the diagnosis of cerebral aneurysms

Background:

Based on numerous reports citing high sensitivity and specificity of non-invasive imaging [e.g. computed tomography angiography (CTA) or magnetic resonance angiography (MRA)] in the detection of intracranial aneurysms, it has become increasingly difficult to justify the role of conventional angiography [digital subtraction angiography (DSA)] for diagnostic purposes. The current literature, however, largely fails to demonstrate the practical application of these technologies within the context of a “real-world” neurosurgical practice. We sought to determine the proportion of patients for whom the additional information gleaned from 3D rotational DSA (3DRA) led to a change in treatment.

Methods:

We analyzed the medical records of the last 361 consecutive patients referred to a neurosurgeon at our institution for evaluation of “possible intracranial aneurysm” or subarachnoid hemorrhage (SAH). Only those who underwent non-invasive vascular imaging within 3 months prior to DSA were included in the study. For asymptomatic patients without a history of SAH, aneurysms less than 5 mm were followed conservatively. Treatment was advocated for patients with unruptured, non-cavernous aneurysms measuring 5 mm or larger and for any non-cavernous aneurysm in the setting of acute SAH.

Results:

For those who underwent CTA or MRA, the treatment plan was changed in 17/90 (18.9%) and 22/73 (30.1%), respectively, based on subsequent information gleaned from DSA. Several reasons exist for the change in the treatment plan, including size and location discrepancies (e.g. cavernous versus supraclinoid), or detection of a benign vascular variant rather than a true aneurysm.

Conclusions:

In a “real-world” analysis of intracranial aneurysms, DSA continues to play an important role in determining the optimal management strategy.

Evaluating a thrombosed azygous vein aneurysm combined with pulmonary arterial thromboembolism by ECG-gated multidetector CT: a case report

Azygous vein aneurysm is a rare congenital lesion that needs to be differentiated from mediastinal mass lesions. Although almost of these anomalies are asymptomatic lesions, we experienced an interesting case in which a thrombus within an azygous vein aneurysm in a 75-year-old woman caused pulmonary thromboembolism. The patient was managed by medical treatment for one month and then the thrombus within both the azygous vein aneurysm and the pulmonary arteries completely resolved.

Time-resolved 3D contrast-enhanced MRA on 3.0T: a non-invasive follow-up technique after stent-assisted coil embolization of the intracranial aneurysm

Objective

To evaluate the usefulness of time-resolved contrast enhanced magnetic resonance angiography (4D MRA) after stent-assisted coil embolization by comparing it with time of flight (TOF)-MRA.

Materials and Methods

TOF-MRA and 4D MRA were obtained by 3T MRI in 26 patients treated with stent-assisted coil embolization (Enterprise:Neuroform = 7:19). The qualities of the MRA were rated on a graded scale of 0 to 4. We classified completeness of endovascular treatment into three categories. The degree of quality of visualization of the stented artery was compared between TOF and 4D MRA by the Wilcoxon signed rank test. We used the Mann-Whitney U test for comparing the quality of the visualization of the stented artery according to the stent type in each MRA method.

Results

The quality in terms of the visualization of the stented arteries in 4D MRA was significantly superior to that in 3D TOF-MRA, regardless of type of the stent (p < 0.001). The quality of the arteries which were stented with Neuroform was superior to that of the arteries stented with Enterprise in 3D TOF (p < 0.001) and 4D MRA (p = 0.008), respectively.

Conclusion

4D MRA provides a higher quality view of the stented parent arteries when compared with TOF.

Guidewire breakage during neurointerventional procedures: a report of two cases

We report on two cases of microguidewire breakage that occurred during endovascular treatment of intracranial aneurysms. The microguidewire can be broken when a part of the wire is stuck due to vascular tortuosity, and, subsequently, application of excessive rotational movement. The mechanical and physical properties of a microguidewire are also important factors in microguidewire breakage. We also suggest technical tips for avoidance of this problem.

Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages

OBJECTIVE

We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm.

CASE DESCRIPTION

A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss.

CONCLUSION

We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.

Cerebral artery dissection: spectrum of clinical presentations related to angiographic findings

Purpose

Cerebral arterial dissections are recognized as a common cause of stroke. However, few studies have reported on the distribution of cerebral arterial dissection and angiographic pattern related to the presenting clinical symptom pattern. We analyzed the distribution of cerebral artery dissection along with angiographic and clinical presenting a pattern as depicted on angiograms.

Materials and Methods

From January 2000 to January 2007, 133 arterial dissection patients admitted to our institutes were retrospectively reviewed. The characteristic angiographic findings of all cerebral arteries were carefully evaluated on 4-vessel angiograms. The male-female ratio was 77: 56 and the mean age was 51 years. According to the angiographic finding depicting the location of the dissection plane in the arterial wall, we categorized to steno-occlusive, aneurysmal, combined and unclassifiable pattern. In each dissection pattern, we evaluated presenting symptoms and presence of infarction or hemorrhage.

Results

The most common symptom on presentation was headache (47%), followed by motor weakness of arm or leg (31%), dysarthria/aphasia (19%) and vertigo (16%). The most common angiographic pattern was steno-occlusive (46%), followed by combined (steno-occlusive and aneurismal) (27%) and aneurysmal (22%) patterns. Steno-occlusive pattern was most commonly related to infarction (33/61, 54%) in contrast that aneurysmal pattern was most frequently related to subarachnoid hemorrhage (SAH) (7/29, 24%). The most frequent abnormality in patients with dissection of the intradural vertebral arteries including posterior cerebral artery (PCA) was SAH (23/70, 33%), followed by infarction. Infarction was the most common abnormality in patients with the extradural and intradural carotid arteries, and the extradural vertebral artery.

Conclusion

In contrast that the extradural arterial dissections tended to result in ischemia with steno-occlusive pattern, the intradural arterial dissections tended to result in SAH with aneurysmal type, especially in the vertebral artery. Dissection requires combined analysis of angiographic pattern and type of stroke depending on the location.

Traumatic Popliteal Artery Pseudoaneurysm Developed during a Soccer Game

A 38-year-old male was admitted to our hospital due to painful swelling of his right popliteal fossa. He had been kicked in his right popliteal fossa during a soccer game about three weeks earlier. Computerized tomographic angiography of the lower extremity demonstrated a 4-cm-wide, 3-cm-long aneurysmal change of the popliteal artery. He underwent aneurysmectomy and graft interposition using a great saphenous vein graft. Pathologic findings of the resected specimen were consistent with those of a pseudoaneurysm.

Spontaneous hemomediastinum and hemothorax caused by a ruptured bronchial artery aneurysm

A bronchial artery aneurysm (BAA) is uncommon and usually associated with chronic inflammatory lung disease or a systemic vascular condition, which is rarely the etiology of mediastinal hemorrhage. A middle-aged person presented with spontaneous hemothorax and hemomediastinum. A diagnostic evaluation identified a bronchial artery aneurysm as the source. To prevent further rupture, we performed a bronchial artery embolization. In the absence of trauma or other causes for hemothorax and mediastinal hemorrhage, the possibility of a BAA should be considered. A bronchial artery aneurysm can be managed by interventional techniques as well as surgery.

Azygos Vein Aneurysm - A Case for Elective Resection by Video-assisted Thoracic Surgery

An azygos vein aneurysm is a very rare cause of a posterior mediastinal mass. Once the diagnosis has been confirmed, no treatment is usually required. However, the aneurysm can thrombose, and this may lead pulmonary thromboembolism, or the aneurysm may rupture. In these instances, the excision of the mass is recommended. Video-assisted thoracic surgery techniques have considerably improved. If it is necessary to remove the aneurysm, video-assisted thoracic surgery may be a good option for surgical treatment. We report a case of an aneurysm of the azygos arch that was successfully resected by video-assisted thoracic surgery.

Aortic root and ascending aortic aneurysm in an adult with a repaired tetralogy of fallot

Surgical repair of the tetralogy of Fallot is one of the most successful operations in the treatment of congenital heart diseases. We report the case of a 65-year-old man who had an aortic valve replacement at the time of complete repair of the tetralogy of Fallot at the age of forty-three. He subsequently had progressive aortic root and ascending aorta dilation to 9 cm. The aortic root and ascending aorta replacement was done using a composite valve-graft and was performed along with other procedures. Thus, meticulous follow-up of aortic root and ascending aorta after corrective surgery for tetralogy of Fallot is recommended following initial curative surgery.

Multislice CT imaging of ruptured left sinus of Valsalva aneurysm with fistulous track between left sinus and right atrium

Sinus of valsalva aneurysm is a rare condition arising from any of the three aortic sinuses. Among them, an aneurysm arising from the left coronary sinus is the rarest. Most of these cases were earlier diagnosed using echocardiography and conventional angiography. But with the availability of advanced imaging modalities like 64 slice cardiac CT and MR modalities, this condition can be accurately assessed noninvasively. We report a case of ruptured aneurysm originating from the left coronary sinus with a long windsock type of fistulous track between the aneurysm and right atrium evaluated by 64 slice cardiac CT imaging. This was later confirmed perioperatively.

Serious Blood-Brain Barrier Disruption after Coil Embolization of Unruptured Intracranial Aneurysm : Report of Two Cases and Role of Immediate Postembolization CT Scan

Abnormal contrast enhancement on brain computed tomography (CT) scan after diagnostic or interventional angiography is not rare, and has known to be induced by temporary blood-brain barrier (BBB) disruption from contrast media. Furthermore, it has been regarded as clinically subtle, but reported to have no symptom or mild transient symptoms. However, we recently experienced two cases of serious BBB disruption during the acute period after coiling of an unruptured intracranial aneurysm. One patient presented with an unruptured paraclinoid internal carotid artery (ICA) aneurysm on the right and the other with an unruptured right supraclinoid ICA aneurysm. Both patients showed similar findings on immediate postembolization CT scan and clinical courses after coiling. Typical radiological, clinical characteristics of BBB disruption were described. In addition, the role of immediate postembolization CT scan are also discussed.

A very unusual anatomical variation and complication of common iliac artery and ureter in retroperitonoscopic ureterolithotomy

Anatomical localization of theureter comes along psoas major muscle and crosses over common iliac artery bifurcation. Common iliac artery aneurysm and impacted atherosclerosis are a rare condition that should be differed from the impacted ureter stone to avoid from undesirable complication. In this case, we present a very unusual anatomical variation and complication of common iliac artery and ureter in retroperitonoscopic ureterolithotomy.

Far-lateral approach for lower basilar artery aneurysms

OBJECTIVES

Aneurysms of the lower basilar artery are surgically difficult to expose and clip. Various cranial base approaches, which are associated with significant morbidity, have been used to access this region. We have used the far-lateral approach without occipital condyle drilling for clipping of lower basilar junction aneurysms to assess the exposure for adequate visualization and clipping, and to study the complications and outcome.

DESIGN

Retrospective review of data.

SETTING

Between 1997 and 2001, four patients with lower basilar artery aneurysms were operated on at Louisiana State University Health Sciences Center in Shreveport. The far-lateral approach without drilling of the occipital condyle was used in each procedure.

PARTICIPANTS

Cases of basilar artery aneurysms.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale (GOS) score.

RESULTS

All four aneurysms were clipped successfully. All patients had good outcome (GOS scores of 5 and 4). There were no instances of cerebrospinal fluid leakage or pseudomeningocele. Two patients experienced transient morbidity in the form of voice hoarseness and swallowing difficulty.

CONCLUSION

The far-lateral approach without drilling of the occipital condyle adequately exposed the lower basilar artery for successful clipping of aneurysms and was associated with minimal morbidity.

Percutaneous endovascular management of recurrent aneurysm of transplant renal artery anastomosed to internal iliac artery

Aneurysm formation constitutes 0.5 to 1% of all vascular complications in transplant patients. Aneurysms may result from infection, injury during procurement or preservation, faulty suture technique or trauma. Transplant renal artery aneurysm presents with hypertension, graft dysfunction and bleeding. We report a case of percutaneous covered stent-graft for recurrent aneurysm with stenosis of transplant renal artery. To our knowledge this is the first report of successful treatment of transplant renal artery aneurysm with covered stent-graft.

Endovascular repair of the thoracic aorta

The emergence of endovascular repair of the thoracic aorta (TEVAR) quickly followed the development of technology for the exclusion of infrarenal abdominal aortic aneurysms. Stent grafts comprised of metal struts covered with fabric made of Dacron/polyester or polytetrafluoroethylene were developed for the purpose of achieving an adequate seal at the proximal and distal aspects of thoracic aneurysms, thus excluding sac flow. The recognition of the decreased morbidity of this approach compared with open repair was readily apparent, as it avoided left thoracotomy, aortic cross-clamping, and left heart bypass. Since then, TEVAR is increasingly being used for other aortic pathologies such as complicated type B dissection, traumatic aortic transection, and aneurysmal disease extending into the arch or visceral segment, requiring debranching procedures.

Splenic artery aneurysm that gradually increased in size over 4 years until threatening rupture

A 47-year-old man was referred to our hospital due to a splenic artery aneurysm. The course of the disease was monitored by ultrasound every 6 months. At each examination, the tumor was found to have increased in size by several millimeters, but the sonographer decided that the increase was within the range of error. After 4 years, the tumor showed a rapid increase in size. With a diagnosis of threatened rupture, the patient's life was saved by surgical intervention. In this case, the observations were only compared to the findings from the previous examination, and the slight increase in tumor size was considered within the range of error. It is important to compare the findings not only with those from the previous examination but also with earlier results.

Emergency surgical salvage for severe intracranial aneurysm rupture during endovascular coiling procedures not amenable to additional coiling

Background:

We report the management and outcomes of six patients who underwent emergency surgical intervention in the setting of severe intraprocedural rupture during endovascular treatment of an intracranial aneurysm not amenable to additional coiling.

Methods:

From July 1997 through December 2010, our neurovascular service treated 1613 patients with coil embolization. During this time, we encountered six patients who suffered severe intraprocedural aneurysm rupture, defined by contrast extravasation during the coiling procedure, in whom additional attempted coiling failed to stop the ongoing extravasation. Hospital records, neuroimaging studies, operative reports, and follow-up clinic notes were complete and reviewed in all cases. The follow-up review in surviving patients ranged from 1.5 to 9 years (average 3.8 years), and no patient was lost to the follow-up review.

Results:

In all cases, persistent extravasation necessitated urgent surgical decompression and securing of the ruptured aneurysm. Of these six cases, three patients achieved a good functional status after prolonged rehabilitation, and one of these had only subtle cognitive changes on formal neuropsychological testing. Two patients died.

Conclusion:

Intraprocedural rupture during aneurysm coiling is a dangerous and potentially fatal event. Despite the seemingly hopeless nature of this situation, in our experience, aggressive management to control intracranial pressure combined with a rapid reversal of anticoagulation and early surgical intervention can result in reasonable outcomes in some patients.

Balloon-assisted coiling of the proximal lobule of a paraophthalmic aneurysm causing panhypopituitarism: Technical case report

Background:

We describe an intra-aneurysmal balloon-assisted technique to limit the coil volume in a large bilobulated paraophthalmic aneurysm. Our intent was to reduce the mass effect and presenting symptoms of diabetes insipidus (DI) with hypopituitarism.

Case Description:

A 32-year-old woman presented with symptoms of DI and her work-up demonstrated hypopituitarism and partial bitemporal visual field defects. Cerebral angiography revealed a large paraophthalmic aneurysm with two distinctive lobules, projecting toward the pituitary fossa. The patient declined craniotomy but consented for endovascular treatment. The plan was to limit the embolization to the proximal lobule only. Initially, we used a dual microcatheter technique with a microcatheter in each lobule. A framing coil in the distal lobule did not prevent coil migration from the proximal lobule. Instead, we elected to use a Hyperform balloon in the distal lobule and were able to successfully coil the proximal lobule only. Her 3-year follow-up angiogram revealed a completely occluded aneurysm. The patient experienced resolution of the DI and improvement of her visual fields. However, she remained in hypopituitarism.

Conclusion:

Intra-aneurysmal balloon-assisted coiling of proximal aneurysmal lobules might be an alternative for the reduction of mass effect related to the coil mass. Careful follow-up is needed because subtotal occlusion carries a future risk of growth, recanalization and rupture. Unruptured intracranial carotid aneurysms can present with reversible DI and usually permanent pituitary disturbances.

Alteration of intra-aneurysmal hemodynamics for flow diversion using enterprise and vision stents

OBJECTIVE

Flow diversion is a novel concept for intracranial aneurysm treatment. The recently developed Enterprise Vascular Reconstruction Device (Codman Neurovascular, Raynham MA) provides easy delivery and repositioning. Although designed specifically for restraining coils within an aneurysm, this stent has theoretical effects on modifying flow dynamics, which have not been studied. The goal of this study was to quantify the effect of single and multiple self-expanding Enterprise stents alone or in combination with balloon-mounted stents on aneurysm hemodynamics using computational fluid dynamics (CFD).

METHODS

The geometry of a wide-necked, saccular, basilar trunk aneurysm was reconstructed from computed tomographic angiography images. Various combinations of 1-3 stents were "virtually" conformed to fit into the vessel lumen and placed across the aneurysm orifice. CFD analysis was performed to calculate hemodynamic parameters considered important in aneurysm pathogenesis and thrombosis for each model.

RESULTS

The complex aneurysmal flow pattern was suppressed by stenting. Stent placement lowered average flow velocity in the aneurysm; further reduction was achieved by additional stent deployment. Aneurysmal flow turnover time, an indicator of stasis, was increased to 114-117% for single-stent, 127-128% for double-stent, and 141% for triple-stent deployment. Furthermore, aneurysmal wall shear stress (WSS) decreased with increasing number of deployed stents.

CONCLUSION

This is the first study analyzing flow modifications associated with placement of Enterprise stents for aneurysm occlusion. Placement of 2-3 stents significantly reduced intra-aneurysmal hemodynamic activities, thereby increasing the likelihood of inducing aneurysm thrombotic occlusion.

Endovascular stenting of an extracranial-intracranial saphenous vein high-flow bypass graft: Technical case report

Background:

The authors describe a case of endovascular stenting of an extracranial–intracranial saphenous vein high-flow bypass graft in the management of a complex bilateral carotid aneurysm case.

Case Description:

A 43-year-old woman was admitted with progressive visual field restriction and headache. Imaging studies revealed bilateral supraclinoid carotid aneurysms. The right carotid aneurysm was clipped and the left one was treated by an endovascular procedure, after performing an internal carotid artery–middle cerebral artery (ICA-MCA) saphenous vein bypass graft. A few months following the bypass procedure, a 70–80% stenosis of the graft was discovered and treated endovascularly with a stenting procedure. Follow-up at 36 months after the first operation showed the patency of the venous graft and no neurological deficits.

Conclusions:

Endovascular stenting of the extracranial–intracranial saphenous vein high-flow bypass graft is technically feasible when postoperative graft occlusion is discovered.

Glue embolization of ruptured anterior thalamoperforating artery aneurysm in patient with both internal carotid arteries occlusion

Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.

Monitoring of brain oxygenation in surgery of ruptured middle cerebral artery aneurysms

Background:

The occurrence of brain ischemic lesions, due to temporary arterial occlusion or incorrect placement of the definitive clip, is a major complication of aneurysm surgery. Temporary clipping is a current technique during surgery and there is no reliable method of predicting the possibility of ischemia due to extended regional circulatory interruption. Even with careful inspection, misplacement of the definitive clip can be difficult to detect. Brain tissue oxygen concentration (PtiO₂) was monitored during surgery of middle cerebral artery (MCA) aneurysm presenting with subarachnoid hemorrhage (SAH), for detection of changes in brain oxygenation due to reduced blood flow, as a predictor of ischemic events, during temporary clipping and after definitive clipping.

Methods:

PtiO₂ was monitored during surgery of 13 patients harboring MCA aneurysms presenting with SAH, using a polarographic microcatheter (Licox, GMS, Kiel, Germany) placed in the territory of MCA.

Results

A decrease in PtiO₂ values was verified in every period of temporary clipping. Brain infarction occurred in 2 patients; in both cases, there was a decrease in PtiO₂ greater than 80% from basal value, a minimum value of less than 2 mmHg persisting for 2 or more minutes during temporary clipping, and an incomplete recovery of PtiO₂ after definitive clipping. In 2 patients, incomplete recovery of values after definitive clipping led to verification of inappropriate placement and repositioning of the clip.

Conclusion:

The results suggest that intraoperative monitoring of PtiO₂ may be a useful method of detection of changes in brain tissue oxygenation during MCA aneurysm surgery. Postoperative infarction in the territory of MCA developed in cases with an abrupt decrease of PtiO₂ and a very low and persistent minimum value, during temporary clipping, and an incomplete recovery after definitive clipping. Verification of clip position should be considered when there is an incomplete recovery or a persistent fall in PtiO₂ after definitive clipping.

Unusual cause of acute right ventricular dysfunction: rapid progression of superior vena cava aneurysm complicated by thrombosis and pulmonary thromboembolism

Aneurysms of the major thoracic veins are rare. They are usually asymptomatic and thus treated conservatively. We report an extremely rare case of rapidly progressing superior vena cava (SVC) aneurysm complicated by thrombosis and acute pulmonary thromboembolism (PTE) with right ventricular dysfunction. Thrombolytic therapy for hemodynamically significant acute PTE was harmful to the patient in the present case, because it induced further thrombosis and mobilization of the thrombi within the aneurysm, subsequently causing de novo PTE. Surgical aneurysmectomy combined with pulmonary artery embolectomy would be a treatment of choice in patients with SVC aneurysm complicated by acute PTE.

Thoracic EndoVascular Stent Graft Repair for Aortic Aneurysm

BACKGROUND

The number of cases employing thoracic endovascular aortic repair (TEVAR) has been increasing due to lower morbidity and mortality compared to open repair technique. The aim of this study is to evaluate the outcome of TEVAR for thoracic aortic diseases.

MATERIALS AND METHODS

Sixteen patients underwent TEVAR from October 2003 to April 2010. Mean age at operation was 59 years (20~78 years), and 11 were male. Indications for TEVAR were large aortic diameter (>5.5 cm) upon presentation in 6 patients, increasing aortic diameter during the follow-up period in 4, traumatic aortic rupture in 3, persistent chest pain in 2, and ruptured aortic aneurysm in one. The mean diameter, length and the number of the stents were 33 mm (26~40 mm), 12 cm (9.5~16.0 cm), and 1.25 (1~2), respectively. Aortography employing Multi-detector computerized tomography (MDCT) technique was performed at one week, and patients were followed up in the out-patient department at one month, 6 months, and one year postoperatively.

RESULTS

Primary technical success showing complete exclusion of the aneurysm was achieved in 15 patients. One patient showed a small endo-leak (type 1). Four patients developed perioperative stroke: Three recovered without sequelae, and one showed mild right-side weakness. There was no operative mortality. Diameter of the thoracic aorta covered by stent graft changed within 10% range in 12 patients, decreased by more than 10% in 3, and increased by more than 10% in one during mean follow-up duration of 18 months (1~73 months). There was no recurrence-related death during this period.

CONCLUSION

Intermediate-term outcome after TEVAR was encouraging. Indications for TEVAR could be extended for other thoracic aortic diseases.

Use of omental pedicles in mycotic abdominal aortic aneurysm repair

We report a case of a sixty year old man with a mycotic infra-renal abdominal aortic aneurysm complicated by a left psoas abscess. After treatment with parenteral antibiotics he underwent early aortic reconstruction with an in-situ prosthetic graft wrapped in an omental pedicle. Mycotic abdominal aortic aneurysms can be treated in this way despite the potential for graft infection from persisting retroperitoneal sepsis.

Monitoring of brain tissue oxygenation in surgery of middle cerebral artery incidental aneurysms

Introduction:

The management of incidental unruptured aneurysms remains a matter of controversy; middle-sized or large anterior circulation incidental aneurysms, in young or middle age patients, should be considered for treatment. Surgical clipping is an accepted treatment for middle cerebral artery unruptured aneurysms. Ischemic events can occur even in cases of incidental aneurysm surgery. Since regional cerebral blood flow can be compromised due to temporary arterial clipping or to incorrect placement of defi nitive clip, we performed intra-operative monitoring of brain tissue oxygen concentration (PtiO₂), to detect changes in brain oxygenation due to reduced blood fl ow, eventually leading to ischemia, during surgery of middle cerebral artery incidental aneurysms.

Methods:

PtiO₂ monitoring was performed during surgery of eight patients harboring incidental MCA aneurysms, using a polarographic microcatheter (Licox, GMS – Kiel, Germany), placed in the temporal lobe on the side of the lesion, from dural opening to dural closure.

Results:

Basal values varied between 2.3 and 27.3 mmHg; these values are lower than those previously described in the literature as “normal” for uninjured brain or in cases of subarachnoid hemorrhage. In all patients, a significant decrease in PtiO2 was found in every period of temporary clipping of MCA. Post-operative infarction in the territory of middle cerebral artery occurred in one patient and, in that case, there was a persistent minimum value of 0.6 mmHg, without recovery after the placement of the definitive clip. In another patient, an incorrect placement of the definitive clip could be predicted by a decrease in PtiO₂ value.

Conclusions:

PtiO₂ monitoring during aneurysm surgery shows brain tissue perfusion in real time and there is a correlation between any episode of reduced blood flow to the affected vascular territory during surgery and a decrease of PtiO2 values. Unexpected low basal values were obtained in “uninjured” brain, with no influence from subarachnoid hemorrhage. The values of risk for brain infarction during temporary arterial occlusion still need further studies, but an incomplete recovery or a persistent fall in PtiO₂ values after definitive clipping should be considered as an indication for verification of the position of the clip.

Ruptured de novo posterior communicating artery aneurysm associated with arteriosclerotic stenosis of the internal carotid artery at the supraclinoid portion

Background:

Several de novo intracranial aneurysms have been described related to changes in hemodynamics after therapeutic occlusion of internal carotid artery (ICA); however, de novo aneurysms related to a supraclinoid arteriosclerotic stenosis of the ICA have not been described yet. Authors consider that it is important to bear in mind the possibility of developing an aneurysm in these special conditions.

Case Description:

The evolution of a 62-year-old patient with subarachnoid hemorrhage, intraparenchymal frontal hematoma with some atypical circumstances that were presented together as well as the treatment he received are shown in this report. We can see this patient suffered a right thalamic hemorrhage at the age of 51 years; this condition was associated to a severe atherosclerotic stenosis of right supraclinoid ICAy. A long term had elapsed since the diagnosis of the stenosis and the discovery of a ruptured ipsilateral de novo supraclinoid internal carotid artery-posterior communicating artery (ICA-PcomA) aneurysm.

Conclusions:

It seems like both conditions: the atherosclerotic supraclinoid ICA which tells of an Samano et at: Ruptured De Novo PcomA Aneurysm Associated with Arteriosclerotic Stenosis of Supraclinoid ICA. Altered vessel environment coupled to a long exposure time, hemodynamic changes, unbalance in the wall sheer stress could all of them lead to the development of the de novo aneurysm.

Hypercholesterolemia increases vasospasm resulting from basilar artery subarachnoid hemorrhage in rabbits which is attenuated by Vitamin E

BACKGROUND

Aneurysm rupture results in subarachnoid hemorrhage (SAH) with subsequent vasospasm in the cerebral and cerebellar major arteries. In recent years, there has been increasing evidence that hypercholesterolemia plays a role in the pathology of SAH. It is known that hypercholesterolemia is one of the major risk factors for the development of atherosclerosis. Among the factors that have been found to retard the development of atherosclerosis is the intake of a sufficient amount of Vitamin E. An inverse association between serum Vitamin E and coronary heart disease mortality has been demonstrated in epidemiologic studies. Therefore, we tested, in an established model of enhanced cholesterol feed in rabbits, the effects of hypercholesterolemia on vasospasm after SAH by using computed tomography (CT) angiograms of the rabbit basilar artery; in addition, we tested the effects of Vitamin E on these conditions, which have not been studied up to now.

METHODS

In this study rabbits were divided into 3 major groups: control, cholesterol fed, and cholesterol + Vitamin E fed. Hypercholesterolemia was induced by a 2% cholesterol-containing diet. Three rabbit groups were fed rabbit diet; one group was fed a diet that also contained 2% cholesterol and another group was fed a diet containing 2% cholesterol and they received i.m. injections of 50 mg/kg of Vitamin E. After 8 weeks, SAH was induced by the double-hemorrhage method and distilled water was injected into cisterna magna. Blood was taken to measure serum cholesterol and Vitamin E levels. Basilar artery samples were taken for microscopic examination. CT angiography and measurement of basilar artery diameter were performed at days 0 and 3 after SAH.

RESULTS

Two percent cholesterol diet supplementation for 8 weeks resulted in a significant increase in serum cholesterol levels. Light microscopic analysis of basilar artery of hypercholesterolemic rabbits showed disturbances in the subendothelial and medial layers, degeneration of elastic fibers in the medial layer from endothelial cell desquamation, and a reduction of waves in the endothelial layer. However, the cholesterol + Vitamin E group did not exhibit these changes. The mean diameter of the basilar artery after SAH induction in the cholesterol-treated group was decreased 47% compared with the mean diameter of the control group. This value was less affected in cholesterol + Vitamin E-treated rabbits, which decreased 18% compared with the mean diameter of the control group.

CONCLUSIONS

Hypercholesterolemia-related changes in the basilar artery aggravate vasospasm after SAH. Adding Vitamin E to cholesterol-treated rabbits decreased the degree of vasospasm following SAH in the rabbit basilar artery SAH model. We suggest that Vitamin E supplements and a low cholesterol diet may potentially diminish SAH complicated by vasospasm in high-risk patients.

Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.

Idiopathic cystic artery aneurysm complicated with hemobilia

Aneurysm of the cystic artery is not common, and it is a rare cause of hemobilia. Most of reported cases are pseudoaneurysms resulting from either an inflammatory process in the abdomen or abdominal trauma. We report a healthy individual who developed hemobilia associated with cystic artery aneurysm. The patient was managed with cholecystectomy and concomitant aneurysm repair. Visceral artery aneurysms are rare and can rupture with potentially grave outcome due to excessive bleeding. Angiographic embolization is a common method of treatment for visceral artery aneurysms. Open cholecystectomy and aneurysm repair was performed in our patient due to radiological evidence of associated cholecystitis.

Isolated iliac artery aneurysm rupture presenting as left iliac fossa pain and diarrhoea: A case report

Isolated iliac aneurysm rupture is rare and difficult to diagnose, but needs to be actively considered and excluded. We document the case of a 71 year old female who presented with left iliac fossa pain and diarrhoea and was subsequently found to have a ruptured isolated iliac artery aneurysm. This case demonstrates the importance of urgent diagnostic CT in surgical patients, who present with features of abdominal pain and shock. The key to survival is early diagnosis, appropriate resuscitation and prompt definitive open or endovascular repair.

Role of multidetector computed tomography in evaluating complications following endovascular repair of aortic aneurysm

Objective:

To study the role of multidetector computed tomography (MDCT) in evaluating various complications following endovascular stenting of aortic aneurysms.

Materials and Methods:

Over a period of 2 years (June 2005 to June 2007), 50 patients with aortic aneurysm on computed tomography (CT) angiogram were prospectively studied. Images were acquired on a 64 slice multidetector row CT scanner (GE—LightSpeed VCT) after intravenous administration of nonionic iodinated contrast. Nineteen patients underwent endovascular stent-graft repair based on their medical and surgical risk factors. Stent-graft related complications were recorded by CT angiography and analyzed using descriptive statistics.

Results:

Most common complication related to the endovascular stent-graft placement was endoleak (44.4%), followed by puncture site hematoma (27.8%), thrombotic occlusion of a limb of the bifurcated stent graft, kinking of the stent-graft, and difficult catheterization with intimal tear in the common iliac artery were 5.6% each. Poststent diameter of the aneurysm was an important predictor of endoleaks. All the patients with either increase or no change in the aneurysm size had endoleaks.

Conclusion:

MDCT angiography is an important modality in identifying, describing, and following up the various complications following endovascular repair of aortic aneurysms, endoleaks being the most common complication. Decrease in the poststent diameter of the aneurysm suggested a good outcome.

Conservative management of post traumatic thoraco diaphragmatico biliary fistula

We report herein a case of thoraco diaphragmatico biliary fistula in a 24-year-old male who was managed conservatively with antibiotics and tube thoracostomy and had complete radiological clearance.

Cardiogenic shock following blunt chest trauma

Cardiac contusion, usually caused by blunt chest trauma, has been recognized with increased frequency over the past decades. Traffic accidents are the most frequent cause of cardiac contusions resulting from a direct blow to the chest. Other causes of blunt cardiac injury are numerous and include violent fall impacts, interpersonal aggression, explosions, and various types of high-risk sports. Myocardial contusion is difficult to diagnose; clinical presentation varies greatly, ranging from lack of symptoms to cardiogenic shock and arrhythmia. Although death is rare, cardiac contusion can be fatal. We present a case of cardiac contusion due to blunt chest trauma secondary to a fall impact, which manifested as cardiogenic shock.

Successful obliteration of unclippable large and giant middle cerebral artery aneurysms following extracranial-intracranial bypass and distal clip application

Large to giant middle cerebral artery aneurysm is a challenging disease, especially when incorporating important perforating arteries. Surgical risk increases by perforator infarction and anatomical complexity. In this clinical setting, extensive consideration of surgical options is needed. The two cases described here were unruptured and had rather stable wall. Because of their large and giant size, hardness and incorporated arteries, it was not affordable to isolate them by means of clipping or trapping. The procedure as the alternative to conventional treatment modalities, extracranial-intracranial bypass followed by clipping of only the efferent artery successfully treated the aneurysms.

Color Doppler ultrasonography of the abdominal aorta

Alterations of the abdominal aorta are relatively common, particularly in older people. Technological advances in the fields of ultrasonography, computed tomography, angiography, and magnetic resonance imaging have greatly increased the imaging options for the assessment of these lesions. Because it can be done rapidly and is also non-invasive, ultrasonography plays a major role in the exploration of the abdominal aorta, from its emergence from the diaphragm to its bifurcation. It is indicated for the diagnosis and follow-up of various aortic diseases, especially aneurysms. It can be used to define the shape, size, and location of these lesions, the absence or presence of thrombi and their characteristics. It is also useful for monitoring the evolution of the lesion and for postoperative follow-up. However, its value is limited in surgical planning and in emergency situations.

Aortic aneurysm formation following coarctation repair by Dacron patch aortoplasty

We describe the finding of an aortic aneurysm in an asymptomatic 43-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 25 years before. The role of magnetic resonance angiography as standard imaging technique in lifelong postoperative surveillance is discussed subsequently. (Neth Heart J 2010;18:376-7.).

Hematuria secondary to an internal iliac artery aneurysm

We report a case of macroscopic hematuria secondary to an aneurysm of the internal iliac artery. An 84-year-old male presented to our department with a 12-hour history of painless gross hematuria. Cystoscopy showed decreased expansion suggesting compression from outside the bladder. At the point of compression, increased vascularization was noted in the bladder mucosa without evidence of active bleeding. No trace of blood was identified coming from the ureteric orifices, the bladder neck, or the prostate. There was no evidence of intra-vesicular masses or other inflammatory changes. The abdominal computed tomography scan revealed left-sided hydronephrosis and an abdominal aortic aneurysm involving the aortic bifurcation and both internal iliac arteries. There was no evidence of rupture. An aneurysm of the internal iliac artery is a rare cause of macroscopic hematuria that can be fatal. Awareness of this as a possible cause of hematuria may assist in immediate diagnosis and appropriate treatment.

A rare case of unruptured sinus of valsalva aneurysm obstructing the right ventricular outflow tract

An unruptured sinus of Valsalva aneurysm is rare and is usually asymptomatic until a symptom associated with its complication develops. Hence, an unruptured sinus of Valsalva aneurysm is not infrequently missed unless echocardiogram is performed with other indications. An unruptured sinus of Valsalva aneurysm rarely protrudes into the right ventricular outflow tract, causing the right ventricular outflow tract obstruction. In this report, I describe a rare case of unruptured sinus of Valsalva aneurysm producing the right ventricular outflow tract obstruction, which was incidentally detected by echocardiography.

Pulmonary valve endocarditis associated with a ruptured aneurysm of the right sinus of Valsalva

Pulmonary valve endocarditis is an extremely rare complication of aneurysm of the sinus of Valsalva. We report the case of a 26-year-old male patient who presented with pulmonary valve endocarditis which was associated with a ruptured aneurysm of the right sinus of Valsalva with aorto-right ventricular outflow tract fistula and aortic valve endocarditis. He underwent aortic valve replacement with a 23 mm pericardial bioprosthesis, reconstruction of the right sinus of Valsalva using a pericardial patch, and debridement of pulmonary valve leaflet vegetations. The operation was a complete success. Intraoperative transesophageal echocardiography showed no residual shunt within the reconstructed right coronary sinus, normal function of aortic bioprosthesis, and mild mitral, tricuspid, and pulmonary regurgitation. Postoperative antibiotics were continued and the patient recovered uneventfully.

Luetic aortopathy: Revisited

We report a case of 38-year-old male, who presented with a large pulsatile swelling on the left side of the anterior chest wall of 4 months' duration with a gradual increase in size. He gave history of sexual promiscuity in the form of unprotected sexual intercourse prior to his marriage in his early 20s. He also gave a history of ulceration on coronal sulcus of glans penis 20 years back with painless right inguinal mass. His blood serology was strongly positive for syphilis and hepatitis B surface antigen (HBsAg); however, serology for retroviral infection was negative. Computed tomography-angiography confirmed the pulsatile swelling as aneurysm of the arch of and ascending aorta. In view of the history, positive serology, and imaging studies, we concluded the aortic aneurysm to be of syphilitic origin. We report this case due to its extreme rarity in the present antibiotic era.

Giant aneurysm formation in sporadic renal angiomyolipoma

Angiomyolipomas are the most common mesenchymal renal neoplasms. Two types have been described: (i) sporadic angiomyolipoma and (ii) angiomyolipoma associated with tuberous sclerosis. Giant aneurysm formation is usually noted in angiomyolipomas associated with tuberous sclerosis and is rare in sporadic variety. Tumor diameter and aneurysm diameter have been used as predictors of rupture. We report a rare case of aneurysm formation in a sporadic angiomyolipoma.

Three-dimensional digital subtraction angiographic evaluation of aneurysm remnants after clip placement

OBJECTIVE

The aneurysm remnants rate was evaluated via three-dimensional digital subtraction angiography (3D-DSA) in the postoperative evaluation of clipped aneurysms.

METHODS

Data on surgically clipped aneurysms of anterior circulation obtained via postoperative 3D-DSA from February 2007 to March 2009 were gathered. The results of the postoperative 3D-DSA and of two-dimensional digital subtraction angiography (2D-DSA) for the detection of aneurysm remnants were compared, and an investigation was performed as to why 2D-DSA had missed some aneurysm remnants that were detected in the 3D-DSA. Various surgical factors that revealed aneurysm remnants in the 3D-DSA were also evaluated.

RESULTS

A total of 39 neck remnants of 202 clipped aneurysms (19.3%) were confirmed in 3D-DSA, and these were classified according to Sindou's classification of aneurysm remnants. Patients with only a neck remnant found in the 3D-DSA represented 17.3% (35/202 aneurysms) of the whole series, and those with a residuum of neck plus sac found in the 3D-DSA represented 1.9% (4/202 aneurysms). The causes of aneurysm remnants were no full visualization (14/39, 35.9%), parent and perforator artery protection (10/39, 25.6%), clip design problems (8/39, 20.5%), and broad-necked aneurysm (7/39, 17.9%).

CONCLUSION

Patients with </= 2 mm aneurysm remnants showed an increased risk of undetectable aneurysm remnants in the 2D-DSA. The most frequent location of the missed aneurysm in 2D-DSA was the anterior communicating artery. 3D-DSA showed more aneurysm remnants than what is indicated in the existing literature, the 2D-DSA.

Treatment of unruptured intracranial aneurysms in South Korea in 2006 : a nationwide multicenter survey from the korean society of cerebrovascular surgery

OBJECTIVE

There have been no clinical studies regarding the epidemiology and treatment outcome for unruptured intracranial aneurysm (UIA) in South Korea yet. Thus, The Korean Society of Cerebrovascular Surgery (KSCVS) decided to evaluate the clinical and epidemiological characteristics, and outcome of the treatment of UIA in 2006, using the nationwide multicenter survey in South Korea.

METHODS

A total of 1,696 cases were enrolled retrospectively over one year at 48 hospitals. The following data were obtained from all patients : age, sex, presence of symptoms, location and size of the aneurysm, treatment modality, presence of risk factors for stroke, and the postoperative 30-day morbidity and mortality.

RESULTS

The demographic data showed female predominance and peak age of seventh and sixth decades. Supraclinoid internal carotid artery was the most common site of aneurysms with a mean size of 5.6 mm. Eight-hundred-forty-six patients (49.9%) were treated with clipping, 824 (48.6%) with coiling, and 26 with combined method. The choice of the treatment modalities was related to hospital (p = 0.000), age (p = 0.000), presence of symptom (p = 0.003), and location of aneurysm (p = 0.000). The overall 30-day morbidity and mortality were 7.4% and 0.3%, respectively. The 30-day mortality was 0.4% for clipping and 0.2% for coiling, and morbidity was 8.4% for clipping and 6.3% for coiling. Age (p = 0.010), presence of symptoms (p = 0.034), size (p = 0.000) of aneurysm, and diabetes mellitus (p = 0.000) were significant prognostic factors, while treatment modality was not.

CONCLUSION

This first nation-wide multicenter survey on UIAs demonstrates the epidemiological and clinical characteristics, outcome and the prognostic factors of the treatment of UIAs in South Korea. The 30-day postoperative outcome for UIAs seems to be reasonable morbidity and mortality in South Korea.

Aneurysmal rebleeding : factors associated with clinical outcome in the rebleeding patients

OBJECTIVE

Aneurysmal rebleeding is a major cause of death and disability. The aim of this study is to investigate the incidence of rebleeding, and the factors related with patient's outcome.

METHODS

During a period of 12 years, from September 1995 to August 2007, 492 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) underwent surgery at our institution. We reviewed the patient's clinical records, radiologic findings, and possible factors inducing rebleeding. Also, we statistically analyzed various factors between favorable outcome group (FG) and unfavorable outcome group (UG) in the rebleeding patients.

RESULTS

Rebleeding occurred in 38 (7.7%) of 492 patients. Male gender, location of aneurysm (anterior communicating artery) were statistically significant between rebleeding group and non-rebleeding group (p = 0.01 and p = 0.04, respectively). Rebleeding occurred in 26 patients (74.3%) within 2 hours from initial attack. There were no statistically significant factors between FG and UG. However, time interval between initial SAH to rebleeding was shorter in the UG compared to FG (FG = 28.71 hrs, UG = 2.9 hrs).

CONCLUSION

Rebleeding occurs more frequently in the earlier period after initial SAH. Thus, careful management in the earlier period after SAH and early obliteration of aneurysm will be necessary.

Saccular aneurysm at the anterior communicating artery complex associated with an accessory middle cerebral artery : report of two cases and review of the literature

Accessory middle cerebral artery (MCA) is an infrequent vascular anomaly of the brain. Cerebral aneurysms associated with this anomalous artery are also very rare. To our knowledge, there have only been ten previous reports of an aneurysm associated with accessory MCA. The authors present two patients with accessory MCA-related aneurysms. A 38-year-old male and a 59-year-old female both presented with sudden-onset severe headache. In both patients, computed tomography (CT) scan revealed subarachnoid hemorrhage. A subsequent angiogram demonstrated an accessory MCA arising from the anterior cerebral artery (ACA) and a saccular aneurysm at the anterior communicating artery (ACoA) complex associated with an accessory MCA. Surgical clipping allowed for complete exclusion of the aneurysm from the arterial circulation. Based on our review of the ten cases of aneurysms associated with accessory MCA documented in the literature, we suggest that accessory MCA-related aneurysms can be classified according to whether the accessory MCA originates from the proximal A1 segment or from the ACoA complex. We also emphasize the importance of precise interpretation of preoperative angiograms and intraoperative precaution in determining the presence of this anomalous artery prior to temporary clip placement.