Pulmonary artery aneurysm rupture

Pulmonary artery aneurysm is a disorder of varying etiology and should be diagnosed early for appropriate interventions. A 45-year-old man was hospitalized for chest pain, dyspnea, cough, chills, diarrhea, and vomiting, which had started 3 weeks before admission. Physical examination indicated a reduced vesicular murmur in the right hemithorax. A chest x-ray performed indicated a pneumothorax and pulmonary abscess in the right hemithorax. Thoracostomy released abundant purulent and fetid fluid. Direct examination of the pleural fluid using saline revealed structures similar to Trichomonas. Non-contrast chest computed tomography revealed right pneumothorax along with an irregular cavitation located at the pleuropulmonary interface of the posterior margin of the right lower lobe. A pleurostomy was performed. On the second postoperative day, the patient suffered a sudden major hemorrhage through the surgical wound and died on the way to the operating room. The autopsy revealed an abscess and ruptured aneurysm of the lower lobar artery in the lower right lung. Microscopic examination revealed extensive liquefactive necrosis associated with purulent inflammation and the presence of filamentous fungi and spores. This case can be characterized as a severe disorder that requires early diagnosis to achieve a good therapeutic response and to avoid fatal outcomes.

Bleeding risk of small intracranial aneurysms in a population treated in a reference center / Risco de sangramento de aneurismas intracranianos pequenos em uma população tratada em um centro de referência

ABSTRACT Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. Methods: We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. Results: The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. Conclusion: In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.

RESUMO Grandes estudos multicêntricos demostram que aneurismas intracranianos pequenos são associados a risco de sangramento mínimo. Outras grandes séries têm evidenciado que aneurismas rotos são em sua maioria os pequenos. Neste estudo questionamos até que ponto os aneurismas pequenos não são perigosos. Métodos: Avaliamos 290 novos casos de aneurismas tratados em nossa instituição durante 6 anos (43,7% rotos). Realizamos análises multivariadas com aspectos epidemiológicos dos pacientes, doenças cardiovasculares e três parâmetros angiográficos: maior diâmetro, diâmetro do colo e diâmetro do vaso nutridor do aneurisma. Estimativas de risco foram calculadas utilizando-se modelo de regressão logística. Parâmetros do tamanho aneurismático foram estratificados de acordo com curvas ROC. Também calculamos a razão de chances (odds ratios) de ruptura baseadas nas análises das curvas ROC. Resultados: O maior diâmetro médio para os grupos de aneurismas rotos e não-rotos foi 13.3 ± 1.7mm e 22.2 ± 2.2 (p < 0.001). Análises multivariadas revelaram uma correlação positiva entre ruptura aneurismática e hipertensão arterial (p < 0.001) e uma correlação inversa entre ruptura e as três medidas angiográficas (p < 0.01). Aneurismas da artéria cerebral anterior foram os que mais sangraram (p < 0.05). Análises das curvas ROC demonstram que no maior diâmetro de 15mm, a sensibilidade e especificidade para se predizer ruptura são de 83% e 36%. Baseando-se nessas estratificações, calculamos uma chance de ruptura para aneurismas menores de 15mm de 46% e de 25% para aneurismas maiores. Conclusão: Na população estudada, aneurismas pequenos são mais propensos a romper. Desta forma, a necessidade de intervenção para aneurismas pequenos não deve ser relevada.

Surgical Management of Ruptured Posterior Circulation Aneurysms ­ A Single Center Experience

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto. Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999­2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt & Hess (H&H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months. Results Between 1999­2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&H1­3, and 13.6% as H&H4­5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2­3 in 18.6%, and mGOS4­5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2­3 in 10.2%, and mGOS4­5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p » 0.011). No correlation was found between the values of the H&H scale upon admission and outcome. Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Objetivo O tratamento dos aneurismas rotos da circulação posterior é uma controvérsia neurocirúrgica. Pretende-se com este trabalho relatar a experiência e os resultados do tratamento cirúrgico precoce desta patologia no Centro Hospitalar do Porto. Métodos Foram analisados retrospectivamente os processos clínicos dos pacientes com idade > 18 anos que, no período entre 1999­2013, foram admitidos no nosso centro com o diagnóstico de aneurisma sacular roto da circulação posterior. Utilizou-se a escala de Hunt & Hess (H&H) para aferir a gravidade clínica dos pacientes, e a Escala de Outcome de Glagow modificada (mGOS) para aferir o outcome dos pacientes à data da alta e aos 6 meses. Resultados Entre 1999­2013, foram operados 59 pacientes com aneurismas rotos da circulação posterior. Oitenta por centro dos pacientes eram do sexo feminino, com uma média de idade média de 58.7 anos. Aneurismas da artéria cerebelosa posteroinferior foram responsáveis por 49,2% das cirurgias, ao passo que os da artéria basilar, por 28,8%. À admissão, 86,4% dos pacientes eram H&H1­3, e 13,6%, H&H4­5. O outcome à data da alta e aos 6 meses foi o seguinte: à data de alta, mGOS1 em 5,1%, mGOS2­3 em 18,6%, e mGOS4­5 em 76,3%; aos 6 meses, mGOS1 em 10,2%, mGOS2­ 3 em 10,2%, e mGOS4­5 em 79,6%. Verificou-se uma correlação estatisticamente significativa entre aneurismas da basilar e um pior outcome (p » 0,011). Não se verificou qualquer correlação entre os valores da escala de H&H à admissão e o outcome. Conclusões O outcome funcional do nosso grupo de pacientes está em linha com o descrito noutras séries da literatura. Contudo, destaca-se uma tendência para uma mortalidade mais baixa, mas uma morbilidade mais alta no nosso grupo de pacientes.

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.

Spontaneous Dissecting Aneurysm of the Intracranial Vertebral Artery: Management Strategies

PURPOSE: Pathogenesis and treatment of spontaneous dissecting aneurysm of the intracranial vertebral artery (VA) remain controversial. This study was designed to provide management strategies and to improve management outcome in patients with these aneurysms. MATERIALA AND METHODS: Among a total of 1,990 patients treated for intracranial aneurysms from February 1992 to June 2005, 28 patients (1.4%) were treated either by surgery (8 patients) or neurointervention (20 patients) for spontaneous dissecting aneurysms of the intracranial VA. Twenty-two patients had ruptured aneurysms. We analyzed indications of surgery or neurointervention for each case, and assessed the management outcome at a 6-month follow-up. RESULTS: For selection of therapeutic options, patients were initially evaluated as possible candidates for neurointervention using the following criteria: 1) poor clinical grade; 2) advanced age; 3) medical illness; 4) unruptured aneurysm; 5) equal or larger opposite VA; 6) anticipated surgical difficulty due to a deep location of the VA-posterior inferior cerebellar artery (PICA) junction. Surgery was considered for patients with: 1) high-risk aneurysms (large or irregular shaped); 2) smaller opposite VA; 3) failed neurointervention; or 4) dissection involving the PICA. Management outcomes were favorable in 25 patients (89.3%). Causes of unfavorable outcome in the remaining 3 patients were the initial insult in 2 patients, and medical complications in one patient. CONCLUSION: Ruptured aneurysms must be treated to prevent rebleeding. For unruptured aneurysms, follow-up angiography would be necessary to detect growth of the aneurysm. Treatment modality should be selected according to the clinical characteristics of each patient and close collaboration between neurosurgeons and neurointerventionists is essential.

Clinico-pathological study of cerebral aneurysms.

AIMS AND OBJECTIVES: A clinico-pathological study of cerebral aneurysms was undertaken to understand the histopathogical nature of the lesions and to ascertain possible etiological risk factors. MATERIAL AND METHODS: Of the 255 cases of cerebral aneurysms operated upon at our Institute during the two-year period between Jan 1999 to Dec 2000, a detailed study was conducted on 57 cases where the aneurysm sac could be excised and subjected to histopathological examination. Aneurysm sacs were fixed in 10% buffered formaldehyde and processed through graded alcohol. Paraffin-embedded sections were examined, using hematoxylin and eosin, Verhoeff van Gieson's and toluidine blue staining techniques. Histopathological observations were analyzed and correlated with clinical features. RESULTS: The ages of the patients ranged from 17-65 years and there were 33 males and 24 females. Twenty-six patients were chronic smokers and 19 patients had hypertension. There were 54 saccular and 3 fusiform aneurysms, predominantly involving the anterior circulation (52 cases) than posterior circulation (5 cases). In 35 cases, histopathological studies demonstrated mucoid deposits between hyperplastic cellular elements in the true and false aneurysm wall and/or parent artery or vasavasora. The changes were associated with dystrophic changes in the internal elastic lamina. CONCLUSION: Besides significant risk factors like smoking and hypertension, such mucoid vasculopathic changes may have predisposed vessels to structural weakness and aneurysm formation in our patients.