An Adolescent with Recurrent Intracranial Hemorrhage, and Skin Lesion / 罕见病研究

We presented an adolescent with recurrent intracranial hemorrhage and skin lesion. The diagnosis was unclear and the treatment was difficult. Through a multidisciplinary effort type Ⅰ interferon disease was suspected and later, an interferon-stimulated gene was further detected. Considering the high morbidity and fatality rate of recurrent intracranial hemorrhage, tofacitinib and hydroxychloroquine were administered. After treatment, the livedo reticularis was significantly regressed. Unfortunately, the intracranial hemorrhage recurred due to a pre-existing cerebral aneurysm, leading to death of the patient. The diagnosis and treatment of this case highlight the importance of multidisciplinary collaboration in the diagnosis and treatment of difficult and rare diseases.

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.

Finite element simulation of stent implantation and its applications in the interventional planning for hemorrhagic cardio-cerebrovascular diseases / 生物医学工程学杂志

Numerical simulation of stent deployment is very important to the surgical planning and risk assess of the interventional treatment for the cardio-cerebrovascular diseases. Our group developed a framework to deploy the braided stent and the stent graft virtually by finite element simulation. By using the framework, the whole process of the deployment of the flow diverter to treat a cerebral aneurysm was simulated, and the deformation of the parent artery and the distributions of the stress in the parent artery wall were investigated. The results provided some information to improve the intervention of cerebral aneurysm and optimize the design of the flow diverter. Furthermore, the whole process of the deployment of the stent graft to treat an aortic dissection was simulated, and the distributions of the stress in the aortic wall were investigated when the different oversize ratio of the stent graft was selected. The simulation results proved that the maximum stress located at the position where the bare metal ring touched the artery wall. The results also can be applied to improve the intervention of the aortic dissection and the design of the stent graft.

Prospects for 3d printing in the treatment of cerebral aneurysm / 中国组织工程研究

BACKGROUND: Interventional treatment can also be used as a palliative treatment for patients who cannot be surgically removed. However, the positioning of the lesion at the beginning of the operation or the catheter during the interventional treatment can only be accurately and clearly displayed through the two-dimensional image, and is related to the operator’s own experience and understanding of the image. The 3D printing model is a physical model with high simulation and individualized features, and has the advantages of individualization and precision in the medical field. It is currently widely used in orthopedics, oral and maxillofacial surgery, but the application in the treatment of craniocerebral aneurysms is rarely reported. OBJECTIVE: To summarize the classification and treatment status of cerebral aneurysms, and to prospect the application prospect of 3D printing technology in the treatment of cerebral aneurysms. METHODS: The authors retrieved CNKI, WanFang, PubMed, and EI database. The search terms were “cerebral aneurysm, clinical classification, treatment, 3D printing”. A total of 96 relevant literatures were retrieved, and 51 articles were summarized according to the inclusion and exclusion criteria. Specifically, it included the classification of cerebral aneurysms, craniotomy and interventional therapy, and the application status of 3D printing technology. RESULTS AND CONCLUSION: At present, the treatment methods of cerebral aneurysms commonly used in clinical practice have their own advantages and limitations. In this case, 3D visualization and 3D printing technology are proposed, which is an important supplement for the clinical treatment of patients with cerebral aneurysms. It can display organ anatomy and spatial structure more intuitively and accurately through operations such as enlargement, rotation and transparency. At the same time, it can accurately locate the aneurysm site, calculate the aneurysm size and volume, and define the aneurysm morphology. This is significant in preoperative diagnosis, planning of surgery, precise operation during surgery, and improvement of surgical success rate for the brain aneurysm. Simultaneously, the solid model of 3D printing is also widely used in the aspects of disease communication and training of resident surgical operations. By summarizing the research progress of 3D printing technology in the treatment of cerebral aneurysms, we have a clearer understanding of the application of 3D visualization and 3D printing technology. Whether it is combined with fluid mechanics for hemodynamic research or refined treatment based on existing treatment schemes, it has promoted the development of clinical research.

Infective Endocarditis with an Infectious Cerebral Aneurysm Rupture and an Acute Myocardial Infarction / 日本心臓血管外科学会雑誌

A 56-year-old woman was referred to our hospital due to anorexia. An echocardiogram demonstrated severe mitral valve regurgitation and vegetation located on the valve. We diagnosed infective endocarditis and started to treat with antibiotics. During antibiotics treatment, cerebral hemorrhage was caused by rupture of an infectious cerebral aneurysm. She was treated by surgical operation. Waiting for cardiac surgery, she had sudden chest pain. Electrocardiogram examination demonstrated an anterior acute myocardial infarction. Emergency coronary angiogram revealed complete obstruction of the left anterior descending coronary artery. She was successfully treated with thrombus aspiration using a catheter device and stenting. However, she was in cardiogenic shock and her blood pressure could not be maintained with catecholamine and IABP. We performed emergency mitral valve replacement. After surgery, the circulation dynamics improved and she was discharged from the hospital.

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.

Endovascular treatment of ruptured tiny aneurysms

OBJECTIVE: Endovascular coiling of ruptured tiny aneurysms (RTAs) in the brain has been known to be technically challenging owing to the higher rate of adverse events, such as thromboembolism and intraoperative rupture. The aim of this study was to report our ex-periences of endovascular treatment of RTAs (size, ≤3 mm).METHODS: From January 2006 to December 2017, 35 RTAs in 35 patients were treated at our institution with an endosaccular coiling. Procedural data and clinical and angiographic results were retrospectively reviewed.RESULTS: The mean size of the RTAs was 2.53 mm (SD: 0.38). The neck remodeling technique was applied to 14 aneurysms, including stent-assisted coiling (n=7) and balloon-assisted coiling (n=7). Procedure-related complications included intraprocedural rupture (n=2), thromboembolic event (n=1), and early rebleeding (n=2), which needed recoiling. Regarding immediate angiographic control, complete occlusion was achieved in 25 aneurysms (71.4%), small neck remnant in 5 (14.3%), and definite remnant in 5 (14.3%). At the end of follow-up, 31 of the 35 patients (88.6%) were able to function independently. Twenty-two of the 35 patients underwent follow-up conventional angiography (mean, 468 days). Stable occlusion was achieved in 20 of the 22 patients (90.9%), minor recanalization in 1 (4.5%), and major recanalization, which required recoiling, in 1 (4.5%).CONCLUSION: Our experiences demonstrate that endovascular treatment for RTAs is both feasible and effective. However, periprocedural rebleedings were found to occur more often (11.4%) than what is generally suspected.

Microscopic polyangiitis associated with subarachnoid hemorrhage / Journal of Rural Medicine

Microscopic polyangiitis (MPA), an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, is a systemic disease that damages all organs through predominantly affecting small vessels. However, few cases of MPA are related to aneurysms on medium-sized muscular vessels, and whether subarachnoid hemorrhage (SAH) is associated with MPA is still unclear. An 85-year-old woman with rapid progressive glomerular nephritis caused by MPA complained of sudden severe headache due to SAH 2 days after admission and subsequently underwent surgery. Cerebrovascular disease occurring simultaneously with MPA might result in poor prognosis, and the complications exacerbate the condition and lead to high mortality; thus, physicians should pay more attention to cerebral aneurysms concurrent with MPA. Among patients with MPA, it is important to identify priority cases and investigate the intracranial vessel environment. To the best of our knowledge, this is a rare report about SAH associated with MPA. We recommend that the presence of cerebrovascular disease should be considered in patients with MPA to improve their prognosis.

Predictive value of cerebral aneurysm neck diameter on the occurrence of progressive cerebrovascular occlusion after stent-assisted coil embolization / 中国脑血管病杂志

Objective: To investigate the predictive factors of developing progressive cerebrovascular occlusion in incomplete occlusion after cerebral aneurysms treated with stent-assisted coil embolization. Methods: Ninety-two consecutive patients with cerebral aneurysm received stent-assisted coil embolization and immediate intraoperative angiography revealed incomplete occlusion at the Department of Neurosurgery, Yulin First Hospital from January 2012 to December 2015 were enrolled retrospectively. According to the follow-up results of angiography 6 months after operation, the patients were divided into progressive occlusion group (n = 59) and non-occlusion group (ra=33). Multi-dimensional angiographic images of patients immediately and 6 months after surgery were collected using a biplane angiography system and a threedimensional rotational angiography system, and the angiographic results of all patients were graded by the Raymond grading criteria. Predictors of progressive cerebrovascular occlusion were assessed using multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. Results: The mean maximum diameter of cerebral aneurysms (6.6 ±2.9 mm) and mean neck diameter (4.9 ± 1.0mm) in the progressive occlusion group were less than those in the non-occlusion group (8.5 ±2.4 mm and 6. 2 ± 1. 2 mm respectively). The differences were statistically significant, (l = -3. 196 and -5.661 respectively,all P < 0.01). Multivariate logistic regression analysis showed that the neck diameter of cerebral aneurysms was an independent influencing factor for progressive cerebrovascular occlusion (OR,0. 44,95% CI 0. 18-0. 79, P =0.030). The cut-off value of neck diameter for predicting cerebrovascular occlusion was 5. 8 mm (specificity 82. 1%,sensitivity 75.8%,and the area under curve 0. 847,P <0. 01). Conclusions: The neck diameter of cerebral aneurysms was an independent predictor for progressive cerebrovascular occlusion after stent-assisted coil embolization. Patients with cerebral aneurysms < 5. 8 mm in neck diameter were more likely to spontaneously develop cerebrovascular occlusion within 6 months after stent-assisted coil embolization.

Clinical analysis of the correlation between transverse sinus drainage dominance and aneurysm formation and rupture / 中国神经精神疾病杂志

To investigate the clinical correlation between transverse sinus classification and variation and aneurysm formation and rupture and to determine the risk factors of intracranial aneurysm rupture. Methods A retrospective data analysis was conducted on a total of 345 cases of intracranial aneurysms from January to December 2018. Clinical characteristics were compared between ruptured aneurysm group (RAG, n=230) and unruptured aneurysms group (URAG, n=115). Logistic regression analysis was performed to analyze the anatomy of venous sinus and clinical features including smoking history, hypertension, diabetes, location and size of the aneurysm in patients with intracranial aneurysm rupture. Results There were significant differences in had statistical significance with the patients' drinking history, smoking history, hypertension, diabetes, location and size of the aneurysm, as well as the dominant venous sinus on the same side as the aneurysm between rupture of intracranial aneurysm group and unruptured aneurysms group (P＜0.05). Multivariate logistic regression analysis suggested that diabetes (OR=10.567), anterior communication (OR=2.214), posterior communication (OR=2.932), small aneurysms (OR=3.841), dominant venous sinus on the same side as the aneurysm (OR=1.736) were independent risk factors for rupture of the unruptured aneurysm. In addition, the dominant side of transverse sinus were more likely to form intracranial aneurysms (P＜0.001). Conclusion The predisposing factors for rupture of intracranial aneurysms are anterior communication, posterior communication, small aneurysms and dominant lateral venous sinuses on the same side as aneurysms. Ipsilateral aneurysms are more likely to form in patients with dominant venous sinuses and can be used to accurately predict aneurysm rupture.

Subarachanoid Hemorrhage Following Spinal Anaesthesia In Case Of Unknown Cerebral Aneurysm

The overall incidence of subarachnoid hemorrhage (SAH) is approximately 9 /100 000 person‐years and in which incidence in women is 1.24 times higher than in men. The exact incidence of SAH after spinal anesthesia is not known, though few cases are reported in the literature. The usual presentation of SAH following subarachnoid block (SAB) is after one or two weeks and most of the cases have history of multiple pricks during SAB with headache. We report a case of SAH following an SAB for total abdominal hysterectomy, presenting within nine hours after SAB with atypical symptoms of hypertension and generalized tonic clonic convulsions. Non contrast CT and MRI showed parafalcine grade I subarachnoid hemorrhage with vasogenic edema and venous infarcts. Subsequently it was found that patient had been suggested to undergo clipping for cerebral aneurysm ten years back. Early diagnosis with aggressive management prevented further complications in our case. Subarachnoid hemorrhage following lumbar puncture can present within 24 hour with atypical presentation. High suspicion index and further management without much hemodynamic variability can prevent fatal complications.

Application of outflow angle-assisted approach in diagnosing cerebral sidewall aneurysms with MRA / 介入放射学杂志

Objective To assess the value of outflow angle-assisted (OA-assisted) approach in diagnosing and differentiating sidewall cerebral aneurysms (SCAs) with magnetic resonance angiography (MRA). Methods A total of 438 patients with suspected SCAs and other cerebrovascular diseases were separately evaluated by OA-assisted approach MRA and digital subtraction angiography (DSA). An OA of ≥90o was considered to represent SCA. The diagnostic accuracy, sensitivity, and specificity of SCAs with OA assisted approach were evaluated with the number of aneurysms and the size of aneurysms. Results DSA revealed 301 SCAs in 267 patients, and no SCAs was detected in the remaining 171 patients, among them a total of 55 infundibulae were observed in 52 patients. OA-assisted approach MRA revealed 300 SCAs in 267 patients, among which 271 aneurysms in 238 patients had an OA of ≥90o(true positive of 90.3％) and 29 aneurysms in 29 patients had an OA of <90° (false negative of 9.7％). Based on the patient, the number of aneurysms and the size of aneurysms, OA-assisted approach MRA had higher accuracy, sensitivity and specificity in diagnosing SCAs. The OA of all 54 infundibulae observed in 51 patients was <90°(98.2％), and only one infundibula in one patient was ≥90° (false positive). Conclusion MRA with OA-assisted approach has higher accuracy in diagnosing SCAs and in differentiating SCAs with infundibula, therefore, it can substitute DSA for the diagnosis and differentiation of SCAs.

Recurrence of Small Cerebral Aneurysms (< 4 mm) Treated Endovascularly Using Target® Nano™ Coils

OBJECTIVE: In our series, endovascular coiling with Target® Nano™ coils (Stryker Neurovascular, Fremont, CA, USA) with diameters of 1 or 1.5 mm exhibited favorable technical feasibility in the treatment of small cerebral aneurysms (< 4 mm). However, little is known about the recurrence of small cerebral aneurysms treated using Target® Nano™ coils. We investigated recurrence following the treatment of small cerebral aneurysms using Target® Nano™ coils. MATERIALS AND METHODS: Between January 2012 and November 2013, 143 patients with 148 small cerebral aneurysms (< 4 mm) were included our study. A total of 135 cerebral aneurysms (91.2%) were unruptured; 45 cerebral aneurysms (30.4%) were treated by endovascular coiling using Target® Nano™ coils. Follow-up radiological images were obtained for 132 cerebral aneurysms (89.2%) over a range of 3 to 58 months (mean, 34.3 months; standard deviation, 14.2). RESULTS: In the group treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 33 (73.3%), residual necks in eight (17.8%), and residual sacs in four (8.9%) cases. Follow-up radiological outcomes revealed complete occlusion in 35 (77.8%) and residual necks in four (8.9%) cases that exhibited stable coil masses. In the group that was not treated with Target® Nano™ coils, radiological outcomes revealed complete occlusion in 69 (67%), residual necks in 18 (17.5%), and residual sacs in 16 (15.5%) cases. Follow-up radiological outcomes revealed complete occlusion in 87 (84.5%) and residual necks (5.8%) in six cases that exhibited stable coil masses. No significant differences were observed in the radiological outcomes or follow-up radiological outcomes between the two groups. No recurrences or retreatments occurred in our series. CONCLUSION: Endovascular treatment using Target® Nano™ coils may be a robust treatment option for small cerebral aneurysms (< 4 mm).

New Pathophysiological Considerations on Cerebral Aneurysms / 신경중재치료의학

Cerebral aneurysm is a common cerebrovascular disease that is sometimes complicated by rupture or an enlarged mass. We are now aggressively evaluating and managing unruptured cerebral aneurysms based on a significant concern for the high morbidity and mortality related to its associated complications. However, the actual rupture rate is very low and the diagnostic and treatment modalities are expensive and invasive, which may lead to unnecessary costs and potential medical complications. This disproportionate situation is related to a poor understanding of the natural course and pathophysiology of cerebral aneurysms. In consideration of the concept that not all cerebral aneurysms must be removed, we need to examine their course and progression more accurately. Cerebral aneurysms may follow a variety of pathophysiological scenarios over their lifetime, from formation to growth and rupture. The disease course and the final outcome can differ depending on the timing and intensity of the pathological signals acting on the cerebral vessel wall. We should delineate a method of predicting the stability and risk of rupture of the lesion based on a comprehensive knowledge of the vessel wall integrity. This review deals with the basic knowledge and advanced concepts underlying the pathophysiology of cerebral aneurysms.

Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search.METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm".RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court.CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Cerebral Aneurysms in Judicial Precedents

OBJECTIVE: From November 30, 2016, the Korean Government carried the revised Medical Dispute Mediation and Arbitration Act into effect. Mediation will start automatically without agreements of the defendant, when the outcome of the patient was death, coma more than a month or severe disability. Cerebral aneurysm has a definite risk of bad outcome, especially in the worst condition. Any surgical intervention to this lesion has its own high risk of complications. Recently, Seoul central district court decided 50% responsibility of the doctors who made a rupture of the aneurysm during coiling (2015Ga-Dan5243104). We reviewed judicial precedents related to cerebral aneurysms in lawsuit using a web search. METHODS: We searched judicial precedents at a web search of the Supreme Court, using the key words, "cerebral aneurysm". RESULTS: There were 15 precedents, six from the Supreme Court, seven from the High Court, and two from district courts. Seven precedents were related to the causation analysis, such as work-relationship. Five precedents were malpractice suits related bad results or complications. Remaining three precedents were related to the insurance payment. In five malpractice precedents, two precedents of the Supreme Court reversed former two precedents of the High Court. CONCLUSION: Judicial precedents on the cerebral aneurysm included not only malpractice suits, but also causation analysis or insurance payment. Attention to these subjects is needed. We also need education of the independent medical examination. To avoid medical disputes, shared decision making seems to be useful, especially in cases of high risk condition or procedures.

Vitreous Hemorrhage after Aneurismal Rupture: Terson Syndrome

Introduction Terson syndrome is described as an intraocular hemorrhage consequent to a spontaneous subarachnoid hemorrhage (SSAH). In the present article, we describe cases of patients who underwent neurosurgical treatment of ruptured cerebral aneurysmat our institution over a period of one year, and who were diagnosed with Terson syndrome. Methods The present study included patients with a diagnosis of SSAH by rupture of a cerebral aneurysm who underwent treatment in our neurosurgical service from December 2009 to December 2010. The patients were followed-up for a minimum of 20 months.We have also performed a literature review and compared the data with those available in the current literature. Results The present study included 34 patients, 18 (53%) of which underwent endovascular treatment, and 16 (47%) who underwent microsurgical clipping. In the sample, the mortality was 14.7% (5 patients), the same percentage of patients who were diagnosed with Terson Syndrome, which is an incidence of 14.7%. Regarding the ophthalmologic evaluation, all patients had vitreous hemorrhage detected by an ultrasound examination, which was unilateral in only two patients. Visual acuity improved in all patients, being incomplete in only one of them. Conclusion Terson syndrome is relatively common and is associated with higher mortality. With the existence of an effective treatment, it should be investigated in all patients with SSAH.

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.

Superficial Temporal Artery-Sparing Mini-Pterional Approach for Cerebral Aneurysm Surgery

OBJECTIVE: The purposes of this study were to introduce a superficial temporal artery (STA)-sparing mini-pterional approach for the treatment of cerebral aneurysms and review the surgical results of this approach. METHODS: Between June 2010 and December 2015, we performed the STA-sparing mini-pterional approach for 117 patients with 141 unruptured intracranial aneurysms. We analyzed demographic, radiologic, and clinical variables including age, sex, craniotomy size, aneurysm location, height of STA bifurcation, and postoperative complications. RESULTS: The mean age of patients was 58.4 years. The height of STA bifurcation from the superior border of the zygomatic arch was 20.5 mm±10.0 (standard deviation [SD]). The craniotomy size was 1051.6 mm²±206.5 (SD). Aneurysm neck clipping was possible in all cases. Intradural anterior clinoidectomy was performed in four cases. Contralateral approaches to aneurysms were adopted for four cases. Surgery-related complications occurred in two cases. Permanent morbidity occurred in one case. CONCLUSION: Our STA-sparing mini-pterional approach for surgical treatment of cerebral aneurysms is easy to learn and has the advantages of small incision, STA sparing, and a relatively wide surgical field. It may be a good alternative to the conventional pterional approach for treating cerebral aneurysms.