1/84. Morphological changes after percutaneous transluminal angioplasty.BACKGROUND: Percutaneous transluminal angioplasty (PTA) dilates constricted arteries at the circle of willis to reverse cerebral ischemia caused by cerebral vasospasm. Although 90% of the patients show angiographic improvement after PTA, only 70% show clinical improvement. Why some patients do not improve after PTA is unknown. We report on a 48-year-old woman who failed to improve after PTA and died from aneurysm rerupture. Pathologic studies were performed to determine why PTA failed to reverse the symptoms of cerebral ischemia. methods: The arteries of the brain were studied by light microscopy using Gomori's trichrome stain. The arteries were also studied by scanning and transmission electron microscopy. RESULTS: The arteries that were dilated with PTA showed compression of the connective tissue, stretching of the internal elastic lamina, and a combination of compression and stretching of the smooth muscle. The small arteries and arterioles that had been treated with an infusion of intraarterial papaverine were constricted with a thickened intimal layer. CONCLUSION: The persistence of cerebral vasospasm in small and perforating arteries may contribute to the failure of cerebral ischemia to reverse after PTA.- - - - - - - - - - ranking = 1keywords = aneurysm (Clic here for more details about this article) |
2/84. Acute dissecting thoracic aortic aneurysm presenting with stroke, consumptive coagulopathy, and gastrointestinal hemorrhage.We report the case of a 70-year-old man who had an acute dissection of a previously undiagnosed thoracic aortic aneurysm. The diagnosis was challenging because of the neurologic and hematologic complications that overwhelmed the clinical presentation. Three simultaneous complications of thoracic aortic aneurysm with dissection (ischemic stroke, consumption coagulopathy, and superior mesenteric infarction with gastrointestinal hemorrhage) made the case unique and the diagnosis difficult.- - - - - - - - - - ranking = 6keywords = aneurysm (Clic here for more details about this article) |
3/84. Failure of a saphenous vein extracranial-intracranial bypass graft to protect against bilateral middle cerebral artery ischemia after carotid artery occlusion: case report.OBJECTIVE AND IMPORTANCE: We present the case of a patient who experienced bilateral middle cerebral artery infarctions after Hunterian ligation and trapping of a ruptured right cavernous aneurysm, despite a high-flow extracranial-intracranial bypass. This is a rare complication, and it highlights the need for further refinements in our understanding of the hemodynamic insufficiency created by major vessel sacrifice. CLINICAL PRESENTATION: The patient was a 59-year-old woman who experienced multiple episodes of massive epistaxis before undergoing angiography, which revealed left internal carotid artery occlusion and an irregular right cavernous aneurysm. The patient was then transferred to our center for treatment. The patient was neurologically intact at presentation, and her epistaxis was controlled by nasal packing. INTERVENTION: The patient underwent an extracranial-intracranial bypass from the external carotid artery to the M2 segment of the right middle cerebral artery, followed by trapping of the aneurysm. Despite evidence of graft patency, the patient experienced bilateral middle cerebral artery distribution infarctions after surgery. CONCLUSION: Although extracranial-intracranial bypasses protect the majority of patients who undergo carotid artery ligation from ischemic complications, this case demonstrates that hemodynamic insufficiency can occur even with a high-flow saphenous vein graft. Better ways to quantitate the hemodynamic needs of the brain after major vessel sacrifice may facilitate matching of the revascularization strategy to the specific needs of each patient, thus further reducing the likelihood of ischemic complications.- - - - - - - - - - ranking = 3keywords = aneurysm (Clic here for more details about this article) |
4/84. An aberrant left subclavian artery aneurysm with right aortic arch: report of a case.The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.- - - - - - - - - - ranking = 5keywords = aneurysm (Clic here for more details about this article) |
5/84. Ischaemic complication following obliteration of unruptured cerebral aneurysms with atherosclerotic or calcified neck.We report three cases of ischaemic complications following direct surgery of unruptured cerebral aneurysms having necks with atherosclerotic or calcified walls. Among 30 patients we treated directly for unruptured aneurysm over the last 4 years, 6 had 8 such aneurysms. Atherosclerotic or calcified neck was a major contributor to postoperative ischaemic sequelae in our recent series of unruptured aneurysms treated surgically, and common technical problems during surgery seemed to have caused ischaemic complications in the 3 patients reported here. In this report, attention is given to ischaemic complications in the treatment of such aneurysms.- - - - - - - - - - ranking = 9keywords = aneurysm (Clic here for more details about this article) |
6/84. Quantitative assessment of vessel flow integrity for aneurysm surgery. Technical note.Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischemic injury and improve patient outcome. The authors report a case of a superior cerebellar artery (SCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in both the SCA and the posterior cerebral artery before and after aneurysm clipping. Following aneurysm clipping, blood flow in the SCA was reduced to less than 25% of its initial baseline value. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip and restore SCA flow to its preclipping value within 5 minutes of initial clip placement. Quantitative vessel-flow measurements were integral to the safe progression of the operation and may have prevented an adverse neurological outcome in this patient. The recommended surgical technique and the principle of operation are described.- - - - - - - - - - ranking = 8keywords = aneurysm (Clic here for more details about this article) |
7/84. Late hemorrhage from persistent pseudoaneurysm in vertebral artery dissection presenting with ischemia: case report.BACKGROUND: vertebral artery dissection lesions tend to resolve spontaneously, but abnormal findings such as aneurysmal-dilatation occasionally persist. However, the clinical features and pathological findings in such cases have never been verified. CASE DESCRIPTION: A 62-year-old man presented with left cerebellar infarction. angiography showed the "pearl and string sign" in the left vertebral artery, and he was diagnosed as having left vertebral artery dissection. Repeated angiography showed persistent aneurysmal dilatation with irregular stenosis. Eleven years after the cerebellar infarction, the patient presented with a subarachnoid hemorrhage from an aneurysm of the left vertebral artery, and the lesion was explored via the left suboccipital approach. The vertebral artery was firm, making the placement of a clip impossible, so the lesion was treated by coating of the bleeding point. The patient died of pneumonia and hyperglycemia on postoperative day 15. Postmortem examination revealed an organized intramural hematoma, thickening of the intima, and fibrous degeneration of the media of the vertebral artery, a fusiform, distended thin arterial wall with intimal disruption at the aneurysmal dilatation, and arteriosclerosis of all cerebral arteries. CONCLUSION: This case indicates that persistent aneurysmal dilatation of a dissection is a pseudoaneurysm prone to rupture, and that healing of the affected vessels might be severely compromised in the presence of pathological conditions such as arteriosclerosis and disturbed intraluminal blood flow in the dissected lesions.- - - - - - - - - - ranking = 10.2549507681keywords = aneurysm, pseudoaneurysm (Clic here for more details about this article) |
8/84. Bypass-surgery and coil-embolisation in the treatment of cerebral giant aneurysms.OBJECTIVE: Operative clipping is the most effective method in the treatment of cerebral giant aneurysms. But about 50% of all giant aneurysms are treatable this way. We want to report about eight patients with giant cerebral aneurysms, which were in our opinion "unclippable" without causing ischaemia in depending brain areas. methods: We describe eight cases of giant aneurysms of the pericallosal artery (n = 1) the middle cerebral artery (n = 3), the basilar tip (n = 3) and of the upper part of the basilar artery (n = 1). One patient with an aneurysm of the pericallosal artery was treated with an extra-intracranial saphenous vein bypass saphenous bypass, in three cases of middle cerebral artery aneurysms an extra-intracranial bypass was also done combined with a resection of the aneurysm. The four patients suffering from an aneurysm of the basilar artery got an extra intracranial bypass too followed by an occlusion of the aneurysm with GD-Coils. RESULTS: There was no peri-operative mortality and no severe peri- or postoperative complication. The neurological symptoms of all patients were unchanged after the operation. An angiographic control showed a complete obliteration of the aneurysm and a free running bypass in all cases. CONCLUSION: Bypass surgery and combined bypass surgery and coil embolisation are effective methods in the treatment of giant cerebral aneurysms, which can not be treated by clipping alone.- - - - - - - - - - ranking = 15keywords = aneurysm (Clic here for more details about this article) |
9/84. Retrocardiac arteriovenous malformation causing recurrent cerebral ischemia.A 28-year-old woman had been suffering from recurrent cerebral embolizations for almost 9 years. A retrocardiac arteriovenous malformation was identified as the source of emboli. It was supplied by chest wall veins and the right upper pulmonary vein, connected to the back wall of the left atrium and a possibly aberrant hepatic vein originating from the abdomen. The aneurysm was resected and all supplying veins ligated. The vein from below the diaphragm was implanted into the right atrium. Her postoperative course was uncomplicated. Long-term follow-up free from cerebrovascular events.- - - - - - - - - - ranking = 1keywords = aneurysm (Clic here for more details about this article) |
10/84. Cerebral oximetry for the detection of cerebral ischemia during temporary carotid artery occlusion.The near-infrared spectroscopy cerebral oximeter was assessed as a monitoring device for detecting and/or predicting cerebral ischemia during carotid endarterectomy (CEA) and the balloon occlusion test in 24 patients, 12 males and 12 females aged 28 to 77 years (mean 59.9 years). Tolerance testing of complete internal carotid artery (ICA) occlusion by balloon inflation for 20 minutes was performed in nine patients (cerebral aneurysm 6, neck tumor 3) and CEA was performed in 15 patients. The probe of the cerebral oximeter was placed on the forehead of the affected side and regional cerebral oxygen saturation (rSO2) was monitored continuously during all procedures. Stump pressure was measured just after ICA occlusion. collateral circulation detected by digital subtraction angiography was classified into three groups: good, moderate, or poor. Stump pressure was 41-90 mmHg (mean 61.3 mmHg) in the good collateral circulation group, 40-43 mmHg (41.5 mmHg) in the moderate group, and 14-30 mmHg (23.8 mmHg) in the poor group. Change in rSO2 after ICA occlusion was 3.5(-)-4.2% (mean -1.6%) in the good collateral circulation group, -1.2(-)-6.6% (-3.2%) in the moderate group, and -2.4(-)-10.2% (-6.6%) in the poor group. Changes in rSO2 were significantly different between the good and poor collateral circulation groups (p < 0.01). A greater than 5% fall in rSO2 was observed in 0 of 15 patients in the good collateral circulation group, one of five in the moderate group, and three of four in the poor group. The cerebral oximeter is a useful, real-time, non-invasive method to measure brain oxygenation during CEA, skull base surgery, or other procedures which need to evaluate brain ischemia. A fall of greater than 10% from the rSO2 baseline value is dangerous, but less than 5% is safe.- - - - - - - - - - ranking = 1keywords = aneurysm (Clic here for more details about this article) |
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