Sequelas em pacientes com hemorragia subaracnóide por ruptura de aneurisma intracraniano / Sequelae in patients with subarachnoid hemorrhage by aneurysm intracranial rupture

Introdução: a hemorragia subaracnóidea (HSA) aneurismática é um evento clínico grave, que apresenta altas taxas de morbimortalidade. Dos indivíduos acometidos por HSA, apenas um terço voltam à vida normal, na grande maioria das vezes desenvolvem sequelas neurológicas significativas. Objetivo: conhecer os tipos de sequelas e prevalência em pacientes com hemorragia subaracnóidea por ruptura de aneurisma intracraniano no Hospital Nossa Senhora da Conceição ? HNSC, Tubarão ? SC. Métodos: pesquisa transversal, constituída por prontuários médicos de pacientes pós-cirúrgicos de HSA por ruptura de aneurisma intracraniano, com idade superior a 18 anos. Resultados: foram analisados 7 prontuários. Houve predominância do sexo feminino (67,6%). A média de idade dos pacientes foi de 52,1 anos. O tempo de internação teve uma média de 36,7 dias. Dentre as complicações pesquisadas o vasoespasmo apresentou-se de forma mais frequente (20,3%), seguido de convulsões (17,6%), ressangramento (10,8%), hidrocefalia (9,5%), hematoma cerebral (4,1%), PIC elevada (1,4%) e outras complicações (4,2%). As sequelas neurológicas mais encontradas entre os indivíduos pesquisados foram: a alteração cognitiva (45,9%) e o déficit motor (31,1%), o déficit comportamental (2,7%) e outras sequelas (4,1%). Conclusão: no HNSC houve uma prevalência significativa de pacientes pós-cirúrgicos com sequelas neurológicas devido a HSA aneurismática. O vasoespasmo esteve associado às principais sequelas; e a taxa de mortalidade mostrou--se baixa em relação à literatura utilizada.

Background: subarachnoid hemorrhage caused by ruptured aneurysms is a severe clinical event that presents high morbimortality rates. Just a third part of patients have a normal life after a subarachnoid hemorrhage. Usually the major part of patients will develop significant neurological sequelae. Objective: to know the prevalence and every kind of sequelae that occurs in patients after subarachnoid hemorrhage event caused by a ruptured aneurysms in Nossa Senhora da Conceição Hospital, Tubarão ? SC. Methods: transversal study constituted by medicals handbooks of patients older than 18 years old after aneurysm intracranial surgery from January of 2000 to May of 2008. Results: 74 medicals handbooks were analyzed. There was a female predominance (67,6%). The age average was 52,1 years old. The time average spent into the hospital for each was 36,7 days. About surgery complications, vasospasm was more common (20,3%), convulsions (17,6%), rebleeding (10,8%), hidrocephalia (9,5%), cerebral hematoma (4,1%), high intracranial pressure (1,4%) and others complications (4,1%). About neurological sequelaes were found: cognitive alteration (45,9%), motor deficits (31,1%), behavior deficits (2,7%) and others sequelaes (4,1%). Conclusion: we verify that had a significant prevalence of patients with neurological sequelae consequently subaracnoid hemorrhage aneurismal in Nossa Senhora da Conceição Hospital. The main sequelaes and vasospasm usually were associated. Comparing with literature, mortality rates were lower.

Carney Complex with Multiple Intracranial Aneurysms

Carney complex is an autosomal dominant disease that displays such characteristic features as cardiac and cutaneous myxomas and spotty pigmentation of the skin. We report here on a case of Carney complex that was accompanied by increased myxoid fibroadenomas in the breast and multiple intracranial aneurysms.

Detection of Intracranial Aneurysms Using Multi-detector Row CT 3D-Angiography: Comparison with Operative Findings

PURPOSE: To assess the efficacy of three-dimensional CT angiography (3D-CTA) using multi-detector row computed tomography (MDCT) in the evaluation of intracranial aneurysms in patients with non-traumatic acute subarachnoid hemorrhage and to describe those aneurysms which were not found 3D-CTA. MATERIALS AND METHODS: 3D-CTA was done in 40 patients with non-traumatic subarachnoid hemorrhage by using a 16-slice MDCT; conventional digital subtraction angiography (DSA) was done in 36 of those patients within 12 hours. The CT and DSA images were reviewed by two radiologists and the site, size and neck of the aneurysms were evaluated. The results from these two modalities were then compared with the operative findings. We calculated the detection rates by 3D-CTA and DSA and evaluated the size differences of aneurysms dignosed with 3D-CTA and those found at surgery. We also analyzed the locations and sizes of aneurysms missed by 3D-CTA and attempted to explain these false negatives. RESULTS: A total of 55 aneurysms were surgically confirmed in 40 patients. 48 of these were detected pre-operatively by 3D-CTA. Thus, the detection rate by 3D-CTA was 87%. The size difference of aneurysms as calculated by 3-D CTA and found operatively was as follows: less than 1 mm in 17 cases, within 1-2 mm in 15 cases, and more than 2 mm in 16 cases. Seven aneurysms were not detected by 3D-CTA. The major cause of these missed aneurysms was their small size. The undetected aneurysms were less than 2 mm in size, except for 2 instances of PCoA aneurysms. One case was not detected due to difficult image evaluation. A possible explanation of the one remaining missed aneurysm was the filling of the aneurismal sac by thrombosis. CONCLUSION: Though there were some limitations in the detection of aneurysms, 3D-CTA using 16-channel MDCT may provide sufficient pre-operative information for the management of patients with intracranial aneurysms in cases of emergency operations or DSA-failure.

Therapeutic embolization of cerebral aneurysms with electro-detachable platinum coil / 介入放射学杂志

Objective To assess the therapeutic effect of cerebral aneurysmal embolization with electro-detachable platinum coils(EDPC), and to discuss the timing of the embolization and points for attention during the procedure. Methods From February 1999 to July 2004, 60 intracranial aneurysms were treated with EDPC in 58 patients, of which 56 cases were subject to subarachnoid hemorrhage (SAH). 36 patients were Hunt & Hess Grade I, 12 Grade II and 8 Grade IV～V. Two of all 58 patients had no SAH. Two sorts of EDPC were used in this group: one is Guglielmi detachable coil from Boston Scientific Corporation and the other is Sapphire detachable coil from Micro Therapeutics Inc. All the sessions of embolization and each detachment of the EDPC were closely monitored both fluoroscopically and angiographically for the accurate and safe embolization of aneurysmal lumen. Results Of all 60 aneurysms, 58 were successfully treated with EDPC and 2 were failed to be embolized due to arterial spasm. The packing degree of aneurismal lumen was complete in 44 cases (75.9%) and incomplete in 12 cases (20.7%). The incidence of non-thrombotic complication was 6.9%. One patient had hemiplegia because of the hernia into the parent artery by EDPC. No death occurred in our group. 41 patients were followed-up during a period of 1～4 years and no SAH onset recurred after embolization. Conclusions Endovascular treatment of intracranial aneurysms with GDC is a better alternative. But the long-term effects should be verified by follow-up in the future.

Traumatic Intracranial Aneurysms in Children

PURPOSE: To describe the imaging findings of traumatic intracranial aneurysms (TICA) in children. MATERIALS AND METHODS: Five boys aged 3-15 (mean, 7) years with surgically confirmed TICA were included in this study. All had a history of nonpenetrating head trauma, and they underwent precontrast CT imaging immediately after the injury and follow-up CT or MRI. In all cases, angiography revealed the presence of aneurysms, which at surgery were shown to be pseudoaneurysms with severe adhesions. RESULTS: Angiography demonstrated that all aneurysms were located in the anterior cerebral artery (ACA) or its branches. The precise locations were the A2 segment of the ACA, the site of origin of the callosomarginal artery or its first branch, or of the anterior internal frontal artery, or between the first and second branch of the pericallosal artery. In all patients, precontrast CT performed immediately after trauma depicted subarachnoid hemorrhage (SAH) in the anterior interhemispheric fissure (AIHF). Follow-up precontrast CT showed nodular high density around the anterior falx in three, recurrent SAH in the AIHF in two, and intracerebral hemorrhage (ICH) with intraventricular hemorrhage in two. In two patients with a nodular high-density lesion, nodular enhancement was demonstrated at postcontrast CT, and in one, follow-up MRI revealed a nodular signal void around the anterior falx; nodular enhancement was seen at postcontrast imaging, and MR angiogram depicted a saccular aneurysm. In one patient, MRI demonstrated infarction in the caudate nucleus and ACA territory. CONCLUSION: If, after head injury, an area of nodular high density is revealed by CT, or a signal void by MRI, or if SAH or ICH is present around the anterior falx, the possibility of TICA should be considered.

Maffucci's Syndrome Associated with Chondrosarcoma and Aneurysm: Case Report

Maffucci syndrome is a rare congenital non-inherited condition characterized by multiple enchondromas and cutaneous hemangiomas. It is associated with increased risk of malignancy, including chondrosarcomas, and because of generalized mesodermal dysplasia, aneurysms can develop. We present a case of Maffucci syndrome associated with intracranial chondrosarcoma and aneurysm.

Usefulness of "Double-catheter" Technique in GDC Treatment of Intracranial Wide-necked Aneurysm

Purpose: To describe two different methods of "double-catheter" techniques for the treatment of wide-necked intracranial aneurysms. MATERIALS AND METHODS: Using two microcatheters simultaneously, we treated two wide-necked ophthalmic aneurysms and one wide-necked basilar bifurcation aneurysm. In the two cases of ophthalmic aneurysms, the two microcatheters were placed in the aneurysm sac, thus allowing two coils to be braced across the aneurysmal neck before either was detached. In the case of the basilar bifurcation aneurysm, a microcatheter was placed in the posterior cerebral artery (PCA), and another within the aneurysm lumen. When making the first frame with a GDC, we tried to ensure that the frame of the coil and the microcatheter in the PCA did not over-lap. Then, through the microcatheter positioned at the PCA, angiography was performed and flow pattern and dye-disappearance time were evaluated. Subsequent coils were introduced, but in order to preserve PCA flow, not beyond the frame of the first coil. RESULTS: All three aneurysms were successfully embolized without parent artery compromise and the patients were discharged in good neurological condition. CONCLUSION: The "double-catheter" technique can provide a valuable option for treating wide-necked aneurysms, especially when 'balloon remodeling' is not feasible and/or the relationship between the aneurysmal neck and adjacent parent artery cannot be ascertained.

Angiographic Analysis of the Circle of Willis: Comparison between Normal and Aneurysm groups

PURPOSE: To evaluate angiographic variations of the circle of Willis in a normal group, and to compare thepattern of these variations between normal and aneurysm groups. MATERIALS AND METHODS: We reviewed 220 cases inwhich subjects had undergone digital subtraction cerebral angiography which showed the circle of Willis in itsentirety. One hundred patients were diagnosed as normal, and 110 had an aneurysm. We reviewed the absence orpresence and relative size of each segment, and the configuration of the distal basilar artery. Where the circlewas complete, we evaluated whether or not the circle was balanced. And we compared the pattern of these variationsbetween the two groups. RESULTS: In the normal group, the most common pattern was a small anterior communicatingartery with symmetrically large A1 segments in the anterior circulation (27%) and symmetrically small posterior communicating arteries with large P1 segments in the posterior circulation (39%). The anterior half of the circlewas complete in 90% of cases, and the posterior half in 63%. In cases in which it was incomplete, there wasagenesis of the anterior communicating artery in 9% of cases, of the A1 segment in 1%, of the posterior communicating artery in 36%, and of the P1 segment in 3%. Unilateral absence of the posterior communicating arteryand P1 segment was noted in two cases. In the distal basilar artery, symmetric cranial fusion was most common,accounting for 77% of cases. In contrast, incomplete circles with agenesis of the A1 (1% vs 12%, p<.05) or P1segment (3% vs 10%, p<.05) were more common in the aneurysm group than among normal subjects. Unbalanced typeswith a size discrepancy between A1 segments (8% vs 18%, p<.05), or posterior communicating arteries equal to orlarger than the P1 segment (27% vs 46%, p<.05) were also more common. In the distal basilar artery, symmetriccranial fusion was most common, and accounted for 69% of cases. CONCLUSION: A complete and balanced circle wasmore common in the normal group. The most common pattern was a small anterior communicating artery withsymmetrically large A1 segments and symmetrically small posterior communicating arteries with large P1 segments.In contrast, incomplete or unbalanced circles were more common in the aneurysm group.

Endovascular Treatment of 20 Acutely Ruptured Cerebral Aneurysms with Detachable Coils

PURPOSE: To evaluate the preliminary results of endovascular coil treatment of acutely ruptured aneurysms. MATERIALS AND METHODS: Between August 1995 and December 1997, 18 patients with 20 ruptured aneurysms weretreated. They were classified as Hunt and Hess grade I (n=3), grade II (n=1), grade III (n=3), grade IV (n=10) orgrade V (n=1). Endovascular treatment was performed at mean 5.2 (range, 1-18) days. The first aneurysm was treatedwith mechanical detachable spirals (MDS) and the others with Guglielmi detachable coils (GDC). Aneurysm size wascategorized as small (n=17) or large (n=3). Ten aneurysms were located in the anterior circulation, and ten in theposterior circulation. Using the Glasgow outcome scale (GOS), clinical outcome was evaluated 5 to 27 months aftertreatment in 11 patients. Three patients had already died. RESULTS: In 14 of the 18 patients (16 of 20 aneurysms: 80%), treatment was successful. Four aneurysms failed due to unsuccessful catheter placement (n=2), smallaneurysm (n=1) or occlusion of the parent vessel (n=1). Total occlusion was observed in 13 aneurysms; 95-99%, orsubtotal occlusion, in two, and less than 95%, or incomplete occlusion, in one. Technical complications includedpassing of wire (n=1) and unintentional parent artery occlusion (n=1). There was a 7.1%(1/14) morbidity rate, butno mortality related to the technique. Six patients with Hunt and Hess grade I-III had good clinical outcome (3with GOS 1, and 2 with GOS 2). Four of the nine patients who were grade IV-V showed clinical improvement (GOS 3);two patients were clinically unchanged (GOS 4), and three died from the severity of primary hemorrhage. CONCLUSION: Endovascular coil treatment is a reasonable alternative for patients who are not candidates forconventional surgical treatment or in whom such treatment has failed.

Endovascular Treatment of Anterior Communicating Artery Aneurysms with Guglielmi Detachable Coils

PURPOSE: To evaluate the usefulness, results, and technical problem of endovascular treatment in anteriorcommunicating artery(Acom) aneurysm using a Guglielmi detachable coil(GDC). MATERIALS AND METHODS: We evaluated 18patients with Acom aneurysm who underwent endovascular treat-ment with GDC. Their clinical presentations weresubarachnoid hemorrhage (n=14), decreased visual acuity (n=2), and remnant aneurysm after surgical clipping (n=2).Hunt and Hess grades of 16 pre-surgical patients were Grade 0 in two patients, Grade I in three, Grade II in five,Grade III in one, Grade IV in three and Grade V in two. The size of aneurysms was 20mm in one lesion that wasclassified as large, while other lesions with diameters ranging from 3 to 12mm were classified as small.Theoutcome of treatment and technical complica-tions were analyzed. Clinical results were evaluated using the Glasgowoutcome scale(GOS). RESULTS: Treatment was successful in 13 patients. Complete occlusion was observed in tenpatients and partial occlusion in three. In five patients, the procedure failed to occlude the aneurysms becauseof proximal arterial tortuousity (n=2), wide neck (n=2) or coil fracture during the procedure (n=1). Technicalcomplications in-cluded thromboembolism (n=1) and coil fracture during the procedure (n=1). Among the 13 patientswho were treated successfully, 11 were GOS I. Two patients died after treatment because of procedure-relatedthromboembolism in one patient and progressive vasospasm, demonstrated on angiography before treatment, in theother. CONCLUSIONS: Treatment of Acom aneurysm using a GDC is useful and has many advantages compared tosur-gical clipping. Because of the anatomical characteristics of the Acom, however, technical failure may be morelikely than in the case of posterior circulation aneurysm. Meticulous evaluation of aneurysms and adjacentar-teries on angiography, as well as careful patient selection, is needed.

Angiographic Analysis of Cerebral Aneurysm

PURPOSE: To analyze the angiographic findings of cerebral aneurysms and to compare them with previousdomestic and foreign reports. MATERIAL AND METHODS: Three hundred and seventeen patients underwent DSA(digitalsubtraction angiography) and the results were retrospectively, reviewed. Among 278 patients, 356 cerebralaneurysms were detected. Patient's age and sex ratio were analysed, as well as the location, size and multiplicityof the aneurysms. RESULT: The most prevalent age group was 40 to 60 years (n=211, 76%), and the male to femaleratio was 1:1.5. Aneurysms were located in the anterior (n=324, 91%) or posterior circulation(n=32, 9%). In theformer, the most common locations were the anterior communicating artery (n=98, 28%), middle cerebral artery (MCA)bifurcation(n=65, 18%) and the posterior communicating artery (n=32, 9%), while in the pasterior circulation, themost common location was the basilar tip(n=11, 3%). One hundred and eighty-eight cerebral aneurysms(53%) were 3-6mm in size, and 75(21%) were 6-10mm. The size of nine aneurysms (3%) was more than 25mm. Multiple aneurysms(n=149)occurred in 65 patients(23%) ; the most common age group was 40 to 60 (74%) and the male to female ratio was 1:4.The most common number of multiple aneurysms were two (77%) and the common locations were the posteriorcommunicating artery (21%), MCA bifurcation (18%) and anterior communicating artery (13%). CONCLUSION: Weanalyzed a large series in a single center and therefore expect that our data will be helpful for the analysis ofaneurysms in the cerebral circulation and for comparison with domestic and foreign studies.

Imaging Features of Intracranial Calcified Aneurysm: Report of 4 Cases

We report the imaging features of four cases with calcified intracranial aneurysm. All four patients underwentCT, CT angiography, MR, magnetic resonance angiography, and angiography. Calcification of the aneurysm wall was clearly demonstrated with CT and CTA in all cases and with conventional angiography in one case. The shape of calcification was curvilinear in two cases and punctate in two. On MR, two curvilinear calcifications were demonstrated as peripheral rim of signal void but two punctate calcifications were not shown.