Hospitalizações por aneurismas cerebrais rotos (hemorragia subaracnoidea não traumática) e não rotos no SUS: embolização ou microcirurgia cerebral? um estudo de 2009 a 2018 / Hospitalizations for ruptured cerebral aneurysms (hemorrhage non-traumatic subarachnoid) and unruptured in SUS: embolization or brain microsurgery? a study from 2009 to 2018

O potencial de ruptura é inerente a todos os aneurismas cerebrais e traz consigo sérias complicações como o acidente cerebrovascular hemorrágico, situação clínica crítica conhecida como hemorragia subaracnoidea que representa uma das mais severas causas de mortalidade. Estima-se que os aneurismas cerebrais estejam presentes em aproximadamente 5% da população, manifestando-se geralmente na fase adulta, quando o risco de ruptura aumenta. As duas principais formas de tratamento dos aneurismas cerebrais rotos e não rotos, cuja finalidade consiste na exclusão do aneurisma da circulação cerebral, são a embolização e a microcirurgia cerebral. Objetivo: Comparar as hospitalizações para tratamento de aneurismas cerebrais rotos (hemorragia subaracnoidea não traumática) e não rotos quanto ao uso das tecnologias de embolização ou de microcirurgia cerebral no Sistema Único de Saúde (SUS) no período 2009 - 2018. Métodos: Análise de dados do Sistema de Informações Hospitalares (SIH)/SUS disponibilizados publicamente. Os procedimentos estudados foram: (i) Grupo 01 Neurocirurgias vasculares ­ código SUS: 040304003-5, 040304004-3, 040304007-8, 040304009-4, 040304010-8, 040304011- 6, e 040304012-4; e (ii) Grupo 02 Tratamento neuro endovascular ­ códigos SUS: 040307002-3, 040307003-1, 040307004-0, 040307005-8, 040307006-6, 040307007- 4, 040307014-7, 040307015-5 e 040307016-3. Considerou-se para o estudo sexo, faixas etárias, macrorregião de residência, tempo de permanência, utilização de unidade de tratamento intensivo (UTI), ocorrência ou não de óbito do paciente, gasto e letalidade hospitalar conforme realização de embolização ou de microcirurgia cerebral. Resultados: Ocorreram 43.927 internações no período 2009 - 2018, sendo 21.305 (48,5%; 10,6/milhão hab./ano) para realização de embolização e 22.622 (51,5%; 11,2/milhão hab./ano) para microcirurgias cerebrais. O sexo feminino apresentou os maiores coeficientes de internação para embolização (15,5/milhão hab./ano) e microcirurgia (15,5/milhão hab./ano) em relação ao masculino (5,5 e 6,8/milhão hab./ano respectivamente). Para embolização, o maior coeficiente foi registrado na faixa etária de 60 a 64 anos (35,5/milhão hab./ano) enquanto para a microcirurgia na de 55 a 59 anos (36,3/milhão hab./ano). Foram observados maiores coeficientes de internação na macrorregião Sul (36,8/milhão hab./ano) independentemente do procedimento adotado. Hemorragia subaracnoidea não traumática foi a principal causa de internação representando 62,6% do total de hospitalizações. Para embolização, o tempo médio de permanência foi de 7,7 dias, 59% utilizaram UTI, a letalidade foi de 5,9% e 77% dos óbitos foram relacionados à hemorragia subarac- noidea. Para microcirurgia cerebral, o tempo médio de permanência foi de 16,2 dias, 85% utilizaram UTI, a letalidade foi de 10,9% e 74% dos óbitos foram relacionados à hemorragia subaracnoidea. O gasto total com ambas as técnicas foi de R$ 551 mi- lhões (66,8% com embolização) e o gasto médio por internação atingiu R$ 17.286,00 para embolização e R$ 8.077,35 para microcirurgia. A letalidade hospitalar para embolização foi menor nos hospitais filantrópicos e federais enquanto para microcirurgia cerebral foi menor nos hospitais federais. Conclusão: A embolização apresentou número menor de procedimentos, maior gasto total e médio por internação, e menores tempo de permanência, percentual de utilização de unidade de tratamento intensivo (UTI) e de óbitos quando comparada a microcirurgia cerebral na rede pública de saúde do Brasil.

The potential for rupture is inherent to all cerebral aneurysms and brings with it serious complications such as hemorrhagic cerebrovascular accident, a critical clinical situation known as subarachnoid hemorrhage, which represents one of the most severe causes of mortality. It is estimated that cerebral aneurysms are present in ap- proximately 5% of the population, usually manifesting in adulthood, when the risk of rupture increases. The two main forms of treatment for ruptured and unruptured cerebral aneurysms, whose purpose is to exclude the aneurysm from the cerebral circulation, are embolization and cerebral microsurgery. Objective: To compare hospitalizations for treatment of ruptured cerebral aneurysms (non-traumatic subarachnoid hemorrhage) and non-ruptured cerebral aneurysms regarding the use of embolization or brain microsurgery technologies in the Unified Health System (SUS) in the period 2009 - 2018. Methods : Analysis of publicly available data from the Hospital Information System (SIH)/SUS. The procedures studied were: (i) Group 01 Vascular Neurosurgeries ­ SUS code: 040304003-5, 040304004-3, 040304007-8, 040304009- 4, 040304010-8, 040304011-6, and 040304012-4; and (ii) Group 02 Neuro endovascular treatment - SUS codes: 040307002-3, 040307003-1, 040307004-0, 040307005-8, 040307006-6, 040307007-4, 040307014-7, 040307015-5 and 040307016-3. For the study, gender, age groups, macroregion of residence, length of stay, use of the intensive care unit (ICU), occurrence or not of patient death, hospital expenses and lethality were considered according to embolization or cerebral microsurgery. Results: From 43,927 hospitalizations, 21,305 (48.5%; 10.6/million inhab./year) were for embolization and 22,622 (51.5%; 11.2/million inhab./year) for microsurgery in the period 2009 - 2018. Females had the highest rates of hospitaliza- tion for embolization (15.5/million inhab./year) and microsurgery (15.5/million inhab./year) compared to males (5.5 and 6.8/million inhab./year, respectively). For embolization, the highest coefficient was registered in the age group of 60 up to 64 years (35.5/million inhab./year) while for microsurgery in the age group from 55 up to 59 years old (36.3/million inhab./year). Higher hospitalization rates were observed in the southern macroregion (36.8/million inhab./year) regardless of the procedure adopted. Non-traumatic subarachnoid hemorrhage was the main cause of hospitalization, representing 62.6% of all hospitalizations. For embolization, the mean length of stay was 7.7 days, 59% used ICU, lethality was 5.9% and 77% of deaths were related to subarachnoid hemorrhage. For brain microsurgery, the mean length of stay was 16.2 days, 85% used ICU, lethality was 10.9% and 74% of deaths were related to subarachnoid hemorrhage. The total expense with both techniques was R$ 551 million (66.8% with embolization) and the average expense per hospitalization reached R$ 17,286.00 for embolization and R$ 8,077.35 for microsurgery. Lethality for embolization was lower in philanthropic and federal hospitals while for microsurgery was lower in federal hospitals. Conclusion: Embolization had a smaller number of procedures, higher total and average expenditure per hospitalization, and shorter length of stay, percentage of intensive care unit (ICU) use and deaths when compared to cerebral microsurgery in the public network of health in Brazil.

Bypass cerebro vascular para manejo de aneurisma cerebral gigante: reporte de primer caso realizado en Bolivia / Cerebrovascular bypass for management of giant cerebral aneurysm: report of the first case carried out in Bolivia

Se presenta un caso del primer Bypass cerebro vascular realizado en Bolivia por un aneurisma gigante de arteria carotida interna derecha, en segmento cavernoso tratado mediante bypass de alto flujo de arteria carótida externa a arteria cerebral media derecha, con injerto de arteria radial y posterior oclusión y exclusión del aneurisma. Se desciben los pasos de la cirugia y se destacan las dificultades de la tecnica y los beneficios de la cirugia. SE discuten los elementos a considerar en la toma de decisiones para la indicación y realización del bypass en el tratamiento de los aneurismas gigantes de la ACI.

Factores asociados al desarrollo de hidrocefalia dependiente de derivación ventrículo peritoneal en pacientes operados de aneurismas cerebrales

RESUMEN Introducción: Diversos factores pueden estar asociados al desarrollo de hidrocefalia en pacientes operados de aneurismas cerebrales que luego son dependientes de derivación ventrículo peritoneal, pueden estar dados por obstrucción mecánica o inflamatoria con disminución de la absorción del líquido cefalorraquídeo (LCR). Objetivo: Determinar factores asociados al desarrollo de hidrocefalia dependiente de derivación ventrículo peritoneal en pacientes con aneurismas cerebrales que han recibido tratamiento quirúrgico para clipaje. Metodología: Estudio observacional, descriptivo, retrospectivo de corte transversal de expedientes clínicos de 171 pacientes operados de aneurismas cerebrales en el Hospital de Clínicas desde el año 2013 hasta febrero del 2020. Resultados: Se han analizado 171 casos operados de aneurismas cerebrales, la mayoría del sexo femenino (71%), con un rango de edad de 17-77 años (mediana 53 años). El 7,6 % desarrolló hidrocefalia con requerimiento de derivación ventrículo peritoneal. De estos pacientes el 61,5 % tuvieron antecedentes de craniectomía descompresiva (p< 0,001). El 84,6 % presentó vasoespasmo tanto clínico como radiológico (p < 0,001). Las localizaciones más frecuentes fueron en las arterias carótida interna y cerebral media con 38,9 % para ambos. La escala de Fisher IV fue la más frecuente con 76,9%, luego Fisher II con 15,3 % (p= 0,14). El 62,2 % fueron operados durante la fase aguda (p= 0,03). Conclusión: Se ha observado en este estudio factores con asociación estadísticamente significativas con el desarrollo de hidrocefalia como la presencia de vasoespasmo y los operados de craniectomía descompresiva los cuales están acordes a la literatura, respecto a la fase de la enfermedad en la que se realizó la cirugía, en este estudio se observó predominio en la fase aguda, en contraste a lo que se observa en varias fuentes bibliográficas.

ABSTRACT Introduction: Various factors may be associated with the development of hydrocephalus in patients operated on for cerebral aneurysms that are later dependent on peritoneal ventricular shunt, may be due to mechanical or inflammatory obstruction with decreased absorption of cerebrospinal fluid (CSF). Objective: To determine factors associated with the development of peritoneal ventricular shunt-dependent hydrocephalus in patients with cerebral aneurysms who have received surgical treatment for clipping. Methods: Observational, descriptive, retrospective cross-sectional study of clinical records of 171 patients operated on for cerebral aneurysms at the Hospital de Clínicas from 2013 to February 2020. Results: 171 cases operated on for cerebral aneurysms have been analyzed, most of the female sex (71%), with an age range of 17-77 years (median 53 years). 7.6 % developed hydrocephalus with a peritoneal ventricle shunt requirement. Of these patients, 61.5% had a history of decompressive craniectomy (p <0.001). 84.6% presented both clinical and radiological vasospasm (p <0.001). The most frequent locations were in the internal carotid and middle cerebral arteries with 38.9% for both. The Fisher IV scale was the most frequent with 76.9%, then Fisher II with 15.3% (p = 0.14). 62.2% underwent surgery during the acute phase (p = 0.03). Conclusion: Factors with a statistically significant association with the development of hydrocephalus have been observed in this study, such as the presence of vasospasm and those undergoing decompressive craniectomy, which are in accordance with the literature, unlike what occurs with the phase of the disease in the that surgery was performed, which in our study showed a predominance in the acute phase, in contrast to what is observed in various bibliographic sources.

Alteraciones cognitivas en pacientes operados de aneurismas cerebrales en el Hospital de Clínicas

RESUMEN Introducción: la hemorragia subaracnoidea por sí misma puede dar lugar a un daño cerebral, por esto, en pacientes sin complicaciones los trastornos cognitivos pueden estar presentes. Objetivos: analizar las alteraciones neuropsicológicos en los pacientes operados de aneurismas cerebrales y los factores que se asocian a su desarrollo. Metodología: estudio analítico, observacional, ambispectivo, 2013-2020, que incluyó pacientes operados de aneurismas cerebrales rotos en el Hospital de Clínicas. La evaluación cognitiva se realizó con el mini examen cognitivo de Lobo. Se consideró alterado cuando la puntuación fue menor a 27. Se analizaron 12 variables asociando las mismas con el tema de estudio. Los datos fueron analizados con Epiinfo 7.2. Resultados: La edad mayor a 60 años se asoció al déficit cognitivo de forma significativa, así como también la lateralidad a izquierda, el uso de clipado temporario durante la cirugía, la ruptura del aneurisma en el intraoperatorio, el vasoespasmo y la hidrocefalia. No se asoció significativamente con el desarrollo de un trastorno cognitivo; el sexo, el nivel de escolaridad, la cantidad de sangre cisternal, la localización del aneurisma, el Glasgow de ingreso ni la fase en la cual se realzó la cirugía. Discusión: en general los hallazgos coinciden con la literatura. Llamó la atención que la escala de Fisher en la muestra estudiada no demostró tener una asociación significativa con el trastorno cognitivo, sin embargo, hay datos en la literatura que sostienen que la cantidad de sangre cisternal al ingreso es un fuerte predictor del estado cognitivo del paciente al alta.

ABSTRACT Introduction: subarachnoid hemorrhage itself can lead to brain damage, so in uncomplicated patient's cognitive disorders may be present. Objective: To analyze the cognitive impairments in patients following clipping of ruptured aneurysms and the factors that are associated with their development. Methodology: analytical, observational, ambispective study, 2013-2020, including patients operated for ruptured aneurysms at the Hospital de Clínicas. The cognitive evaluation was performed with the Lobo mini cognitive exam. It was considered altered when the score was less than 27. Twelve variables were analyzed associating them with the study topic. The data was analyzed with Epiinfo 7.2. Results: Age over 60 years was significantly associated with cognitive deficit, as well as left laterality, the use of temporary clipping during surgery, intraoperative aneurysm rupture, vasospasm, and hydrocephalus. It was not significantly associated with the development of a cognitive disorder; sex, level of education, amount of cisternal blood, location of the aneurysm, admission Glasgow, and the timing in which the surgery was performed. Discussion: In general, the findings coincide with the literature. It was noteworthy that the Fisher scale in the studied sample did not show to have a significant association with cognitive disorder, however, there are data in the literature that maintain that the amount of cisternal blood on admission is a strong predictor of the patient's cognitive state at discharge.

Casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas - Paraguay, desde el 2011 al 2019 / Casuistry, management and results of brain aneurysms at the Hospital de Clínicas - Paraguay, from 2011 to 2019

Introducción: La Hemorragia Subaracnoidea es el sangrado en el espacio subaracnoideo. La causa espontánea en la mayoría de las veces se debe a ruptura de un aneurisma cerebral. Objetivo: Describir la casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas. Pacientes y método: Estudio observacional, descriptivo, transversal, incluyendo pacientes operados de aneurismas cerebrales, mayores de 17 años, en el Hospital de Clínicas del 2011 al 2019. Las variables descriptas fueron: edad, sexo, motivo de consulta, estudios radiológicos, escala de Glasgow y Hunt y Hess, localización, segmento, cantidad, fase, clipado temporario, vasoespasmo e hidrocefalia. Resultados: Se incluyó 249 pacientes; 45% masculino, 65% femenino, con edad promedio de 47,5 años. El motivo de consulta más frecuente fue cefalea. Al ingreso tuvieron predominantemente Hunt y Hess 2, y, Glasgow 15. El 43,2% eran Fisher 4. El Glasgow de egreso fue mayor o igual a 14 en 82,1%. Se diagnosticó el 51,7% con arteriografía; el 50,9% de los aneurismas en la carótida interna y, fueron múltiples en 10,84%. Se operaron en fase aguda 28,3%, 65% en fase tardía y, el 6,7% de los aneurismas fue de hallazgo casual. En 36,44% de los casos se realizó clipado temporario y, en el 70,4% se perforó la lámina terminalis. La mortalidad fue de 4,2%. Presentaron vasoespasmo radiológico en un 46% y, vasoespasmo clínico en 24,5 %. El 11% fue sometido a craniectomía descompresiva y, 5,5% desarrolló hidrocefalia dependiente de VDVP. Conclusión: El clipado de los aneurismas cerebrales es una técnica con buenos resultados y la única accesible en el sector público.

Introduction: Subarachnoid hemorrhage is bleeding in the subarachnoid space. The spontaneous is caused most of the time by rupture of a cerebral aneurysm. Objective: Describe the casuistry, management and results of cerebral aneurysms at the Hospital de Clínicas. Patients and methods: Observational, descriptive, cross-sectional study including patients operated for cerebral aneurysms, older than 17 years, at the Hospital de Clínicas from 2011 to 2019. The variables described were: age, sex, reason for consultation, radiological studies, Glasgow and Hunt and Hess scale, location, segment, quantity, phase, temporary clipping, vasospasm and hydrocephalus. Results: 249 patients were included; 45% male, 65% female, average age 47.5 years. The most frequent reason for consultation was headache. At admission they had predominantly Hunt and Hess 2, and Glasgow 15. 43.2% were Fisher 4. The Glasgow of discharge was greater than or equal to 14 in 82.1%. 51.7% were diagnosed with arteriography; 50.9% internal carotid aneurysms, multiple 10.84%. 28.3% were operated in acute phase, 65% late phase, 6.7% were a casually found. In 36.44% of cases a temporary clipping was performed and in 70.4% the lamina terminalis was perforated. Mortality was 4.2%, radiological vasospasm 46%, clinical vasospasm 24.5%, 11% underwent decompressive craniectomy and 5.5% developed VDVP-dependent hydrocephalus. Conclusion: The clipping of cerebral aneurysms is a technique with good results and the only one in the public sector.

Seguridad del tratamiento quirúrgico en aneurismas cerebrales no rotos, en la región de Coquimbo, Chile / Safety of surgical treatment in unruptured cerebral aneurysms, in the region of Coquimbo, Chile

Introducción: El tratamiento microquirúrgico de los aneurismas cerebrales no rotos, ha demostrado ser seguro en distintas series, la indicación quirúrgica en estos casos es discutible y generalmente esta en relación a su riesgo de sangrado por características morfológicas y ubicación del aneurisma. Este trabajo tiene como objetivo, determinar si en nuestra región, el tratamiento microquirúrgico de los aneurismas cerebrales no rotos es seguro y así poder dar una recomendación de tratamiento a nuestros pacientes. Materiales y métodos: Treinta y un pacientes, 33 aneurismas cerebrales no rotos fueron tratados, En clínica Elqui y Hospital San Pablo de la Región de Coquimbo, entre mayo del 2017 y marzo del 2019, se hizo un seguimiento al total de los pacientes y se evaluó su resultado neurológico según la escala de Rankin modificado. Resultado: 97% de los pacientes obtuvieron un resultado neurológico favorable (Rankin < 3), solo un 3% de los pacientes, un caso, obtuvo un resultado desfavorable (Rankin > 2). Conclusión: El tratamiento microquirúrgico de los aneurismas cerebrales no rotos en nuestra región es seguro, obteniendo una muy baja morbilidad y 0% de mortalidad

Introduction: The microsurgical treatment of unruptured cerebral aneurysms has been shown to be safe in different series, the surgical indication in these cases is debatable and is generally related to the risk of bleeding due to morphological characteristics and location of the aneurysm. The objective of this work is to determine if in our region the microsurgical treatment of unruptured cerebral aneurysms is safe and thus be able to give a recommendation of treatment to our patients. Materials and methods: 31 patients, 33 unruptured cerebral aneurysms were treated. At the Elqui clinic and San Pablo Hospital in the Coquimbo Region, between may 2017 and March 2019, the total number of patients was monitored and their Neurological outcome according to the modified Rankin scale. Result: 97% of the patients obtained a favorable neurological outcome (Rankin <3), only 3% of the patients, one case, obtained an unfavorable outcome (Rankin> 2). Conclusion: The microsurgical treatment of unruptured cerebral aneurysms in our region is safe, obtaining a very low morbidity and 0% mortality

Adenosina para presillamiento de aneurismas cerebrales: revisión de la literatura actual / Adenosine for clamping of cerebral aneurysms: review of current literature

Resumen: El presillamiento de aneurismas cerebrales sigue siendo una cirugía bastante compleja aun con los avances en las neurociencias. El objetivo de este tipo de cirugía es evitar su ruptura y ocasionar daños colaterales en la misma, al tratar de exponer al máximo tanto el cuello del aneurisma para su manipulación como la oclusión temporal de la arteria proximal a éste. El uso de paro cardíaco transanestésico en el presillamiento de aneurismas cerebrales es una técnica empleada para cierto tipo de aneurismas cerebrales y existen varios métodos para realizarlo, desde la hipotermia profunda o severa, estimulación ventricular rápida hasta llegar al paro circulatorio con el uso de adenosina. En esta revisión de la literatura se darán las bases enfocadas en el uso de adenosina para el presillamiento de aneurismas cerebrales y, aunque parezca un método inocuo y que no requiere mucha preparación y logística, sólo debe realizarse por personal experto en neuroanestesiología para lograr obtener un mejor resultado para el paciente.

Abstract: The clipping of cerebral aneurysms remains a very complex surgery even with advances in neurosciences. The goal of surgery in the clipping of cerebral aneurysms is to prevent rupture and cause collateral damage in the same, trying to expose both the neck of the aneurysm to its maximum for clipping as well as temporary occlusion of the artery proximal to it. The use of trananesthetic cardiac arrest in the clipping of cerebral aneurysms is a technique used for certain types of cerebral aneurysms and there are several methods to perform it, from deep or severe hypothermia, passing through ventricular pacemaker at high frequencies until it reaches the circulatory arrest with the use of adenosine. This review of the literature will focus on the use of adenosine for the clipping of cerebral aneurysms and, although it seems a safe method and does not require much logistical preparation, it should only be performed by expert personnel in neuroanesthesiology to achieve a better result for the patient.

Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida.

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way.

Aneurisma ateroesclerótico roto de la arteria carótida interna izquierda intracerebral / Broken atherosclerotic aneurysm of the intracerebral left internal carotid artery

ResumenLos aneurismas cerebrales son lesiones arteriales caracterizadas por el debilitamiento y la dilatación de un segmento del vaso sanguíneo. La localización más frecuente es en las bifurcaciones de las arterias del polígono de Willis y su ruptura produce una hemorragia subaracnoidea, que puede causar la muerte¹. Este artículo describe el caso de una mujer de 62 años, sin antecedentes personales patológicos ni traumáticos conocidos, que según el informe de muerte en investigación, se desvaneció mientras se bañaba y fue declarada fallecida en el lugar.Posterior a la autopsia médico legal, se constató como causa de muerte una ruptura de aneurisma ateroesclerótico de la arteria carótida interna izquierda.

Abstract:Cerebral aneurysms are arterial lesions characterized by weakening and expansion of a segment of blood vessel.The most common location is in the bifurcations of the arteries of the circle of Willis and the rupture produces a subarachnoid hemorrhage, which can cause death¹. This article describes the case of a woman of 62 years without pathological or traumatic personal history known, according to the report of death investigation, he vanished while bathing and was declared dead at the scene. After the forensic autopsy, it was found as the cause of death atherosclerotic aneurysm rupture of the left internal carotid artery.

Bitemporal Postoperative Hemorrhage Following Pterional Craniotomy for the Treatment of an Internal Carotid Aneurysm

Introduction Postoperative hemorrhage is a well-known complication after intracranial surgeries. It usually occurs at the site of the operation; however, there are many reports of cerebellar hemorrhage following supratentorial craniotomies. Despite that, there are only three cases of multiple postoperative supratentorial hemorrhages (distant from the site of the operation) following aneurysm clipping in the current literature. Case Report A 52-year-old previously healthy woman underwent a left pterional craniotomy for the clipping of an unruptured aneurysm. The surgery was performed without any intraoperative rupture or other occurrences. On the follow-up computed tomography (CT) scan performed 24h after surgery, bilateral posterior temporal lobe hematomas were identified, and they had no relation to the surgical site. The patient developed symptomatic vasospasm, with right-sided hemiparesis. This complication was treated conservatively, and the outcome was good. Conclusions Intracerebral hemorrhage far from the site of the craniotomy is an infrequent complication after neurosurgical procedures, especially in vascular neurosurgery. The present report warns of the occurrence of this entity even in asymptomatic patients.

Introdução Hemorragia pós-operatória é uma complicação bem conhecida após cirurgias intracranianas. Geralmente ocorre no sítio cirúrgico, porém há vários relatos de hemorragias cerebelares após craniotomias supratentoriais. Apesar disso, há somente três casos de hemorragias múltiplas supratentoriais (distantes do sítio cirúrgico) após clipagem de aneurisma intracraniano. Relato do Caso Paciente feminina, de 52 anos, previamente hígida, foi submetida a craniotomia pterional para clipagem de aneurisma não roto. A cirurgia ocorreu sem ruptura intraoperatória ou outra intercorrência. Na tomografia de crânio de controle, realizada 24h após o procedimento, 2 hematomas temporais posteriores foram identificados sem relação com o sítio cirúrgico. A paciente posteriormente desenvolveu vasoespasmo sintomático, com hemiparesia direita, mas essa complicação foi tratada conservadoramente, e teve boa evolução clínica, sem déficit residual. Conclusões Hemorragias intracranianas distantes do sítio cirúrgico são complicações infrequentes, especialmente em neurocirurgia vascular. O presente caso adverte para a ocorrência dessa complicação mesmo em pacientes assintomáticos.

Vasoespasmo cerebral y déficit isquémico tardío en la hemorragia subaracnoídea aneurismática: guías para su manejo clínico / Cerebral vasospasm and delayed ischemic deficit in the aneurysmal subarachnoid hemorrhage: guidelines to its clinical management

La presente revisión del tema Vasoespasmo y Déficit Isquémico Cerebral tardío (DIT) en la Hemorragia subaracnoidea aneurismática tiene como objetivo actualizar su manejo, basado en las hipótesis mas aceptadas que se han logrado para explicar su patogénesis. Se efectúa una introducción con conceptos generales, se revisan las bases patogénicas del Vasoespasmo y se plantea su manejo, tomando en cuenta su diagnóstico, monitorización, profilaxis y manejo avanzado de acuerdo a las últimas Guías de Manejo Clínico y según medicina basada en las evidencias.

The objective of the present review on cerebral vasospasm and cerebral delayed isquemic deficit due to subarachnoid haemorrhage secondary to ruptured cerebral aneurysm, is to update their management, based on the most accepted pathophysiological hypotesis explaining their pathogenetic mechanisms. An introduction is performed presenting general concepts, review of the most recent research works explaining their pathogenesis, and the management is stated touching diagnosis, monitoring, prophylaxis, and advanced management according with the last clinical guidelines for his management using medicine based on evidences.

Cerebral Aneurysm in Takayasu's Arteritis: A Case Report and Review of the Literature

Cerebral aneurysms are rarely observed in patients with Takaysu's arteritis. To our knowledge, this report presents the first case described in Brazil. Hemodynamic stress caused by obstructions of the cervical vessels developes cerebral aneurysms in these patients and they have higher rates of multiple and posterior circulation aneurysms than general population. In the majority of cases, microsurgical treatment is indicated mainly due to changes in the cervical vessels that preclude an endovascular approach.

Aneurismas cerebrais são raramente observados em pacientes com arterite de Takayasu. Este é o primeiro caso desta associação descrito no Brasil. O estresse hemodinâmico causado pelas obstruções vasculares cervicais desenvolve os aneurismas cerebrais nestes pacientes e eles apresentam maiores taxas de aneurismas múltiplos e de acometimento da circulação cerebral posterior. Na maioria dos casos, o tratamento microcirúrgico está indicado pois as alterações anatômicas dos vasos cervicais dificultam a abordagem endovascular.

Cavernomatosis múltiple y aneurisma cerebral trombosado: una asociación inusual / Cavernous haemangioma multiple and brain aneurysm thrombosed: an unusual association

Los cavernomas son malformaciones angiográficamente ocultas, pueden ser únicos o múltiples y esporádica o familiar.Suelen asociarse a otras malformaciones vasculares como las anomalías de drenaje venoso, sin embargo no es habitual su asociación con aneurismas cerebrales. Los aneurismas son malformaciones evidenciables en angiografía, sin embargo cuando se encuentran trombosados puede dificultarse su diagnostico, observándose en algunos casos como lesiones pseudotumorales. Nuestro objetivo es exponer una rara asociación entre cavernomatosis múltiple y aneurisma cerebral trombosado en un paciente pediátrico. Presentamos una paciente de 2 años de edad con diagnóstico de cavernomatosis múltiple y aneurisma cerebral trombosado. Se realiza una revisión de la literatura de ambas entidades y su rara asociación, medianteuna búsqueda exhaustiva en la base de datos de PUBMED Y COCHRANE utilizando las siguientes palabras claves: Cavernous angioma. Familial cavernomatosis. Hemorrhagic stroke. Multiple cavernomatosis. Cerebral aneurysm. Thrombosed aneurysm. Se discute la epidemiologia, diagnóstico y manejo quirúrgico de la cavernomatosis múltiple y sus asociaciones, preconizando fundamentalmente la evaluación pre quirúrgica de estos pacientes. No encontramos ningún caso de asociación entre cavernomatosis múltiple y aneurismas en nuestra revisión bibliográfica. Dado que se pueden presentar como lesiones pseudotumorales, la tomografía computada, resonancia magnética y la angiografía cerebral son métodos fundamentales para llegar a un diagnostico prequirúrgico certero. La indicación quirúrgica debe ser evaluada individualmente en cada paciente, y se debe realizar un seguimiento clínico-imagenologico.

Cavernomas are angiographically occult malformations may be single or multiple and sporadic or familial. Usually associated with other vascular malformations such as venous drainage anomalies, however it is not common its association with brain aneurysms. Aneurysms are into evidence malformations in angiography, however when they meet their diagnosis can be difficult thrombosed observed in some cases as pseudotumoral injuries. Our goal is to present a rare association between multiple cavernous haemangioma and thrombosed cerebral aneurysm in a pediatric patient. We present a patient 2 years old diagnosed with multiple cavernous haemangioma and thrombosed cerebral aneurysm. A review of the literature of both entities and its rare association is done through an exhaustive search in the database PUBMED and COCHRANE using the following keywords: Cavernous angioma. Familial cavernous haemangioma. Hemorrhagic stroke. Multiple cavernous haemangioma. Brain aneurysm. Thrombosed aneurysm. The epidemiology, diagnosis and surgical management of multiple cavernous haemangioma and their associations is discussedessentially advocating the presurgical evaluation of these patients. No case of association between multiple cavernous haemangioma and aneurysms in our literature review. Because can be presented as pseudotumoral lesions, computed tomography, magnetic resonance imaging and cerebral angiography are fundamental methods to reach an certain diagnosis preoperatively. The surgical indication should be evaluated individually for each patient, and should be performed a clinical-imaging follow-up.

Clinical outcomes of surgical clipping for intracranial aneurysms in patients with a Hunt and Hess grade 4 or 5 / Desfechos clínicos da clipagem cirúrgica de aneurismas intracranianos de graus 4 e 5 segundo a escala de Hunt & Hess

ABSTRACT We retrospectively evaluated the records of 49 grade 4 and 5 patients with 42 intracranial aneurysms treated within 72 h of subarachnoid hemorrhage (SAH). In total, 35 patients (71%) were grade 4, and 14 (29%) were grade 5. A total of 42 (85%) patients had one aneurysm, 6 (12%) had two aneurysms, and 1 (3%) had three aneurysms. Out of 49 patients, one technical (2%) and one clinical (2%) complication occurred at surgery. Twenty-one (43%) patients recovered well, including 7 with postoperative hematoma requiring an immediate evacuation of a clot. Fourteen (29%) patients had hydrocephalus and required a ventriculo-peritoneal shunt; 12 patients underwent tracheotomy postoperatively due to coma and pulmonary infection. We found that patients with Hunt and Hess grade 4 and 5 aneurysms can undergo successful neurosurgical clipping of the aneurysms after SAH. However, the morbidity and mortality rates remain high because of their poor clinical condition and a high incidence of vasospasm during treatment.

RESUMO Avaliamos retrospectivamente os registros de 49 pacientes com 42 aneurismas intracranianos de graus 4 e 5, tratados nas primeiras 72 horas após uma hemorragia subaracnóidea (HSA). Trinta e cinco pacientes (71%) apresentavam grau 4 e catorze (29%) grau 5. Quarenta e dois pacientes (85%) tinham um único aneurisma, seis (12%) tinham dois aneurismas, e um paciente (3%) tinha três aneurismas. Dos 49 pacientes, uma complicação técnica (2%) e uma complicação clínica (2%) ocorreram durante a cirurgia. Vinte e um pacientes (43%) recuperaram-se bem, incluindo sete que tiveram hematomas pós-operatórios que requereram a imediata evacuação do coágulo. Catorze pacientes (29%) tiveram hidrocefalia e submeteram-se à derivação ventrículo-peritoneal; doze pacientes submeteram-se à traqueostomia no pós-operatório, devido a coma e infecção pulmonar. Pacientes com aneurismas de graus 4 e 5, segundo a escala de Hunt & Hess podem submeter-se com sucesso à clipagem dos aneurismas após HSA. Entretanto, as taxas de morbidade e mortalidade ainda são altas, devido à condição clínica precária e à alta incidência de vasoespasmo durante o tratamento.

Alterações endocrinológicas após hemorragia subaracnóidea / Endocrinological Changes after Subarachnoid Hemorrhage

A avaliação da função hipofisária na fase aguda ou tardia dos pacientes que sofrem hemorragia subaracnóidea (HSA) é infrequente; entretanto, a HSA apresenta um risco significante de disfunção pituitária, principalmente devido à vulnerabilidade da sua suplência vascular. Há poucos estudos tratando do tema, mas os existentes sugerem que distúrbios hormonais pós-hemorragia subaracnóidea são mais prevalentes do que inicialmente se suspeitava. Não somente a hipófise anterior parece estar envolvida nessas alterações; a hiponatremia no estágio agudo pode ser uma manifestação de disfunção da hipófise posterior. As alterações hormonais após HSA ainda recebem pouca atenção das equipes assistenciais, podendo ser uma das complicações potencialmentegraves sendo tratável quando há suspeição pelo diagnóstico clínico e laboratorial.

The evaluation of pituitary function in the acute and at late time in the patients with subarachnoid hemorrhage (SAH) is unusual. Meanwhile the SAH present with a high risc of pituitary disfunction primarily by the vulnerability of the vascular feeding vessels. Few studies about this subject suggest that hormonal disturbance are more prevalent that were suspected before. Both the anterior and posterior pituitary areinvolved. The hormonal changes after SAH are not well recognized by the physicians and can be treated even been a critical medical situation with clinical and laboratorial findings.

Momento quirúrgico apoyado con doppler transcraneal en pacientes con hemorragia subaracnoidea aneurismática / Surgical timing supported by transcranial doppler in patients with subarachnoid hemorrhage from aneurisms rupture

Introducción: La cirugía de la hemorragia subaracnoidea aneurismática (HSA) realizada en las primeras 72 horas es beneficiosa. Cuando los casos arriban transcurrido este período el mejor momento quirúrgico es controversial. Objetivo. Evaluar la influencia sobre los resultados de la cirugía en la HSA de un protocolo para decidir el momento quirúrgico apoyado en el monitoreo con Doppler transcraneal (DTC). Material y Método: Se comparan los resultados quirúrgicos al alta y al año de seguimiento según la escala de Glasgow para resultados (EGR), en una serie de 233 casos con HSA rotos operados Enero de 2006 - Diciembre de 2010 y seguidos hasta Enero de 2012, en los que la cirugía en el período intermedio se decidió teniendo en cuenta las velocidades de flujo de los segmentos proximales del polígono de Willis registradas por DTC, con los de un grupo control histórico operado Diciembre de 1983 - Diciembre de 2005 sin la ayuda de dicho monitoreo. Resultados: La mortalidad al alta y al año en la serie de estudio fue de 4,3 y 4,5 por ciento y en el grupo control 7 y 7,7 por ciento respectivamente. Se observaron resultados satisfactorios (grados 4 y 5 en EGR) en el 93,1 al alta y 92,8 por ciento al año en la serie de estudio. Entre los controles históricos estos índices fueron 85,6 y 88,1 por ciento respectivamente (p = 0,004 y p = 0,036). Conclusiones: Los resultados del tratamiento microquirúrgico de la HSA se benefician con la atención protocolizada y la consideración de los resultados del DTC para seleccionar el momento quirúrgico.

Background: Aneurysmal subarachnoid hemorrhage (SAH) surgery, practiced in the first 72 hours is beneficial. The optimal surgical timing, for microsurgical clipping of ruptured intracranial aneurysms, remains controversial when patients arrive between 4 and 14 days. Some surgeons favor a prompt operation regardless the timing. Other ones prefer to wait 2 weeks. Most patients in developing countries are taken to neurosurgical attention late, which not permit an early surgery. Object. To evaluate the surgical outcome in a series of patients with subarachnoid hemorrhage (SAH) managed according to a dynamic protocol. Methods: The authors evaluated surgical outcome by means of Glasgow Outcome Scale (GOS) score in a series of 233 patients with SAH who received neurosurgical clipping in the years 2006-2010 and were followed until January 2012, whose surgical timing was decided according to transcranial Doppler (TD) monitoring. These outcomes were compared with results in a series of 445 historic controls operated 1983-2005. Results: Series mortality at the discharge and at the year were 4.3 and 4.5 percent, and 7 and 7.7 percent in the control group respectively. Series show good outcomes (grade 4 and grade 5 in GOS score) in 93.1 at the discharge and 92.8 percent at the year. Among the historic controls cases with good outcome were 85.6 and 88.1 percent respectively (p = 0.004 y p = 0.036). Conclusions: Surgical outcomes of SAH can be favored by the impact of protocolized attention and TD to decide the best surgical timing in SAH.

Tratamiento quirúrgico de aneurisma de la arteria cerebelosa postero inferior gigante embolizado / Surgical treatment of embolized giant posteroanterior cerebellar artery aneurysm

Objetivo: descripción de la resolución quirúrgica de un aneurisma complejo, gigante de circuito posterior (arteria cerebelosa posteroinferior), embolizado previamente, y la evolución postoperatoria. Descripción: Paciente de 48 años de edad con antecedentes de hidrocefalia obstructiva, e hipertensión de fosa posterior, la cual fue tratada por vía endovascular hace 4 años, con colocación de derivación ventricular, y craniectomía descompresiva de fosa posterior, con evolución progresiva de déficit de pares craneales bajos, y síndrome de hipertensión endocraneana. Intervención: Se realizó abordaje extremo lateral con drilado parcial del cóndilo occipital, control proximal de la arteria vertebral, y reconstrucción de la pared aneurismática del sector arteria vertebral- arteria cerebelosa posteroinferior (PICA), mediante microcirugía, con posterior apertura del saco dural y remoción de coils y trombosis intraaneurismática, removiendo el efecto de masa aneurismático. Conclusión: El tratamiento microquirúrgico con la técnica de la reconstrucción parietal del aneurisma y el control proximal del mismo, en conjunto con abordajes de base de cráneo permiten el definitivo y adecuado tratamiento para los aneurismas gigantes de la pica.

Objective: to describe the surgical treatment for complex, giant, embolized, PICA aneurysm and the follow up.Description: 48 years old, female patient with clinical history of obstructive hydrocephalus and posterior fossa´s hipertension. The treatment was endovascular surgery with coils and venricular shunt with posterior fossa´s deccompresive surgery 4 years ago. The clinical evolution was poor. Due to low cranial nerves déficit and progressive posterior fossa´s hipertension, we performed microsurgical treatment Intervention: We performed extreme lateral approach with partial drilling of occipital condile, wiht proper proximal vascular vertebral control, and vascular parietal artery reconstruction in the vertebral-posterior inferior cerebellar artery (PICA) aneurysmatic segment,with microsurgery, posterior opening of the dome and coils remotion. Conclusion: Microsurgical treatment with reconstruction parietal technique, proximal vascular control and skull base approaches are the definitive and more adecuated treatment for giant PICA aneurysms.

Correlación de los hallazgos de la angiotomografia tridimensional con el diagnóstico post operatorio en pacientes con aneurisma cerebral / Correlation of the findings of the three-dimensional angiotomography with postoperative diagnosis in patients with cerebral aneurysm

Objetivo: determinar la correlación de los hallazgos de la Angiotomografía Tridimensional con el diagnostico post operatorio en pacientes con aneurisma cerebral que acuden a urgencias del Hospital Obrero #2 en el periodo comprendido entre enero del 2010 a diciembre del 2013. Métodos: se realiza un estudio de tipo retrospectivo, transversal, descriptivo con un enfoque cuantitativo, de un universo de 100, se seleccionó a 30 pacientes que cumplieron con los criterios de inclusión y exclusión. Resultados: el grado más representativo del estudio fue el Grado II con un porcentaje de 40 % (n=12). La escala de Fisher por tomografías encontrada en mayor proporción fue el Grado II con un 40 % (n=12). Las características angiotomografías de los aneurismas encontrados con más frecuencia son el tamaño del saco aneurismático entre 10 -25 mm( n=23), tamaño de cuello del aneurisma que es mayor a 4 mm en 77 % (n=23), relación cuello y saco entre 1/3 a 1 (n=22); morfología del tipo sacular es de 97 % (n=29); la localización del aneurisma es en el segmento carotideo supraclinoideo 33% (n=10); se encontró una correlación en 29 pacientes del total de 30, entre el diagnostico tomográfico y los hallazgos posoperatorios (en cuanto a tamaño, forma y localización), sin embargo solo se encontró una variante en cuanto a la localización, esto fue descrito en la tomografía que estaba localizado en el segmento clinoideo C5 y el postoperatorio en el segmento comunicante C7. Resultado: en el presente estudio se encontró una buena correlación entre el diagnóstico de la angiotomografia y el postoperatorio ya que hizo el diagnóstico correcto a 88% de nuestros pacientes, con solo una variación respecto a la localización. Creemos que permitió realizar el tratamiento quirúrgico oportuno en pacientes con HSA que ingresaron a nuestro hospital.

Objective. To determine the correlation of the findings of the three-dimensional angiography with post operative diagnosis in patients with cerebral aneurysm attending emergency of the Hospital Obrero #2 in the period from January 2 010 to December 2 013. Metodos: do a study retrospective, tranverse, descriptive type with a quantitative approach, counting with a universe of 100 patients of whom 30 patients who met the inclusion and exclusion criteria were chosen with a intentional non-probability sampling. Results: in those 30 cases the age group that showed higher frequency of aneurysmal rupture was 50-59 years old representing 33%, with 58years old as high peak. The most affected was the female gender with 73% (n = 22). According to clinical evaluation with scale Hund and Hess the most representative of the study was the Grade II level with a percentage of 40% (n = 12) .The Scale of Fisher found in greater proportion was Grade II with 40 % (n = 12) .The Angiotomograffas characteristics of aneurysms most frequently found are: aneurysm sac size 10 -25 mm (n = 23) of the aneurysm neck size: more than 4 mm: 77% (n = 23 ) Relationship neck / sac 1/3 -1 (n = 22); Saccular sac morphology: 97% (n = 29); Aneurysm location: supraclinoid carotid segment 33% (n = 10); A good correlation of 30 patients between the tomographic diagnosis in size, shape and post operative findings was found, however only one variant was found in terms of location: it was described on CT which was located in Segment clinoid C5 and postoperative communicating segment C in July. Conclusions: In this study, a good correlation between the diagnosis and postoperative angiotomography. was found to be diagnosed 100% of our patients, with only one variation, regarding the location. We believe that allowed carrying out timely surgical treatment in patients with SAH admitted to our hospital.

Head positioning for anterior circulation aneurysms microsurgery / Posicionamento da cabeça para microcirurgias de aneurismas da circulação anterior

Objective To study the ideal patient's head positioning for the anterior circulation aneurysms microsurgery. Method We divided the study in two parts. Firstly, 10 fresh cadaveric heads were positioned and dissected in order to ideally expose the anterior circulation aneurysm sites. Afterwards, 110 patients were submitted to anterior circulation aneurysms microsurgery. During the surgery, the patient's head was positioned accordingly to the aneurysm location and the results from the cadaveric study. The effectiveness of the position was noted. Results We could determine mainly two patterns for head positioning for the anterior circulation aneurysms. Conclusion The best surgical exposure is related to specific head positions. The proper angle of microscopic view may minimize neurovascular injury and brain retraction. .

Objetivo Estudar o posicionamento da cabeça para a cirurgia de aneurismas cerebrais da circulação anterior. Método Dividimos o estudo em duas partes. Inicialmente, dez cabeças de cadáveres frescos foram posicionadas e dissecadas de modo a expor, de maneira ideal, os principais sítios de aneurismas na circulação anterior do cérebro. Posteriormente, 110 pacientes foram submetidos a microcirurgia para clipagem de aneurismas cerebrais da circulação anterior. Durante as cirurgias, as cabeças foram posicionadas de acordo com a localização específica de cada aneurisma e o resultado obtido no estudo dos cadáveres. Cada paciente teve sua posição avaliada quanto a sua eficácia. Resultados Obtivemos basicamente dois padrões de posicionamento da cabeça para cirurgias de aneurismas cerebrais da circulação anterior. Conclusão A melhor exposição cirúrgica está relacionada à posição específica da cabeça para cada localização aneurismática. O ângulo de visão microscópica adequado minimiza lesões neurovasculares e a excessiva retração cerebral. .

Morphological distinguish of rupture status between sidewall and bifurcation cerebral aneurysms / Caracterización morfológica del estado de ruptura entre aneurismas cerebrales en paredes laterales y bifurcaciones

We suspect that morphological change of two types of aneurysms in ruptured and unruptured aneurysms are distinguishing because of different location and haemodynamics. So it is necessary to discuss sidewall and bifurcation type aneurysms in ruptured and unruptured state respectively. We used 209 consecutive aneurysms (144 ruptured, 65 bifurcation type) to assess the following parameters in 3D: maximum diameter (Dmax), maximum height (Hmax), aspect ratio (AR), size ratio (SR), height/width ratio (HW), bottleneck factor (BNF, width/neck) and inflow angle (IR). These aneurysms were divided into four groups by whether ruptured and sidewall or bifurcation. 4 groups were pairwise compared by univariate analysis and some parameters with significant variation were analyzed by multinomial logistic. Hmax (P=0.014) and HW (P=0.001) were different significantly between ruptured bifurcation and sidewall by multinomial logistic. There was no difference between unruptured bifurcation and sidewall (P>0.05) except for SR (P=0.002) by multinomial logistic. All data of ruptured aneurysms are different significantly from unruptured aneurysms (P<0.05) except for sidewall HW (P=0.414) by univariate analysis. But only SR (P < 0.001) and IR (P=0.006) of sidewall and SR (P=0.011) and HW (P=0.001) of bifurcation was significantly different by multinomial logistic. Volume of sidewall aneurysms are larger than bifurcation aneurysms and stretch characteristic of bifurcation is more obvious in ruptured aneurysms. Flow angle is the important criteria to predict fracture not in bifurcation aneurysms but in sidewall aneurysms. Size ratio is always a very important parameter to predict rupture of aneurysm no matter in bifurcation and sidewall type.

Sospechamos que el cambio morfológico de dos tipos de aneurismas, con y sin ruptura, son distinguibles por diferencias en su hemodinamia y ubicación. Por esto, es necesario discutir sobre el estado de ruptura en los aneurismas ubicados en una pared lateral o bifurcación, respectivamente. Utilizamos 209 aneurismas consecutivos (144 con ruptura y 65 de bifurcación) para evaluar los siguientes parámetros en tres dimensiones: diámetro máximo (Dmax), altura máxima (Amax), relación de aspecto (RA), relación de tamaño (RT), relación de altura/ancho (AA), factor de cuello de botella (FCB, ancho/cuello) y ángulo de entrada (AE). Los aneurismas se dividieron en cuatro grupos por su estado de ruptura (rotos y no rotos) y ubicación (pared lateral y bifurcación). Los grupos se compararon por pares mediante análisis univariado y quienes presentaran variación significativa fueron analizados por logística multinomial. La Amax (P=0,014) y AA (P=0,001) mostraron diferencias significativas entre aneurismas con ruptura en bifurcación y pared lateral, según la logística multinomial. No hubo diferencias entre los aneurismas sin ruptura en bifurcación y pared lateral (P>0,05), excepto para RT (P=0,002) por logística multinomial. Todos los datos de aneurismas con ruptura mostraron diferencias significativas con los sin ruptura (P<0,05), excepto para la AA en la pared lateral (P=0,414) según el análisis univariado. Sólo las RT (P<0,001) y AE (P=0,006) de la pared lateral, y RT (P=0,011) y AA (P=0,001) en bifurcación tuvieron diferencias significativas mediante logística multinomial. El volúmen de los aneurismas de pared lateral fue mayor que los de bifurcación, así como la ruptura fue más evidente en el tramo característico de la bifurcación. El AE es un criterio importante para predecir la rotura en los aneurismas de pared lateral. La RT siempre es un parámetro importante para predecir la rotura de un aneurisma, tanto para los que ocurren en bifurcación y en la pared lateral.