An Excellent Functional Recovery Following Grade IV Subarachnoid Hemorrhage From a Cerebral Aneurysm Rebleed With Ultra-Early Surgical Intervention: A Case Report.

Aneurysms are focal abnormal dilations of the arterial wall occurring frequently at branching points along the arteries of the base of the brain. Aneurysmal rupture is one of the possible aneurysm complications and can cause aneurysmal subarachnoid hemorrhages (aSAH). Treatment of aSAH consists of pharmacologic, surgical, or endovascular approaches. The ultra-early intervention of ruptured aSAH occurs within the first 24 hours after ruptured aSAH. This case is about a 49-year-old obese male with multiple comorbidities who suffered from a grade IV subarachnoid hemorrhage and underwent an ultra-early surgical clipping approximately four hours after admission to the emergency center. The patient had excellent functional recovery at a six-month follow-up. Ultra-early surgical intervention for high-grade aSAH with rebleeding could improve outcomes.

Intermediate pressure-normalized principal wall strain values are associated with increased abdominal aortic aneurysmal growth rates.

Introduction: Current abdominal aortic aneurysm (AAA) assessment relies on analysis of AAA diameter and growth rate. However, evidence demonstrates that AAA pathology varies among patients and morphometric analysis alone is insufficient to precisely predict individual rupture risk. Biomechanical parameters, such as pressure-normalized AAA principal wall strain (ερ+¯/PP, %/mmHg), can provide useful information for AAA assessment. Therefore, this study utilized a previously validated ultrasound elastography (USE) technique to correlate ερ+¯/PP with the current AAA assessment methods of maximal diameter and growth rate. Methods: Our USE algorithm utilizes a finite element mesh, overlaid a 2D cross-sectional view of the user-defined AAA wall, at the location of maximum diameter, to track two-dimensional, frame-to-frame displacements over a full cardiac cycle, using a custom image registration algorithm to produce ερ+¯/PP. This metric was compared between patients with healthy aortas and AAAs (≥3 cm) and compared between small and large AAAs (≥5 cm). AAAs were then separated into terciles based on ερ+¯/PP values to further assess differences in our metric across maximal diameter and prospective growth rate. Non-parametric tests of hypotheses were used to assess statistical significance as appropriate. Results: USE analysis was conducted on 129 patients, 16 healthy aortas and 113 AAAs, of which 86 were classified as small AAAs and 27 as large. Non-aneurysmal aortas showed higher ερ+¯/PP compared to AAAs (0.044 ± 0.015 vs. 0.034 ± 0.017%/mmHg, p = 0.01) indicating AAA walls to be stiffer. Small and large AAAs showed no difference in ερ+¯/PP. When divided into terciles based on ερ+¯/PP cutoffs of 0.0251 and 0.038%/mmHg, there was no difference in AAA diameter. There was a statistically significant difference in prospective growth rate between the intermediate tercile and the outer two terciles (1.46 ± 2.48 vs. 3.59 ± 3.83 vs. 1.78 ± 1.64 mm/yr, p = 0.014). Discussion: There was no correlation between AAA diameter and ερ+¯/PP, indicating biomechanical markers of AAA pathology are likely independent of diameter. AAAs in the intermediate tercile of ερ+¯/PP values were found to have nearly double the growth rates than the highest or lowest tercile, indicating an intermediate range of ερ+¯/PP values for which patients are at risk for increased AAA expansion, likely necessitating more frequent imaging follow-up.

SAD score of intracranial aneurysms for rupture risk assessment based on high-resolution vessel wall imaging.

OBJECTIVE: We aimed to develop a comprehensive model that integrates the radiological, morphological, and clinical factors to assess rupture risk for intracranial aneurysms. METHODS: We prospectively enrolled patients with intracranial saccular aneurysms who underwent high-resolution vessel wall imaging (HR-VWI) preoperatively. Clinical characteristics, aneurysm features and aneurysm wall enhancement scale (AWES) were recorded. AWES was categorized into three grades (no/faint/strong enhancement) by comparing AWE to enhancement of the pituitary infundibulum or choroid plexus on HR-VWI. Univariate and multivariate logistic regression analyses were performed to determine risk factors associated with aneurysmal rupture. RESULTS: A total of 25 ruptured and 116 unruptured aneurysms were included. Multivariate logistic regression analysis revealed that non-ICA site (OR 6.25, 95% CI 1.35-28.30, P = 0.019), AWES (OR 5.99, 95% CI 2.51-14.29, P < 0.001) and daughter sac or lobulated shape (OR 6.22, 95% CI 1.68-23.16, P = 0.006) were independent factors associated with ruptured aneurysms. The "SAD" model was generated and named after the first letters of each of these factors. SAD scores of 0-4 predicted 0, 2%, 12%, 42% and 100% ruptured aneurysms, respectively. The area under the receiver operating characteristic curve for the SAD model was 0.8822. CONCLUSION: The SAD model aids in distinguishing aneurysm rupture status and in managing unruptured aneurysms. Larger cohort studies are needed to confirm its applicability in predicting the rupture risk of unruptured aneurysms.

Effect of circulating miR­126 levels on intracranial aneurysms and their predictive value for the rupture of aneurysms: A systematic review and meta­analysis.

Intracranial aneurysm (IA) is a common cerebrovascular disease with a high risk of rupture. At present, the mechanisms underlying the formation and rupture of IAs is not clinically clear. MicroRNAs (miRNAs/miRs) are involved in the development of IAs. The present study aimed to determine the efficacy of circulating miRNA-126 (miR-126) levels as potential biomarkers for predicting aneurysmal ruptures. The present study searched comparative articles involving circulating miR-126 levels and intracranial aneurysms through electronic databases from 1980 to February, 2023. Collected variables included the first author's name, covered study period, publication year, total number of patients and age, and number of males. We collected information about the expression levels of circulating miR-126 in serum. Three articles met the eligibility criteria. The total number of patients was 379 [226 with IA rupture and 153 with non-rupture or/+ controls (healthy)]. The circulating miR-126 can be used as a biomarker for predicting aneurysmal rupture. Interestingly, an aneurysmal size >10 mm was associated with an IA rupture.

Clinical Profile and Outcome in Patients with Spontaneous Subarachnoid Hemorrhage from a South Indian Tertiary Centre: A Prospective Observational Study.

Objective Spontaneous subarachnoid hemorrhage (SAH) is a neurological condition that causes significant morbidity and mortality. It is known to have regional differences in its incidence. Indian studies have shown conflicting results about the incidence of aneurysms as the cause of SAH, varying from 35% to 80%. The data available on the epidemiology of spontaneous SAH in the South Indian population are very few. Our study aims to describe the clinical profile of patients presenting with spontaneous SAH to the emergency department in a tertiary center in South India and describe the factors influencing the clinical outcome. Materials and Methods The study included 75 patients diagnosed with spontaneous SAH in our emergency department. Demographic data, medical history, details about the first medical contact, clinical features at admission, complications during the hospital stay, and interventions underwent were recorded. The study participants were followed-up at 6 weeks after discharge from hospital to assess the neurological outcome based on modified Rankin Scale (mRS) score, using a 9-point questionnaire. Results Of the 75 patients with spontaneous SAH, the majority were females, and in the age group of 50 to 69 years. The median time to first medical contact was observed to be 2 hours; and SAH was diagnosed at the first medical contact only in 37% of the patients. Hypertension was the most common comorbid condition associated with SAH (53%). Almost 80% of the patients who underwent angiographic studies had aneurysmal SAH (aSAH). Hydrocephalus was the most common complication seen in 37% of the patients, followed by hyponatremia (28%) and vasospasm (25%). At the time of follow-up after 6 weeks, we found that 36% of the patients were having a neurologically favorable outcome with an mRS score of 0 to 2, 8% of patients were having moderate to severe disability (mRS 3 to 5) and were living a dependent life. The mortality rate (mRS 6) was observed to be around 50% (6% lost to follow-up). Conclusion We observed a relatively higher incidence of aneurysmal rupture among the patients with spontaneous SAH in our region. The misdiagnosis rate at first medical contact was higher. The mortality rate was observed to be around 50% at 6 weeks. Loss of consciousness at ictus, aneurysmal rupture, WFNS grades IV-V, hydrocephalus, vasospasm, hypernatremia, and delayed cerebral ischemia were found to be the mortality predictors in SAH.

Characteristics of ANCA-associated vasculitis with aneurysms: Case series and review of the literature.

INTRODUCTION: ANCA-associated vasculitis (AAV) is an exceptional cause of small and large vascular aneurysms. Here, we present the phenotypic characteristics of patients with AAV associated with the presence of aneurysms. METHODS: We conducted a retrospective multicenter study and a systematic review of the literature. Only AAV patients with positive ANCA results and > 1 aneurysm(s) were enrolled. Patients were recruited through a call of observations among the French Vasculitis Study Group (FVSG) and the French Internal Medicine Network. Patients with aneurysm rupture were compared to those without. RESULTS: We enrolled 51 patients in the cohort, including 31 (67%) with granulomatosis with polyangiitis. The median Birmingham Vasculitis Activity Score was 18 [6-41]. A total of 92 aneurysms were noted, 74% of which involved medium-sized arteries, particularly the renal artery. During a follow-up of 24 [6-56] months, 22 (43%) patients experienced aneurysmal rupture, 91% of which involved medium-sized vessels. Patients with aneurysmal rupture showed significantly more pulmonary infiltrates and higher creatinine levels at baseline than patients without rupture. Initial treatments did not differ between the two groups. Ten (20%) patients died during the follow-up, including three from an aneurysmal rupture. CONCLUSION: Aneurysms were more frequently observed in GPA patients and predominantly affected medium-sized vessels, especially the renal arteries. The risk of rupture was high and occurred in >40% of patients. Because of their increased mortality, further studies are required to better manage this subset of patients.

Single Center Retrospective Analysis of Cerebral Aneurysms from a Patient Sample Data Collection at a Comprehensive Stroke Center.

INTRODUCTION: Institutional self-monitoring of cerebral aneurysm data should occur regularly. The objective of this retrospective single center study was to examine the reproducibility of a data collection and analytic method to examine cerebral aneurysm characteristics and trends. METHODS: A single center retrospective analysis was performed from 2018 to 2021 of the most recent 100 patient presentations with a newly diagnosed cerebral aneurysm. Data collection included patient demographics, radiographic features, ruptured or unruptured status, location, grading scale, treatment strategy, survival, and length of stay, which were extracted and presented in tabular form and analyzed for overall trends. RESULTS: Of the collected 100 patients meeting ICD-10 criteria, 10 (10%) patients were excluded due to having been previously diagnosed at the institution and not meeting the criteria of a new discovery of cerebral aneurysm for inclusion. The remaining 90 sample patients presented with newly diagnosed aneurysms to the authors' Emergency Department between 2018 and 2021. Most patients were between the ages of 25 and 65 with 55 (61%) patients identifying themselves as female sex. Of the 90 eligible sample patients, 59 (66%) had aneurysms that were not ruptured. Eighty-eight (97.7%) patients had cerebral aneurysms that were < 7mm in size. The most common location for aneurysms was in the anterior cerebral circulation, with identification of 27 middle cerebral artery aneurysms. Length of stay (LOS) ranged from 0-171 days with a mean of 11.97 days (SD = 19.9). Of the seven (7.7%) patients who expired, four (57%) experienced spontaneous subarachnoid hemorrhages, with two (29%) occurring in the anterior communicating artery and one (14%) in the left middle cerebral artery and basilar artery respectively. CONCLUSIONS: The typical presentation of a cerebral aneurysm is unruptured with a pre-dominance in middle-aged females. Our findings are congruent with the literature regarding the location of the aneurysm originating in the anterior circulation. However, most aneurysms in our clinical cohort were located on the MCA/ICA in contrast to the literature reported (i.e., most anterior communicating artery). Of those patients who presented unruptured, outpatient follow-up and routine monitoring were appropriate with medical management in the setting of small aneurysms. The risk of progression and subsequent rupture was relatively small in this patient cohort. Multi-year examinations of single institution comprehensive stroke centers regarding cerebral aneurysms would enable researchers to conduct regional analyses and comparisons to national and international trends.

Impact of Obesity and Diabetes on Postoperative Outcomes Following Surgical Treatment of Nontraumatic Subarachnoid Hemorrhage: Analysis of the ACS-NSQIP Database.

BACKGROUND: Nontraumatic subarachnoid hemorrhage (SAH) refers to high pressure extravasation of blood into the subarachnoid space that typically occurs spontaneously from rupture of cerebral aneurysm. The purpose of this study was to identify postoperative complications requiring increased surveillance in obese, diabetic, and hypertensive patients. METHODS: Patients who underwent surgical treatment for nontraumatic SAH were queried in the American College of Surgeons National Surgical Quality Improvement Program database from the years 2012-2018. Cases were identified using International Classification of Diseases codes and then classified independently by 3 dichotomous diagnoses: obesity, diabetes, and hypertension. RESULTS: Among 1002 patients meeting inclusion criteria, 311 (31%) were obese (body mass index >30), 86 (9%) had diabetes treated with insulin or noninsulin agents, and 409 (41%) required medication for hypertension. There was a statistically significant association between diabetes and postoperative pneumonia (odds ratio [OR] = 1.694; 95% confidence interval [CI] = 0.995-2.883; P = 0.050), prolonged ventilator dependence (OR = 1.700; 95% CI = 1.087-2.661; P = 0.019), and death (OR = 1.846; 95% CI = 1.071-3.179; P = 0.025). Medication-dependent hypertension was statistically associated with incidence of stroke/cerebrovascular accident (OR = 1.763; 95% CI = 1.056-2.943; P = 0.023). Obesity was not associated with adverse outcomes in this population. CONCLUSIONS: In patients undergoing surgical management of SAH, hypertensive and diabetic patients had poorer outcomes, including prolonged ventilator dependence, pneumonia, stroke/cerebrovascular accident, and death. Surprisingly, preexisting obesity was not associated with poor outcomes. In fact, overweight body mass index, class I obesity, and class II obesity had decreased need for transfusion in the 30-day postoperative period.

Multiple Ruptured Aneurysms Over Basilar Artery Fenestration: Endovascular Management.

Basilar artery fenestrations (BAF) are rare vascular anomalies. Surgical intervention for aneurysms in this vascular segment is exceptionally arduous because of the complexity of the neurovascular structures in the vicinity of the brainstem. Endovascular therapy (ET) is the treatment of choice because of its safety and efficacy. Here, we report a 62-year-old female presenting with a two-day history of sudden onset severe headache, vomiting, and altered sensorium. A computed tomography (CT) and subsequent CT angiogram (CTA) revealed subarachnoid hemorrhage (SAH) and BAF with an aneurysm on each arm of the fenestration. Digital subtraction angiogram (DSA) with a three-dimensional rotational angiogram (3DRA) was employed before initiating ET. We used coiling and flow diversion to exclude the aneurysms from circulation. A six-month follow-up angiography reconfirmed the complete obliteration of the aneurysms. There was no focal neurological deficit.

Ruptured infected popliteal artery aneurysm treated with endovascular therapy: A case report.

An 86-year-old woman was admitted for a ruptured popliteal artery aneurysm (rPAA, 26 × 28 mm). Due to the patient's age and comorbidities, emergency endovascular repair was performed. After the failed antegrade guidewire crossing, a retrograde approach from the anterior tibial artery and snaring was performed for lesion crossing, and stentgraft (5 × 50 mm) was deployed from antegrade fashion. At the 14-month follow-up, computed tomography angiogram demonstrated stentgraft patency and reduced aneurysmal size. Although open surgery remains the first-line treatment for infected rPAA, our approach adds to the evidence and can be applied to emergency cases or high-risk surgical patients.

Clinical Factors Associated with the Risk of Intracranial Aneurysm Rupture in Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: The occurrence of intracranial aneurysms is higher in patients with autosomal dominant polycystic kidney disease (ADPKD) than in the healthy population. However, research concerning the factors related to the risk of intracranial aneurysm rupture in patients with ADPKD is still insufficient. OBJECTIVES: The aim of the study was to investigate the prevalence of intracranial aneurysms and aneurysmal subarachnoid hemorrhage (SAH) and to analyze the systemic factors associated with high-risk aneurysms in patients with ADPKD. METHODS: We screened patients who underwent cerebral angiography between January 2007 and May 2017 in the ADPKD registry. Patients were examined for the presence of intracranial aneurysms and subsequently reclassified into 3 groups based on the risk of aneurysmal rupture: the aneurysm-negative (group 1), low-risk aneurysm (group 2), or high-risk aneurysm (group 3). Various systemic factors were compared, and independent factors associated with high-risk aneurysms were analyzed. RESULTS: Among the 926 patients, 148 (16.0%) had intracranial aneurysms and 11 (1.2%) had previous aneurysmal SAH. Patients with intracranial aneurysms were further classified into group 2 (low-risk aneurysms, 15.5%) or group 3 (high-risk aneurysms, 84.5%). Age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, p = 0.004), female sex (OR 3.13, 95% CI 1.94-5.0 6, p < 0.001), dolichoectasia (OR 8.57, 95% CI 1.53-48.17, p = 0.015), and mitral inflow deceleration time (DT) (OR 1.01, 95% CI 1.00-1.01, p = 0.046) were independently associated with high-risk aneurysms, whereas hypercholesterolemia (OR 0.46, 95% CI 0.29-0.72, p = 0.001) was negatively associated. CONCLUSION: In the present study among patients with ADPKD, the prevalence of intracranial aneurysms and aneurysmal SAH was 16 and 1.2%, respectively. Age, female sex, dolichoectasia, and mitral inflow DT were positively associated with high-risk aneurysms, whereas hypercholesterolemia was negatively associated. A subsequent large-scaled longitudinal study is needed to define the plausibility of the clinical parameters.

Aneurysms of the Lenticulostriate Artery: A Systematic Review.

BACKGROUND: Lenticulostriate artery aneurysms (LSAs) are rare vascular aberrations. Despite the potentially catastrophic sequelae of aneurysmal rupture, the optimal management strategy for LSA aneurysms has not been determined. The aim of the present review is to provide an overview of the clinical presentation and treatment strategies for LSA aneurysms. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was conducted in the PubMed, Cochrane, EBSCOhost, Scopus, Web of Science, and ProQuest search engines to identify reported studies of LSA aneurysms until July 1, 2020. A descriptive analysis was performed. RESULTS: A total of 71 studies with 112 cases of LSA aneurysms were included. Patient age ranged from 2 months to 83 years (median, 44.5 years). Male and female patients were affected similarly (49% and 51%, respectively). The most common presentation was aneurysmal rupture (78%), and headache was the most frequently reported symptom (36%). Overall, 48% of the patients had undergone underwent surgical treatment, 30% conservative management, 21% endovascular treatment, and 1% radiosurgery. Four patients died, all of whom had presented with aneurysmal rupture. CONCLUSION: We have summarized the reported cases of LSA aneurysms, with their clinical presentation, management, and outcomes, for physicians who may be confronted with this diagnosis. Future studies that use available classification systems and include as much detail as possible should be encouraged to fully elucidate the optimal management strategy for these patients.

CURRENT ENDOVASCULAR MANAGEMENT OF INFECTED DISTAL BRANCH INTRACRANIAL ANEURYSMS: A CASE REPORT AND INSIGHT INTO THE LITERATURE.

Infected intracranial aneurysms are a rare type of inflammatory vascular lesions that occur due to infection of intracranial arterial wall. Brain aneurysms of distal arterial branches are equally rare and frequently multiple, including those situated at the peripheral middle cerebral artery segments. Although both types represent a small percentage of all intracranial aneurysms, they may bring about high mortality in case of rupture. The management of such aneurysms includes conservative treatment with broad-spectrum antibiotics, and microsurgical or endovascular treatment, which is gaining more prominence for both asymptomatic and ruptured aneurysms. Herein, we present a case of a 61-year-old male patient with a history of cardiac infective disease and multiple bilateral aneurysms of infected distal branch middle cerebral arteries, discussing the efficacy of available endovascular treatment modalities and reviewing the literature. In conclusion, selective endovascular coiling is a preferable method in the current management of distal branch infected ruptured intracranial aneurysms, which may bring a favorable outcome.

Fatal Subarachnoid Hemorrhage From Ruptured Intracerebral Aneurysm After Carotid Endarterectomy.

Concomitant carotid stenosis with cerebral aneurysm is a rare entity with an incidence reported to be about 1.9-3.2%. The effect of carotid revascularization on pre-existing cerebral aneurysm, along with risk factors for aneurysmal rupture, is not fully understood. We report a 61-year-old man who underwent carotid endarterectomy (CEA) for symptomatic carotid stenosis, and 6 days post-operatively the patient suffered a fatal subarachnoid hemorrhage from the rupture of a known basilar artery aneurysm. This rare but potentially fatal complication of a ruptured cerebral aneurysm after CEA warrants a discussion on the management of concomitant pathology.

Intraoperative Rupture Cerebral Aneurysm and Computational Flow Dynamics.

Intraoperative aneurysmal rupture (IAR) is the most fearsome complication of aneurysm surgery. IAR associates with high morbidity and mortality. In recent years, we have many studies regarding using computational fluid dynamics (CFD) in aneurysm surgery. CFD helps in calculating the velocity of blood flowing in the aneurysm sac, the pressure in the aneurysm sac, and wall shear stress (WSS). CFD also helps in predicting nature of aneurysm wall and thus may warn about different intraoperative microscopy findings in aneurysms. Using its application, surgeon may become more careful in doing microsurgical sharp dissection. A 40-year-old female admitted with diagnosis of unruptured anterior communicating artery aneurysm. CFD analysis demonstrated high intra-aneurysmal pressure and divergent WSS in dome. During sharp dissection, there was intraoperative rupture aneurysm twice which was managed with cotton tamponade and glue and temporary clipping aneurysm. Indocyanine green video angiography showed working parent arteries and nonfunctioning aneurysm. After operation, the patient recovered fully and had a modified Rankin score of 1. This case demonstrated importance of preoperative planning of aneurysm surgery using CFD analysis. IAR is associated with an increased risk for an unfavorable outcome. Accurate preoperative planning with studying flow dynamics and structure of aneurysm may help in use sharp microsurgical dissection more cautiously.

Pure tentorial subdural hematoma from rupture of aneurysm along the transmastoid branches of the occipital artery.

BACKGROUND: Pure subdural hematoma (without subarachnoid, intraventricular, or intraparenchymal hemorrhage) due to a ruptured intracranial aneurysm is rare. Most reported cases involve an aneurysm along the internal carotid artery, posterior communicating artery, or middle cerebral artery. No reports have described an aneurysm along the transmastoid branches of the occipital artery. CASE DESCRIPTION: A 70-year-old female presented with sudden-onset, excruciating headaches, associated with dizziness, nausea, and emesis. There was no history of trauma. Computed tomography (CT) head demonstrated a pure tentorial subdural hematoma. Vascular imaging revealed bilateral aneurysms along the transmastoid branches of the intracranial portion of both the occipital arteries. Consequently, these branches were embolized, with no residual filling of the aneurysms. After the procedure, the patient remained neurologically well. The patient was monitored appropriately for vasospasm, and was discharged home 10 days after presentation. CONCLUSION: Rupture of aneurysms along intracranial branches of the occipital artery can lead to pure subdural hematoma along the tentorium.

[Aneurysmal rupture complicating aortitis: a case report]. / Aortite polyanévrismale compliquée de rupture : à propos d'un cas.

Tropical aortitis is a rare and poorly described aortic disease, sometimes confounded with Takayasu's disease, mainly in people from Africa. In this case report, the panaortic aneurysmal disease in a young woman from Haiti, first diagnosed after a work-up on renovascular hypertension, would appear to approach this particular arterial disease with no clinical, radiological or biological argument for an infectious etiology. The initially suspected diagnosis of Takayasu's disease had to be rethought because of the presence of several saccular aneurysms extending from the aortic arch to the infrarenal aorta, rarely described in Takayasu's aortitis. Expert opinions from vascular surgeons and clinicians tagged this aortic disease as similar to tropical aortitis which remained asymptomatic for more than a decade. Hypertension was managed with successful balloon angioplasty of the left renal artery stenosis and anti-hypertensive combination therapy. Surgical management of the extended aortic aneurysms was not proposed because of the stability and asymptomatic nature of the aneurysmal disease and the high risk of surgical morbidity and mortality. More than ten years after diagnosis, the course was marked with inaugural and sudden-onset chest pain concomitant with contained rupture of the descending thoracic aortic aneurysm. This case report underlines the persistent risk of aneurysmal rupture and the importance of an anatomopathological study for the diagnosis of complex aortic disease.

Aneurysmal rupture of the costo-cervical trunk in a patient with neurofibromatosis type 1: A case report.

INTRODUCTION: Rupture of blood vessels associated with neurofibromatosis type 1 (NF-1) is a rare but life threatening complication. We report the first case of an aneurysmal rupture from the costocervical trunk in a NF-1 patient treated by endovascular embolisation. PRESENTATION OF CASE: A 43 year-old gentleman with a past medical history of NF-1 presented with sudden onset left sided neck swelling. A computed tomography (CT) revealed a large cervical haematoma, which was causing airway compromise, requiring the patient to be intubated. Percutaneous embolisation of the bleeding vessel from the costo-cervical trunk was performed with successful haemostasis and no immediate complications. A repeat CT scan showed a reduction in the original cervical haematoma. However, six days post embolisation, the patient arrested with complete whiteout of the left hemithorax. DISCUSSION: CT angiography is the gold standard for diagnosis of an aneurysmal rupture in NF-1 patients, and percutaneous embolisation is the preferred modality in patients who are haemodynamically stable due to arterial fragility and high intra operative mortality rates. The increasing haemothorax could be explained by the original cervical haematoma draining down into the pleural space, or the possibility of a new second bleed. CONCLUSION: This is the first reported episode of bleeding from the costocervical trunk in NF-1 patients. Ruptured aneurysms require urgent CT angiography, if haemodynamically stable, and further input from the vascular surgeons and vascular radiologists.

Aneurismas del ápex carotideo en la edad pediátrica: Reporte de un caso / Carotid apex aneurysms in children: Case report

Introducción. Las malformaciones aneurismáticas del polígono de Willis comprenden un raro grupo de anomalías congénitas que se presentan en edades pediátricas. Son causa importante de morbimortalidad en este grupo de edad; en consecuencia, el manejo de estas lesiones es complejo y potencialmente letal, y puede plantear problemas para el paciente y su tratamiento. Caso clínico. Presentamos el caso de una niña de 10 años que inició de manera súbita con síncope neurogénico y crisis convulsivas tónico-clónicas generalizadas. Al llegar a urgencias, se le realizó una tomografía donde se identificó hemorragia subaracnoidea Fisher II. En la angiografía cerebral de 4 vasos se observó una lesión sacular del ápex carotideo, de aproximadamente 5.1 x 7.2 mm, con cuello visible y domo dirigido hacia la parte cefálica y hacia la parte frontal. Se le realizó craneotomía fronto-pterional derecha. Durante el transquirúrgico, se llevaron a cabo un ultrasonido pre-clipaje, que identificó la lesión aneurismática, y uno post-clipaje, para verificar la permeabilidad de las ramas distales al clipaje. Conclusiones. Las malformaciones aneurismáticas en la edad pediátrica son extremadamente raras. Por ello, métodos como la endoscopia y la sonografía transoperatoria y postoperatoria son de gran utilidad, ya que evidencian detalles que en ocasiones los estudios de imagen convencionales no revelan. Todo esto condiciona un procedimiento con menor riesgo de morbimortalidad para este tipo de pacientes.

Background. Aneurysm malformations of the circle of Willis comprise a rare group of congenital anomalies that occur during the pediatric age and are a major cause of morbidity and mortality in this age group. Consequently, management of these lesions is complex and potentially lethal and may pose problems for the patient and affect their treatment. Case report. We report the case of a 10-year-old girl who had a sudden onset of neurogenic syncope and tonic-clonic seizures. After arriving at the emergency room, she underwent a CT scan, identifying a Fisher II subarachnoid hemorrhage. Four-vessel cerebral angiography identified apex saccular carotid injury ~5.1 x 7.2 mm with visible neck and dome partially cephalic and partially frontal. Right frontopterional craniotomy was performed and preclipping during trans-surgical ultrasound was performed, identifying the aneurysmal lesion and post-clipping to verify patency of the distal branches to clipping. Conclusions. Aneurysmal malformations in children are extremely rare. For this reason, methods such as endoscopy, trans- and postoperative ultrasound are very useful. These procedures sometimes reveal details that conventional imaging studies do not, determining use of a procedure with less risk of morbidity and mortality for these patients.