A rare case of gastroduodenal artery aneurysm in a highly active antiretroviral therapy induced acute pancreatitis case presenting with lump in abdomen

Gastroduodenal artery (GDA) aneurysm is a rare but potentially fatal vascular disease, with chronic pancreatitis being reported as the commonest etiological factor. Rupture, which is not uncommon, carries a high risk of mortality. The typical patient with palpable epigastric mass, upper gastrointestinal bleeding and pain, may not present in the emergency and the lesion is often picked up incidentally on abdominal ultrasound or a computed tomography. We describe a critical case presenting with lump in abdomen which was found out to be gastroduodenal artery aneurysm on scanning, developing in a patient with recurrent highly active antiretroviral therapy (HAART) induced pancreatitis managed with transfemoral catheter embolization. The patient in question succumbed due to post procedure hepatic failure. The management of aneurysms since historic times have been challenging, the open procedures are being gradually replaced by endovascular techniques, which are yielding better results.

Intraarterial Tirofiban Thrombolysis for Thromboembolisms During Coil Embolization for Ruptured Intracranial Aneurysms

OBJECTIVE: Thromboembolus can occur during endovascular coil embolization. The aim of our study was to show our experience of intraarterial (IA) tirofiban infusion for thromboembolism during coil embolization for ruptured intracranial aneurysms. METHODS: This retrospective analysis was conducted in 64 patients with ruptured aneurysms who had emergent endovascular coil embolization from May 2007 to April 2011 at a single institute. Thromboembolic events were found in ten patients (15.6%). Anticoagulation treatment with intravenous heparin was started after the first coil deployment in ruptured aneurysmal sac. When a thrombus or embolus was found during the procedure, we tried to resolve them without delay with an initial dosage of 0.3 mg of tirofiban up to 1.2 mg. RESULTS: Three patients of four with total occlusion had recanalizations of thrombolysis in myocardial infarction (TIMI) grade III and five of six with partial occlusion had TIMI grade III recanalizations. Eight patients showed good recovery, with modified Rankin Scale (mRS) score of 0 and one showed poor outcome (mRS 3 and 6). There was no hemorrhagic or hematologic complication. CONCLUSION: IA tirofiban can be feasible when thromboembolic clots are found during coil embolization in order to get prompt recanalization, even in patients with subarachnoid hemorrhage.

Endovascular Treatment of Cerebral Aneurysm: Early Experience in a Malaysian Tertiary Centre

Universiti Kebangsaan Malaysia Medical Center (UKMMC) started neurointerventional service in August 2008. In this study, we aimed to evaluate the immediate and short term outcome of endovascular treatment (EVT) of cerebral aneurysm during early period of the services. A retrospective study for cerebral aneurysm treated by endovascular technique, from the Neurosurgical and Radiology Department from September 2008 till February 2010 was performed. Patient’s demographic data, initial clinical presentation and assessment of the aneurysm were performed. The immediate results and short term assessment post EVT were evaluated based on standard criteria. Recurrence and complications during and following EVT procedures, were recorded. Twenty one patients with total of 22 aneurysms were treated. The mean age was 54.52 years with 57% being males and 43% females. The majority (81%) had single aneurysm. The most common site was anterior communicating artery (28 %). Mean aneurysm sac size was 6.19 mm and 2.55 mm for aneurysm neck. At follow-up, 3 (27.2%) had a small residual neck. Four patients (37.2%) had residual aneurysm filling, but three of them were treated with stent aiming to achieve flow diversion effect instead of complete occlusion during initial treatment. There was no rebleed or rupture from the immediate to follow-up. Significant complications up to 30-days was observed in 4 patients (20%) whereby 2 patients showed improvement and 2 patients died (10 % mortality rate). Endovascular treatment of cerebral aneurysms performed in our centre had early outcome, morbidity and mortality compared to other higher volume centres. Longer term follow up is needed to evaluate the long term outcome/occlusion rate, morbidity and mortality.

Giant Vertebrobasilar Junction Aneurysm Treated with Proximal Occlusion of Parent Artery Followed by Coil Embolization of Partially Thrombosed Aneurysm: A Case Report / 신경중재치료의학

In the case of giant vertebrobasilar junction aneurysm with an outflow directly draining into the basilar artery, trapping of ipsilateral vertebral artery is technically challenging. Endosaccular coil embolization may be an option, but it may aggravate symptoms due to mass effect or aneurysmal regrowth after coil compaction. Occlusion of the ipsilateral vertebral artery proximal to the aneurysm may be another option. However, complete thrombosis should be eventually achieved to prevent symptom progression from the retrograde flow or mass effect by the partial thrombosis within the aneurysm. The authors describe a case of giant vertebrobasilar aneurysm initially treated with proximal occlusion. As the aneurysm getting partial thrombosis, the bulbar compression symptom was slowly aggravated. We performed endosaccular coiling of small remaining sac 2 months later, which resulted in complete resolution of compression symptom.

"Misery Collaterals" as Poor Angiographic Findings: Definition, Classification, and Practical Application

OBJECTIVE: Unique internal carotid artery angiographic findings have been found especially in very poor grade aneurysmal subarachnoid hemorrhage(SAH) patients before and during the endovascular coiling. The author investigates their patterns and classifies them into four subtypes. METHODS: Among Hunt&Hess grade IV, V SAH patients, the author could gather eight patients who showed abnormal intracranial circulation in cerebral catheter-based angiography. RESULTS: The author introduces new term 'misery collaterals' first and has classified them into four types with the case illustrations. Type 1 is the worst condition defined as almost no intracranial circulation. Type 2 is the condition of little intracranial circulation with contrast filling just only at vessels of brain base, type 3 is of no or little cortical circulation with contrast filling at bilateral large vessels of brain base through circle of Willis channel and type 4 is of visible bilateral cortical circulation but delayed intracranial circulation time. The prognosis of these eight patients showed misery collaterals were disappointed. CONCLUSION: These finding can be used as the supportive information in deciding a management plan in poor grade SAH patients.