Manejo ultra temprano del aneurisma cerebral roto. Reporte de caso y revisión de la literatura / Ultra-early management of ruptured brain aneurysm. A case report and literature review

Introducción : Los aneurismas intracraneales representan el 85% de casos de hemorragias subaracnoideas, dentro de las cuales las no traumáticas tienen una alta tasa de mortalidad (40-60%). En el manejo endovascular y microquirúrgico de esta enfermedad, el debate ha sido siempre intenso respecto a si el tratamiento temprano produce un beneficioso resultado funcional y reduce la morbi-mortalidad del paciente. Caso Clínico : Paciente mujer de 54 años, admitida con cefalea súbita y cuadro neurológico que cursó con rápido deterioro. La tomografía mostró hemorragia subaracnoidea por ruptura aneurísmica del complejo comunicante anterior; fue sometida a microcirugía dentro de las primeras 24 horas y transferida luego a UCI, sin complicaciones. Discusión : El tiempo de resolución, sea mediante clipaje microquirúrgico o tratamiento endovascular es tema de intensos debates. Las guías actuales señalan la necesidad del manejo más temprano posible de la patología. Conclusión : En nuestro caso, se obtuvo un buen resultado funcional debido a varios factores uno de ellos el ingreso precoz a cirugía. La actualización de las guías y nuevos estudios ayudarán a mejorar el conocimiento de la enfermedad y protocolos hospitalarios adecuados a la realidad clínica ayudarán a reducir su tiempo de resolución.

SUMMARY Introduction : Intracranial aneurysms account for 85% of all subarachnoid hemorrhages. Non-traumatic SAH has a high mortality rate (40-60%). Regarding the microsurgical and endovascular management for this pathology, there has been intense debate on whether early action is beneficial in terms of functional outcome and reduction of morbi-mortality. Clinical case : A 54-year-old woman admitted with a sudden, severe headache and a rapidly deteriorating neurological state at baseline, and with deterioration at the next hour. Tomography showed a subarachnoid hemorrhage due to ruptured aneurysm of the anterior communicating artery; the patient underwent surgery within the first 24 hours, with subsequent ICU management without complications. Discussion : The resolution time of this condition, either by micosurgery or endovascular management is a matter of intense debate. International guidelines point out the need of an earliest possible treatment. Conclusion : In our case, a good functional result was obtained due to several factors, one of which was early admission to surgery. The updating of guidelines and new studies will help to better understand the pathophysiology of SAH, and the creation of hospital protocols adapted to clinical realities will assist to reduce the resolution time of this pathology.

Tratamiento endovascular del aneurisma esplénico incidental y en la urgencia / Endovascular treatment of incidental and emergency splenic aneurysm

Resumen Los aneurismas esplénicos verdaderos son dilataciones saculares que involucran todas las capas de la arteria esplénica. Se presentan más frecuentemente en mujeres, en el embarazo y pacientes con hipertensión portal. Son habitualmente asintomáticos y diagnosticados incidentalmente durante el estudio de otra afección abdominal. Hasta un 10% se puede presentar con ruptura, lo que supone un escenario con una alta morbilidad y mortalidad. El tratamiento de los aneurismas esplénicos es aún un tema de controversia y existen variadas modalidades terapéuticas. Presentamos dos casos de pacientes con aneurismas esplénicos: uno de ellos que se manifestó con rotura y el otro por un diagnóstico incidental. Ambos fueron resueltos mediante embolización endovascular con resultados óptimos. Esta modalidad terapéutica poco difundida para el tratamiento de aneurismas esplénicos gigantes o rotos, nos permitió resolver el cuadro de forma segura y efectiva, con mínima morbilidad y mortalidad.

Abstract True splenic aneurysms are saccular dilations of all the layers of the splenic artery, more common in women, pregnancy and portal hypertension. They are usually asymptomatic and diagnosed incidentally during the study of other abdominal diseases. Up to 10% may present with rupture, which implies a high morbidity and mortality. Treatment of splenic aneurysms is still a subject of controversy and there is a great variety of therapeutic modalities. We present two cases of patients with splenic aneurysms: one who presented with rupture and the other one incidentally diagnosed. Both were treated with endovascular embolization achieving optimal results. Although the utility of this therapy has not been assessed for giant or ruptured aneurysms, it allowed us to solve these scenarios in a secure and effective way, with minimum morbidity and mortality.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES: This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients. METHODS: This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping. RESULTS: From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter. CONCLUSIONS: The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Resultado imediato do tratamento endovascular com stents paralelos do aneurisma roto justarrenal / Immediate outcome of endovascular treatment of ruptured juxtarenal aneurysm with parallel stents

Resumo A ruptura do aneurisma de aorta abdominal é um evento com alta mortalidade, e o seu tratamento nesses casos é uma emergência médica. O tratamento endovascular desses aneurismas tem se estabelecido como uma alternativa minimamente invasiva à cirurgia aberta clássica, tornando-se a opção de primeira escolha. Contudo, 20 a 50% dos pacientes portadores de aneurisma de aorta abdominal não apresentam anatomia favorável para o tratamento endovascular devido à presença de colo curto ou pelo acometimento de ramos viscerais pelo aneurisma. Relatamos um caso de uma paciente de 70 anos submetida à correção endovascular de aneurisma roto justarrenal com implante de stents paralelos para as renais (técnica de chaminé). São apresentados dados clínicos e detalhes do procedimento. O sucesso técnico foi obtido e não houve relato de complicações pós-operatórias.

Abstract Rupture of an abdominal aortic aneurysm is an event with a high mortality rate and treatment is a medical emergency. Endovascular treatment of these aneurysms has become established as a minimally invasive alternative to classical open surgery and is now the first-choice option. However, 20 to 50% of patients with abdominal aortic aneurysms do not have anatomy favorable for endovascular treatment because of a short aneurysm neck or because visceral branches are involved by the aneurysm. We report the case of a 70-year-old patient who underwent endovascular repair of a ruptured juxtarenal aneurysm with deployment of parallel stents in the renal arteries (in a chimney technique). Clinical data and details of the procedure are reported. Technical success was achieved and there were no postoperative complications.

Rotura de aneurisma de artéria poplítea em paciente clinicamente diagnosticado com síndrome de Marfan / Ruptured popliteal artery aneurysm in a patient with a clinical diagnosis of Marfan syndrome

Resumo A artéria poplítea é o principal local para a ocorrência de aneurismas periféricos. Suas formas de apresentação agudas são potencialmente ameaçadoras à viabilidade do membro e à vida, dentre as quais destacamos a sua rotura. Apesar de ser um evento raro, sua rotura demanda rápida proposta de intervenção para satisfatório desfecho terapêutico. O tratamento padrão-ouro é o cirúrgico convencional e se dá pela interposição de veia safena magna. Trabalhos feitos nas últimas décadas vêm encontrando associações entre a síndrome de Marfan e aneurismas periféricos. Este relato apresenta um caso de um aneurisma de artéria poplítea esquerda roto tratado com sucesso em um paciente de 82 anos diagnosticado clinicamente como portador de síndrome de Marfan previamente desconhecida.

Abstract The popliteal artery is the main site of occurrence of peripheral aneurysms. Acute presentations constitute a potential threat to limb viability and to life, especially in the event of rupture. Rupture is a rare event, but one that demands an immediate intervention decision to achieve a satisfactory treatment outcome. The gold standard treatment is conventional surgery, effecting repair by interposition of a great saphenous vein graft. Studies conducted in recent decades have found associations between Marfan Syndrome and peripheral aneurysms. This report presents a case of a ruptured left popliteal artery aneurysm successfully treated in an 82-year-old patient clinically diagnosed with previously unknown Marfan syndrome.

Ruptured Sinus of Valsalva Aneurysm Presenting as Complete Heart Block - A Rare Presentation

The dissection of the sinus of Valsalva aneurysm into the interventricular septum leading to complete heart block is a rare complication with only few cases reported in the literature. We report a case of young farm laborer, who presented with multiple episodes of syncope. Upon clinical evaluation, we found third-degree atrioventricular block due the rupture of right sinus of Valsalva into the interventricular septum.

4-Vessels Angiography: A Tinkering Tool In Multi-Faceted Manner.

Introduction:The global incidence of spontaneous intracranial vascular conditions such as: Spontaneous Subarachnoid hemorrhage (SAH); Nonaneurysmal subarachnoid hemorrhage (NASAH); and arterio-vascular malformation, which are low incidence conditions though lethal pathologies due to leakage of blood within the cranial cavity. Missed such conditions are mutual agony among healthcare providers. Management of these pathologies is imperative to an early diagnosis. Stimulatingly, despite the reiterated imaging studies that have been established for diagnosing intracranial vascular pathologies, 4-vessels angiography had ranked superior multidimensionally. Thus, this study targets to address the diagnostic significance of angiography in spontaneous intracranial hemorrhages as the cardinal tool of management with reference point comparison of our findings with those reported in literature. Methods: A retrospective chart review of patients presented with spontaneous intracranial hemorrhages over a period of 3-years from January 2014 till January 2017 at the neurosurgical department of King Hussein Medical Center was conducted. All patients had clinical features of sudden onset of severe headache, decrease level of consciousness of sudden neurological deficit, who were hospitalized within 72-hours after the bleeding onset. Clinical data, non-invasive radiological imaging studies confirmed the spontaneous intracranial hemorrhages presence. Patients underwent subsequent diagnostic workup. The results and complications of the Digital subtraction angiography (DSA) study were analyzed. Repeated DSAor computed tomography angiography (CTA) was performed 6-8 weeks later if initial angiographic result were negative. Results: Of 141-patients who underwent cerebral angiography following spontaneous subarachnoid hemorrhage in the three-year time period, 81- females (57.47%), 60-males (42.55%), mean age 50.76 year. Fifty four examinations revealed aneurysms, another 26- small aneurysms were diagnosed in the angiogram negative cases on the follow-up studies. Eighteen patients had non-aneurysmal subarachnoid haemorrhage, fourteencase showed arteriovenous malformation (AVM) and five-case showed dural fistula. Sixty-seven percent of the patients classified their headache as being the worst headache of their life and approximately 54 % described maximum intensity of the pain within the first 2-hours. Sudden loss of consciousness (LOC) occurred in 42% of the patients due to increased intracranial pressure. LOC often is transitory; however, approximately 15 % of the patients remained comatosed for several days. Seizures during the acute phase occurred in 16-patients (11.35%). Conclusion: Spontaneous intracranial hemorrhages is a devastating and multifarious disease which must be managed in well- established and dedicated centers. In our center, DSA following non-conclusive CT imaging of the brain was therefore a test of extremely high yield, utility, and also associated with decreased morbidity and mortality. Non-aneurysmal SAH cases have better neurological status compared with aneurysmalcases.

The therapeutic effect of balloon-assisted coiling and stent-assisted coiling of ruptured intracranial aneurysms in the acute phase / 中华急诊医学杂志

Objective To investigate the perioperative complications and therapeutic effects of balloon-assisted coiling (BAC) and stent-assisted coiling (SAC) in patients with ruptured intracranial aneurysms in the acute phase. Methods Totally 91 patients with 91 intracranial ruptured aneurysms were treated with BAC or SAC in our hospital between January 2014 and December 2016. Among them, 37 patients were treated with BAC and 54 patients with SAC respectively. Of the two groups, the position distribution and shape of aneurysms, and the complications after procedures and the therapeutic effects were summarized and evaluated retrospectively using chi-square test. Results The width of the aneurysm neck was narrower in the BAC-treated group compared to the SAC-treated group (3.31±1.63 mm vs. 4.35±2.10 mm, P=0.01). The aneurysm body/neck ratio (B/N) was lower in the BAC-treated group than in the SAC-treated group (1.64 ± 0.46 vs. 1.35±0.66, P=0.025). The recurrence rate was higher in the BAC-treated group than that in the SAC-treated group (18.9％ vs. 0.9％, P=0.005). There was no statistical difference in perioperative complication in both the BAC-treated group and SAC-treated group. However, 2 patients died due to the relative postoperative intracranial bleeding in the SAC-treated group. Better outcomes (Modified Rankin Score, mRS, 0-2) were achieved in the BAC-treated group compared to the SAC-treated group (94.6％ vs. 88.9％, P=0.028) at the follow-up visit. Conclusions These findings suggested that there is no difference between the BAC-treated group and the SAC-treated group in the risk of complication. BAC can achieve a better prognosis,but it is more prone to relapse. The SAC method was more appropriate for wider neck aneurysms. It was also an option to coiling the aneurysm in BAC in acute phase firstly, followed by additional treatment in SAC during the follow-up period.

The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm

Background: Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000–2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. Material and Method: A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I–III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin’s Scale (mRS). The mRS scores of 0 to 2 were grouped into the “favourable” category and mRS scores of 3 to 6 were grouped into the “unfavourable” category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P-value of < 0.05 was considered to be statistically significant. Result: A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review (n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. Conclusion: In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient’s surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient’s follow up.

Safety of external ventricular drainage after stent-assisted embolization for poor-grade ruptured aneurysm / 医学研究生学报

Objective The management of poor-grade ruptured aneurysm is important and challenging in intravascular inter-vention. This study aimed to investigate the safety of external ventricular drainage(EVD)after stent-assisted embolization for patients with poor-grade ruptured aneurysm in the acute stage. Methods From January 2015 to July 2017,27 patients with poor-grade rup-tured aneurysm underwent EVD after endovascular embolization by stent-assisted coiling(n=14)or simple coiling(n=13). We com-pared the clinical data about and the postoperative complications between the two groups of patients. Results There were no statisti-cally significant differences in the patients'age,gender,Glasgow Coma Scale(GCS)scores before embolization and discharge,the in-terval between EVD and the end of embolization,preoperative intraventricular hemorrhage and hydrocephalus,puncture-related bleed-ing after EVD,catheter-indwelling time,perioperative bleeding in other parts,or poor prognosis between the stent-assisted coiling and simple coiling groups(all P>0.05). Conclusion EVD after stent-assisted embolization is a relatively safe strategy for the treatment of poor-grade ruptured aneurysm in the acute stage.

Analysis on occurrence status quo and related factors of cerebral vasospasm after cerebral ruptured aneurysm embolization / 重庆医学

Objective To investigate the occurrence status quo and related factors of cerebral vasospasm after cerebral ruptured aneurysms embolization.Methods Sixty-six patients withruptured cerebral aneurysms undergoing embolization treatment were selected as the research subjects,and conducted routine aneurysm embolization treatment.The cerebral vasospasm occurrence rate during hospitalization period was statistically calculated,and the related factors of cerebral vasospasm after cerebral aneurysm rupture embolization were analyzed.Results The cerebral vasospasm occurrence rate was 22.73 ％.Age,body mass index (BMI),hypertension rate,smoking history,aneurysms number,Fisher grade,Hunt-Hess grade,operation timing and Glasgow coma index (GCS) had statistically significant difference between the patients with and without cerebral vasospasm (P＜0.05).The related factors of cerebral vasospasm after embolization of ruptured aneurysms were age,hypertension,smoking history,number of aneurysms,Fisher grade,Hunt-Hess grade,operation timing and GCS index.Conclusion The cerebral vasospasm rate after embolization of ruptured aneurysms is high,and related to age,hypertension,smoking history,number of aneurysms,Fisher grade,Hunt-Hess grade,operation timing and GCS index.

Reparo de aneurisma de artéria ilíaca roto em criança / Repair of ruptured iliac artery aneurysm in a child

Resumo Relatamos o caso de uma menina de 12 anos que deu entrada na unidade de emergência com quadro de abdome agudo hemorrágico, massa abdominal pulsátil e instabilidade hemodinâmica. Confirmado o diagnóstico de aneurisma roto de artéria ilíaca direita, foi realizada correção cirúrgica de emergência por reparo aberto com reconstrução extra-anatômica, utilizando enxerto sintético de fino calibre, compatível com a anatomia. O tratamento foi bem-sucedido e a criança apresentou evolução favorável em curto prazo.

Abstract We describe the case of a 12-year-old girl who presented at the emergency department with hemorrhagic acute abdomen, an abdominal pulsating mass and hemodynamic instability. A diagnosis of ruptured right iliac artery aneurysm was confirmed and an emergency open repair procedure was performed with extra-anatomic reconstruction, using a small-caliber synthetic graft, compatible with her anatomy. The treatment was successful and the child was doing well at short-term follow-up.

TEVAR for ruptured descending thoracic aortic aneurysm: case report / TEVAR para aneurisma roto da aorta torácica descendente: relato de caso

Abstract A ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening condition associated with high morbidity and mortality. Endovascular treatment for rDTAA promotes effective aneurysm exclusion with a minimally invasive approach. The authors report a case of a 76-year-old man with hemodynamically unstable 9-cm-diameter rDTAA treated with emergency thoracic endovascular aortic repair (TEVAR).

Resumo O aneurisma roto de aorta torácica descendente constitui uma situação ameaçadora associada a alta morbidade e mortalidade. O tratamento endovascular desse tipo de aneurisma promove exclusão eficaz com uma terapêutica minimamente invasiva. Os autores relatam o caso de um paciente do sexo masculino, 76 anos, hemodinamicamente instável, com aneurisma roto de aorta torácica descendente de 9 cm de diâmetro, tratado em caráter emergencial por cirurgia endovascular.

Open Repair of Ruptured Abdominal Aortic Aneurysm: The Suitability of Endovascular Aneurysm Repair Does Not Influence Operative Mortality

PURPOSE: We analyze the outcomes of open repair (OR) in patients with ruptured abdominal aortic aneurysm (RAAA) according to the anatomic suitability for endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: We reviewed retrospectively all consecutive RAAA patients who underwent OR from January 2005 to March 2014. All suspected patients underwent preoperative computed tomography (CT). Outcomes were major morbidities and mortality. Multivariate analysis was performed by using logistic regression adjusted by controlled variables; gender, Hardman index, maximal aneurysmal diameter, rupture type, perioperative transfusion requirement, and perioperative urinary output. RESULTS: Among 54 consecutive patients with RAAA who underwent OR, 45 patients were included after exclusion of 9 patients (7, suprarenal; 1, infected; 1, inflammatory). Preoperative CT showed 27% (12/45) EVAR-suitable patients. Hostile neck anatomy was found in 88% (29/33) among unsuitable anatomy (UA) (n=33). The maximal aneurysmal diameter was statistically larger (83.1+/-21.0 mm vs. 68.8+/-12.3 mm, P=0.032) in the UA group. The 30-day mortality was 28.9% (13/45; 33% vs. 17% in UA group vs. suitable anatomy [SA] group, P=0.460; adjusted P=0.445). UA group had more patients with cardiac morbidity (55% vs. 25%, P=0.079; adjusted P=0.032; odds ratio, 12.914; 95% confidence interval, 1.238-134.675). There was no statistical difference in survival rate between SA and UA groups (74.1%, 74.1%, and 74.1% vs. 60.6%, 55.6%, and 32.4% at 1-, 3- and 5-year, respectively; P=0.145). CONCLUSION: In this study, relatively unfavorable outcomes were found in the EVAR-unsuitable group after OR in RAAA patients. However, unsuitable anatomy did not influence patient survival after OR by multivariate analysis.

Open Repair of Ruptured Huge Aorto-Iliac Aneurysm: Warning of Colon Ischemia

A giant abdominal aortic aneurysm (AAA) renders surgical treatment much more difficult by deforming the proximal infrarenal aortic neck (shortened length and disturbed angulation), by altering the iliac arteries (marked tortuosity and aneurysmal dilatation), and by displacing abdominal organs. Because the retroperitoneal rupture of giant AAA makes the mesentery more elongated and deformed, compromising its blood flow and thus increasing the risk of mesenteric ischemia such as colon ischemia. We describe here the surgical repair of a large infrarenal AAA with a ruptured huge left common iliac artery aneurysm of 13.5 cm in diameter, accompanied by colostomy due to colon ischemia which occurred during the operation. We discuss the pathophysiology and preventive strategy of colon ischemia during ruptured giant AAA repair.

Ruptured true superficial femoral artery aneurysm / Aneurisma verdadeiro roto de arteria femoral superficial

Femoral artery aneurysms are rare and generally affect elderly patients. They are often diagnosed in combination with aneurysms in other locations, such as peripheral and aortic aneurysms. This case report describes a young patient whose superficial femoral artery (SFA) had a clinical presentation suggestive of a ruptured aneurysm. The patient underwent standard treatment, with aneurysmectomy and interposition of the ipsilateral saphenous vein. A review of the literature confirms the rarity of this case.

Os aneurismas de artéria femoral são raros e ocorrem geralmente em pacientes idosos. Estão frequentemente associados a outros aneurismas, tanto periféricos como de aorta abdominal. O presente relato refere-se a um jovem portador de aneurisma de artéria femoral superficial (AFS), cuja apresentação clínica foi a ruptura. O paciente foi submetido ao tratamento convencional, com ressecção do aneurisma e interposição de veia safena magna ipsilateral. A revisão da literatura corrobora a raridade do caso.

Spontaneous Massive Hemothorax in a Patient with Neurofibromatosis Type 1 with Successful Transarterial Embolization

Vascular involvement in neurofibromatosis type 1 is rare but has the potential to be fatal. We report a case of a patient with spontaneous rupture of a left intercostal artery aneurysm, which presented as a massive left hemothorax and was successfully treated by transarterial coil embolization.

Treatment of a Ruptured Vertebrobasilar Fusiform Aneurysm Using Pipeline Embolization Device

Treatment options of ruptured vertebrobasilar fusiform aneurysms (VFA) are limited and often carry significant mortality and morbidity. We report the use of Pipeline Embolization Device (PED) to successfully treat a patient with a ruptured vertebrobasilar fusiform aneurysm (VFA) who presented with subarachnoid hemorrhage (SAH). A 73 year-old man with a history of cardiac stent placement seven days earlier presented with Hunt-Hess II SAH. He was taking aspirin and clopidogrel. Computed tomography angiogram revealed a large vertebrobasilar fusiform aneurysm. Microsurgical treatment options are technically challenging and carry high risk. He underwent endovascular treatment of the ruptured VFA using overlapping PEDs. Five PEDs were placed in a telescoping fashion to reconstruct the affected portions of the left vertebral and basilar arteries. An additional 2-mm blister aneurysm in the right vertebral artery was also discovered during the conventional cerebral angiography and was treated with one additional PED. The patient remained neurologically intact after the procedure. He was continued on aspirin and clopidogrel. Follow-up magnetic resonance imaging at three months demonstrated patency of the stents without any evidence of ischemic change. Follow-up conventional cerebral angiogram at six months demonstrated thrombosis of the VFA and reconstruction of the vertebrobasilar system. The patient remained clinically well. An endovascular approach using PEDs can be a safe and effective treatment option for ruptured VFA in selected cases.

Functional Outcome of Microsurgical Clipping Compared to Endovascular Coiling

Endovascular coiling has been used increasingly as an alternative to neurosurgical clipping for treating subarachnoid hemorrhage secondary to aneurysm rupture. In a retrospective cohort review on the treatment methods of aneurysm rupture in Hospital Kuala Lumpur over the period of five years (2005-2009) a total of 268 patients were treated. These patients were broadly categorized into two groups based on their treatment mode for ruptured aneurysms. Statistical analysis was determined using Chi- Square tests to study these associations. In our study, 67.5% of patients presented with Good World Federation of Neurosurgical Societies (WFNS) grade (WFNS1-2) while 32.5% patients presented with Poor WFNS prior to intervention. In our outcome, it was noted that 60.4% had good functional outcome (mRS grade 0-2) as compared to 39.6% patients who had poor mRS(modified rankin scale) outcome (mRS 3-6). In the good WFNS group, 76% of patients in clipping group had a good mRS outcome while, 86.5% patients in coiling group had good mRS outcome (p=0.114). In poor WFNS presentation, it was noted that in 77.3% patients in clipping group, had poor mRS outcome. Similarly with poor WFNS presentation, 83.3% of patient in coiling group had poor outcome. (p=1.00). Hence when we control the WFNS group, there was no significant association between treatment group (clipping and coiling) and mRS outcome at 6 months. The outcome of patient is determined by initial clinical presentation (WFNS grade) and influenced by requirement of Extraventricular drain (EVD) in presence of hydrocephalus, CSF infection and pneumonia. Therefore the decision regarding treatment option needs to be individualized based on the presentation of the patient.

Characteristics of Verbal Memory after Subarachnoid Hemorrhage caused by Ruptured Aneurysm / The Japanese Journal of Rehabilitation Medicine

Objective : To clarify the characteristics of memory impairment caused by ruptured aneurysm induced subarachnoid hemorrhage, we examined memory function using the auditory verbal learning test (AVLT). Methods : Subjects were 45 patients with subarachnoid hemorrhage caused by ruptured aneurysm in 14 anterior cerebral arteries (ACA), 12 middle cerebral arteries, 7 vertebrobasilar arteries (VA), and 12 internal cerebral arteries. We discussed the scores of short-term memory (STM), total immediate memory (TIM), verbal learning ability (VLA), retroactive interference effect (RI), recognition and learning curve in different portions of ruptured aneurysm. Additionally, we compared them with healthy subjects (HS). Results : The scores of VLA in ACA were lower than that in HS, and the scores of RI in VA were higher than that in HS. There were no difference in STM, TIM and recognition among groups. The learning curve in ACA and VA were flattening in later trials. Conclusion : Because patients after ruptured subarachnoid hemorrhage in ACA and VA have higher rate of memory impairment, we supposed detailed assessment for memory is important.