Aneurismas del ápex carotideo en la edad pediátrica: Reporte de un caso / Carotid apex aneurysms in children: Case report

Introducción. Las malformaciones aneurismáticas del polígono de Willis comprenden un raro grupo de anomalías congénitas que se presentan en edades pediátricas. Son causa importante de morbimortalidad en este grupo de edad; en consecuencia, el manejo de estas lesiones es complejo y potencialmente letal, y puede plantear problemas para el paciente y su tratamiento. Caso clínico. Presentamos el caso de una niña de 10 años que inició de manera súbita con síncope neurogénico y crisis convulsivas tónico-clónicas generalizadas. Al llegar a urgencias, se le realizó una tomografía donde se identificó hemorragia subaracnoidea Fisher II. En la angiografía cerebral de 4 vasos se observó una lesión sacular del ápex carotideo, de aproximadamente 5.1 x 7.2 mm, con cuello visible y domo dirigido hacia la parte cefálica y hacia la parte frontal. Se le realizó craneotomía fronto-pterional derecha. Durante el transquirúrgico, se llevaron a cabo un ultrasonido pre-clipaje, que identificó la lesión aneurismática, y uno post-clipaje, para verificar la permeabilidad de las ramas distales al clipaje. Conclusiones. Las malformaciones aneurismáticas en la edad pediátrica son extremadamente raras. Por ello, métodos como la endoscopia y la sonografía transoperatoria y postoperatoria son de gran utilidad, ya que evidencian detalles que en ocasiones los estudios de imagen convencionales no revelan. Todo esto condiciona un procedimiento con menor riesgo de morbimortalidad para este tipo de pacientes.

Background. Aneurysm malformations of the circle of Willis comprise a rare group of congenital anomalies that occur during the pediatric age and are a major cause of morbidity and mortality in this age group. Consequently, management of these lesions is complex and potentially lethal and may pose problems for the patient and affect their treatment. Case report. We report the case of a 10-year-old girl who had a sudden onset of neurogenic syncope and tonic-clonic seizures. After arriving at the emergency room, she underwent a CT scan, identifying a Fisher II subarachnoid hemorrhage. Four-vessel cerebral angiography identified apex saccular carotid injury ~5.1 x 7.2 mm with visible neck and dome partially cephalic and partially frontal. Right frontopterional craniotomy was performed and preclipping during trans-surgical ultrasound was performed, identifying the aneurysmal lesion and post-clipping to verify patency of the distal branches to clipping. Conclusions. Aneurysmal malformations in children are extremely rare. For this reason, methods such as endoscopy, trans- and postoperative ultrasound are very useful. These procedures sometimes reveal details that conventional imaging studies do not, determining use of a procedure with less risk of morbidity and mortality for these patients.

Aneurysmal Rupture of the Internal Carotid Artery in a Presumed Neurofibromatosis Type I Patient / 대한법의학회지

Aneurysm of the internal carotid artery is a rare disease and is known to be associated with congenital arterial anomalies such as neurofibromatosis type I (NF-I). NF-I is an autosomal dominant neurocutaneous disorder characterized by a variety of manifestations that involve the central and peripheral nervous systems, skin, vascular system, and skeleton. In particular, the involvement of vascular abnormalities in NF-I is well known. Any vessel may be affected by this condition, although the renal artery is most frequently involved. The vascular abnormality can be occlusive or an aneurysmal degenerative change. Therefore, symptomatic presentations might assume an indolent pathophysiologic course such as hypertension, or manifest as a catastrophic event such as arterial rupture that could result in sudden death. We report a rare autopsy case of an aneurysmal rupture of the internal carotid artery in a woman with suspected NF-I, who collapsed in her home.

Massive Gastrointestinal Bleeding due to Aneurysmal Rupture of Ileo-colic Artery in a Patient with Behcet's Disease / 대한소화기학회지

Behcet's disease has been recognized as a systemic vasculitis characterized by the involvement of multiple organs such as orogenital ulcers, eye lesions including uveitis and optic neuritis, and skin lesions including folliculitis and erythema nodosum. Vascular involvement occurs occasionally and is classified into thrombosis and aneurysm. However, massive gastrointestinal bleeding from arterial aneurysm is a rare manifestation of intestinal Behcet's disease. Recently, we experienced a case of intestinal Behcet's disease presenting with massive gastrointestinal bleeding due to aneurysmal rupture of ileo-colic artery. A 30-year-old male with Behcet's disease was admitted because of massive gastrointestinal bleeding. A large ileo-cecal ulcer was revealed as a bleeding focus on colonoscopic examination. Celiac angiography showed aneurysm and stenosis of ileo-colic artery. After the failure of hemostasis with arterial embolization, ileocecectomy was performed. After the resection hematochezia was completely stopped.

A Less Invasive Approach for Ruptured Aneurysm with Intracranial Hematoma: Coil Embolization Followed by Clot Evacuation

OBJECTIVE: The presence of an intracerebral hematoma from a ruptured aneurysm is a negative predictive factor and it is associated with high morbidity and mortality rates even though clot evacuation followed by the neck clipping is performed. Endovascular coil embolization is a useful alternative procedure to reduce the surgical morbidity and mortality rates. We report here on our experiences with the alternative option of endovascular coil placement followed by craniotomy for clot evacuation. MATERIALS AND METHODS: Among 312 patients who were admitted with intracerebral subarachnoid hemorrhage during the recent three years, 119 cases were treated via the endovascular approach. Nine cases were suspected to show aneurysmal intracerebral hemorrhage (ICH) on CT scan and they underwent emergency cerebral angiograms. We performed immediate coil embolization at the same session of angiographic examination, and this was followed by clot evacuation. RESULTS: Seven cases showed to have ruptured middle cerebral artery (MCA) aneurysms and two cases had internal carotid artery aneurysms. The clinical status on admission was Hunt-Hess grade (HHG) IV in seven patients and HHG III in two. Surgical evacuation of the clot was done immediately after the endovascular coil placement. The treatment results were a Glasgow Outcome Scale score of good recovery and moderate disability in six patients (66.7%). No mortality was recorded and no procedural morbidity was incurred by both the endovascular and direct craniotomy procedures. CONCLUSION: The results indicate that the coil embolization followed by clot evacuation for the patients with aneurysmal ICH may be a less invasive and quite a valuable alternative treatment for this patient group, and this warrants further investigation.

A Case of Spontaneous Rupture of Left Lumbar Artery Aneurysm on the Fifth day of Vaginal Delivery / 대한주산의학회잡지

Retroperitoneal hemorrhage caused by intra-abdominal vascular injury during pregnancy or puerperium is rare, but a very fatal complication. Massive retroperitoneal hemorrhage causes the high mortality rate of mother and fetus. But the difficulty of diagnosis and rarity may delay prompt treatment. We experienced a case of massive retroperitoneal hemorrhage, which was caused by a suspected left lumbar artery aneurysm rupture on the fifth day of vaginal delivery. The patient was successfully treated by surgery and arterial embolization. We reported this case with a brief review of literature.

Two Cases of Classic Polyarteritis Nodosa with Multiple Aneurysmal Ruptures / 대한피부과학회지

Classic polyarteritis nodosa (PAN) is a systemic segmental necrotizing vasculitis which shows transmural fibrinoid necrosis with surrounding inflammation in small to medium-sized muscular arteries, preferentially at vessel bifurcations, resulting in microaneurysm formation. Classic PAN commonly affects the kidney, liver, muscle, nerve, gastrointestinal tract and heart. Arteriography demonstrates microaneurysm or occlusion of the visceral arteries in 90% of the patients with classic PAN. However, rupture of the hepatic or renal artery aneurysm is uncommon cascade. We report two exceptional cases who presented with aneurysmal ruptures of the hepatic or renal artery and visceral infarction.

A Case of Systemic Vasculitis with Intraperitoneal Aneurysmal Rupture / 대한신장학회잡지

Though systemic vasculitidis are a group of diseases with extremely low incidence and prevalence, vessels with diverse size from aorta to capillaries are involved. It has been argued how to classify and define systemic vasculitidis, especially how to discriminate poly arteritis nodosa (PAN) and microscopic polyangiitis (MPA). Since there are lots of overlapping between them, clinical manifestations, antineuclear cytoplasmic antibody (ANCA) and angiographic findings besides pathologic findings should be considered altogether. We report a case of systemic vasculitis in which crescentic necrotizing glomerulonephritis with positive perinuclear-type ANCA occurred with intraperitoneal aneurysmal rupture simultaneously. Our case can be a typical one that shows definite overlapping between PAN and MPA.

Clinical Analysis of Risk Factors Affecting Rebleeding in Patients with an Aneurysm

BACKGROUND: The mortality of patients with rebleeding of an aneurysmal rupture is very high despite scheduling of an early operation. The period of greatest risk of rebleeding is during the time in which the patient is undergoing transport, assessment, diagnostic testing, and management in the emergency room or ward. If rebleeing can be prevented, it is clear that the overall clinical outcome for patients with an aneurysmal rupture will be dramatically improved. MATERIALS AND EMTHODS: To determine the risk factors for rebleeding in patients with an aneurysmal rupture between admission in emergency room and operation, we retrospectively reviewed the cases of 194 patients with an aneurysmal rupture that had been confirmed by CT scanning and cerebral angiography between January 1, 1998 and December 31, 2000. RESULT: Thirty-eight(19.6%) of the 194 patients had rebleeding. The incidence of rebleeding significantly increased in patients with stroke symptoms and signs on first-time aneurysmal ruptures(loss of consciousness, decreased mentality, coma, or motor deficits), in those with poor neurological conditions on admission, in those with a poor Hunt-Hess grade on admission(IV or V), and in those with a intracerebral hematoma indicated on the CT scanning compared to those without these factors. Multivariate analysis revealed that the following three factors were independently associated with rebleeding: the symptoms and signs on first-time aneurysmal ruptures, the Hunt-Hess grade on admission, and the value of prothrombin time on admission. CONCLUSION: A considerably high risk of rebleeding was observed in those patients who had stroke symptoms and signs, who were in a poor Hunt-Hess grade(grade IV or V), and who had extremely delayed values of the prothrombin time.

The Rebleeding of Ruptured Intracranial Aneurysm during Induction of Anesthesia / 대한마취과학회지

The intraoperative rupture of an intracranial aneurysm can dramatically interrupt the fine operative procedure and jeopardize the patient's chance for meaningful survival. A sudden increase of the arterial pressure and intracranial pressure during laryngoscopy and intubation is potentially dangerous and may lead to fresh bleeding from an aneurysm in patient with recent subarachnoidal hemorrhage due to aneurysmal rupture. But aneurysmal rupture during induction occurs rarely. Recently we experienced rebleeding due to sudden increased arterial blood pressure during laryngoscopy and intubation in 39 years old female patient who was scheduled for clipping of ruptured intracranial aneurysm on 11th day after ictus. And she died of cerebral death on 6th postoperative day. Here we discuss the incidence, prognosis, diagnosis, management and prophylaxis of the aneurysmal rupture during induction with a brief review of the literature.

Transcranial Doppler Measurement of Intracraial Arterial Flow Velocity in Subarachnoid Hemorrhage

The velocity of blood flow through the middle cerebral arteries was measured by transcranial Doppler sonography in 18 patients with aneurysmal subarachnoid hemorrhage. The velocity became greater from 4th day after the hemorrhage, reached a plateau on 6th-11th day and declined thereafter. 2) In the cases of laterally localized aneurysms, the velocity through the arteries ipsilateral to the aneurysm was significantly greater than that through the arteries contralateral to the aneurysm. 3) The velocity through the arteries of the patients who showed thick subarachnoid clots on CT scan within 3 days after the hemorrhage was significantly greater than that of the patients who showed thin subarachnoid clots. 4) The maximum mean velocity in the patients with delayed ischemic deficits(DID) was greater than that in the patients without DID. The results suggest that the transcranial Doppler monitering is helpful to detect early vasospasm.

Evaluation of Subarachnoid Hemorrhage due to Aneurysmal Rupture and Cerebral Vasospasm by CT

Cerebral vasospasm is one of the most serious complication after subarachnoid hemorrhage due to aneurysmal rupture. To date, the treatment of vasospasm remains unsatisfactory in a large numbers of cases in spite of recent therapeutic advances. Prompt diagnosis of this complication, before the establishment of lasting ischemic damage, should obviously improve the results of treatment. The possibility of predicting which patients will develop vasospasm, constitutes a further advance in the management of this complication. In this study, the value of the computed tomographic scan for the prediction of vasospasm was investigated in a consecutive series of 67 patients submitted to computed tomography within 7 days of the most recent subarachnoid hemorrhage.