Association between surgical repair of aortic aneurysms and the diagnosis of intracranial aneurysms

ObjectiveAortic aneurysms (AAs) and intracranial aneurysms (IAs) share several clinical risk factors, a genetic predisposition, and molecular signaling pathways. Nonetheless, associations between IAs and AAs remain to be thoroughly validated in large-scale studies. In addition, no effective medical therapies exist for unruptured IAs or AAs.MethodsData for this nationwide, population-based, retrospective, cohort study described herein were obtained from the National Health Insurance Research Database in Taiwan. The study outcomes assessed were (1) the cumulative incidence of IAs, which was compared between AA and patients without an AA and (2) the cumulative incidence of IAs in patients with AAs during the 13-year follow-up period, which was further compared among those who underwent open surgical repair (OSR), endovascular aneurysm repair or nonsurgical treatment (NST).ResultsOur analyses included 20,280 patients with an AA and 20,280 propensity score-matched patients without an AA. Compared with the patients without an AA, patients with AA exhibited a significantly increased risk of an IA diagnosis (adjusted hazard ratio [HR], 3.395; P < .001). Furthermore, 6308 patients with AAs were treated with surgical intervention and another 6308 propensity score-matched patients with AAs were not. Patients with an AA who underwent OSR had a significantly lower risk of being diagnosed with an IA than patients with an AA who underwent endovascular aneurysm repair or NST (adjusted HR, 0.491 [P < .001] and adjusted HR, 0.473 [P < .001], respectively).ConclusionsWe demonstrated an association between IAs and AAs, even after adjusting for several comorbidities. We also found that OSR was associated with fewer recognized IAs than NST.     

Abdominal aortic aneurysms: screening,epidemiology and open surgical repair

Abdominal Aortic Aneurysm (AAA) is a dilatation of the infra-renal abdominal aorta to greater than 3 cm. Population screening is offered to men in their 65th year in the UK. Patients with small AAAs (<5.5 cm) are entered into surveillance programs and should have cardiovascular risk factors managed aggressively. An AAA with ≥5.5 cm diameter should be considered for surgical repair to prevent rupture. Open surgical repair has proven to be a durable treatment for AAA and while less often performed than endovascular aneurysm repair (EVAR) it remains a common approach in the surgical management of AAA. While associated with higher short-term risks than EVAR, the long-term outcomes are similar and many younger patients have a preference for open repair as routine follow-up is not required.     

Surgical outcome for multiple intracranial aneurysms

Summary The surgical outcome of 221 cases with multiple intracranial aneurysms operated upon during the years 1988 to 1994 were reviewed. The patients were classified into three groups according to the locations of the aneurysms; group 1: multiple aneurysms located unilaterally in the anterior circulation only (147 cases); group 2: multiple aneurysms located bilaterally in the anterior circulation only (44 cases) and group 3: multiple aneurysms located in both anterior and posterior circulation or in the posterior circulation alone (30 cases). In 132 cases of group 1 (89.8%) all aneurysms were treated in one-stage operations. Twenty-eight patients from group 2 (63.6%) received partial treatment, where only the ruptured or the symptomatic aneurysms were treated. In 12 other cases from group 2 (27.3%) all multiple aneurysms were treated in two-stage operations. In group 3 patients, one-stage operations were performed in 18 cases (60%), while 9 patients (30%) received partial treatment only. Of the 221 multiple aneurysm cases, 162 (73.3%) presented with manifestations of subarachnoid haemorrhage (SAH). The remaining 59 multiple aneurysms cases (26.7%) presented with manifestations other than SAH (unruptured aneurysms). In the postoperative follow-up, of the 221 multiple aneurysms cases, 113 (51.1%) were free of neurological deficit (excellent), 48 cases (21.7%) were capable of leading an independent life (good), 32 cases (14.5%) were not independent and needed to be assisted (fair), and 28 patients (12.7%) died. These results were comparable to the results of patients with single aneurysms operated on during the same period.Based on our results, we recommend that whenever possible all multiple aneurysms should be treated in one-stage operations. In unruptured multiple aneurysm cases surgical management is the recommended treatment. In poor grade SAH patients or unruptured multiple aneurysms in old patients, two-stage operations or partial treatment of only the ruptured or the symptomatic aneurysms may be adopted.     

Surgical treatment of multiple intracranial aneurysms

Summary A retrospective review of 126 patients with multiple aneurysms seen over a 10 year period was undertaken. They had a total of 302 aneurysms. Thirty-seven percent of the patients were males, and 63% were females. Direct operations were performed on 97 cases. Both the ruptured and unruptured aneurysms were treated in 71% (69 of the 97 cases), and only the ruptured aneurysms were treated in 29% (28). In 69 cases in whom both ruptured and unruptured aneurysms were treated, one-stage operations were used for 48 cases, and two-stage operations were used for 21 cases. Thirty-four of the 48 cases, who were treated in one-stage operations, were operated on by day 4 after subarachnoid haemorrhage. In 12 cases, a total of 13 small unruptured aneurysms, which had not been found by preoperative angiograms, were discovered during surgery, and 9 of the 13 were discovered while removing blood clots to reduce cerebral vasospasm. Regardless of the operative method selected and the timing of operations, the surgical outcome of patients with multiple aneurysms was comparable to that of the 228 cases with single aneurysms treated during the same period at the same hospital.The analysis of this study suggests that surgical results for multiple aneurysms are satisfactory, even for early operations. Further, the actual incidence of multiple aneurysms may be higher than has been reported to date because small unruptured aneurysms which have been discovered during clot removal may not have been reported.     

Enlargement of intracranial saccular aneurysms

Summary A case of enlargement of a middle cerebral artery aneurysm is reported. Cerebral angiography demonstrated an increase in the size of this aneurysm. Possible factors causing aneurysmal enlargement are discussed.     

Surgical treatment of unruptured intracranial aneurysms

Summary The author has reviewed a series of 19 patients with unruptured aneurysms treated surgically during a 5-year period from 1976 to 1981. Unruptured aneurysms found in patients with multiple aneurysms and subarachnoid haemorrhage due to ruptured aneurysms are not included in this series. Literature on this subject is reviewed. There was no mortality and results were excellent in 7 patients with asymptomatic aneurysms. In 12 patient with symptomatic aneurysms there was no mortality and results were good to excellent in 9 patients. In 2 the results were unsatisfactory.The series included aneurysms varying in size from 5 mm to over 2.5 cm (giant aneurysm). Controversial aspects of surgery of unruptured intracranial aneurysms are discussed. The authors recommend surgical treatment of unruptured intracranial aneurysms regardless of size until such time when more definitive information is available about the natural history of these lesions.     

Microsurgical treatment of intracranial saccular aneurysms

Summary A consecutive series of 200 patients with intracranial saccular aneurysms subjected to surgery with the aid of an operating microscope is presented.Presented in part at the Workshop on Cerebral aneurysms-Advances in Diagnosis and Therapy. Bad Nauheim (Germany), March 4–5, 1977.     

Rerupture of intracranial aneurysms during angiography

Summary We analyzed 70 patients (64 from the literature and 6 of our own cases) who had suffered from rerupture of their aneurysms during angiography. When these cases are compared with those who had suffered rupture of their aneurysms only once and a rerupture, which did not coincide with angiography, they were clinically distinguished by a higher Hunt-Hess grade, a higher rate of IC aneurysms, less operability, far miserable outcome and concentration of aneurysmal rerupture within three hours after the initial subarachnoid haemorrhage. It is suggested waiting at least 3 hours after SAH before performing angiography and to use digital subtraction angiography in order to prevent aneurysmal rerupture during angiography.     

Familial occurrence of multiple intracranial aneurysms case reports and review of the literature

Summary The authors report a family in which two members had multiple intracranial aneurysms. This is the third reported family with more than one member affected by multiple cerebral aneurysms. The congenital nature and the patterns of inheritance of the disease are discussed. The indications for elective investigation of the asymptomatic relatives and surgical prophylaxis on asymptomatic aneurysms are also briefly discussed.     

经微导管送入国产钨丝微螺旋圈治疗颅内囊状动脉瘤

报告１０例颅内囊状动脉瘤，其中后交通动脉瘤４例，前交通动脉瘤４例，大脑中动脉瘤１例，基底动脉分叉部动脉瘤１例，均行血管内治疗，应用自制钨丝螺旋圈闭塞动脉瘤，保持载瘤动脉通畅，全部治愈。     

De novo aneurysm formation and aneurysm growth following therapeutic carotid occlusion for intracranial internal carotid artery (ICA) aneurysms

Summary In a consecutive series of 312 surgical aneurysm cases more than 90% of the patients reached neurosurgical expertise within 48 hours from bleeding. Computed tomography permitted prediction of the assumed rupture site based on blood clot location in the majority (86%) of cases. This target vascular territory was usually investigated by selective angiography and in 9 out of 10 patients an aneurysm, ultimately shown to be the correct source of bleeding, was demonstrated. In 14% of the cases the source of bleeding could not be established thus calling for complete four vessel studies.It is concluded that limited angiographic studies are compatible with preserving a high surgical standard in cases unequivocally exhibiting a localizing clot pattern on the CT scan. Though suboptimal in a general sense, incomplete vascular studies, if four vessel angiography is not obtainable without delay or risk, should not delay earliest possible clipping of ruptured aneurysms to avoid the devastating effects of recurrent bleeds.     

Multiple intracranial aneurysms in elderly patients

Summary The clinical characteristics of elderly patients with multiple intracranial aneurysms were studied. A total of 481 patients, in whom the exact location of their ruptured aneurysms could be confirmed, were classified into two age groups, that is, those aged 59 years or younger (group 1: 247 cases, 51%) and those aged 60 years or older (group 2: 234 cases, 49%). The incidences of multiple aneurysms were 30% for group 1 and 27% for group 2. This difference is statistically not significant. The rate of multiple aneurysms was less frequent in males than in females in group 2, whereas no difference could be found in group 1. The age distribution of patients with multiple aneurysms was basically similar to that of patients with single aneurysms. While the highest rupture rate was observed in the anterior communicating artery aneurysms of both groups, this tendency was more prominent in group 2(79%) than in group 1 (59%). The rupture rates for other sites in group 2 were 50% for distal anterior cerebral artery aneurysms, 40% for internal carotid artery aneurysms and 28% for middle cerebral artery aneurysms. The pattern of surgical outcome showed no major differences between multiple and single aneurysms in either group 1 or 2. However, group 1 had better surgical results than group 2.Even though the surgical outcome for multiple aneurysms in elderly patients was satisfactory, awareness of the probability of rupture at each site is helpful, especially when it is necessary to decide whether unruptured aneurysms should be operated on or not.     

Types of unruptured cerebral aneurysms reviewed from operation video-recordings

Summary To estimate the proportion of unruptured cerebral aneurysms with thin-walled sac, we have analyzed the operative findings of 78 incidental cerebral aneurysms found in 51 consecutive surgical cases by reviewing of intra-operative videotape recordings. Among 78 unruptured aneurysms, 23 (30%) were evaluated as thick-walled aneurysms (Type A), 39 (50%) with partially thin-walled sac (Type B) and 16 (20%) with entirely thin wall sacs (Type C). The mean size of Type A aneurysms was 10.4 mm (ranging from 3 to 22 mm), in Type B it was 9.8 mm (ranging 4 to 25 mm) and in Type C it was 4.4 mm (between 2–12 mm). Approximately two-thirds of Type C aneurysms were 4 mm in size or smaller, and Type C aneurysms were significantly smaller than Type A aneurysms. In summary, this preliminary study has provided two original data. 1) About 70% of incidental unruptured aneurysms have a partially or entirely thin-walled sac. 2) Many of the small aneurysms have an entirely thin sac. Assuming that thin-walled aneurysms are at a high risk of subsequent rupture, the surgical intervention for incidental unruptured aneurysms may be recommended irrespective of their size if the surgical risk is considered low.     

Rupture of intracranial aneurysms and ventricular opacification during carotid angiography

Summary Two cases of rupture of intracranial aneurysms and opacification of the lateral ventricles occurring during carotid angiography are reported and X-rays of the haemorrhage from the aneurysms are presented.Though the possibility of this complications remains a real one, the early use of this valuable procedure should not be precluded.     

Surgical prognosis of unruptured intracranial arterial aneurysms

Summary The authors analyze a series of 53 patients who presented with unruptured intracranial aneurysms. Fifty were operated upon, 2 died during the post-operative period, 5 were left with their pre-operative neurological deficit, 43 were cured and have not subsequently presented with any cerebral or meningeal haemorrhages. None of the 3 patients who were not operated upon has since presented with a cerebro-vascular accident.Twenty-five aneurysms were asymptomatic, discovered fortuitously during angiographic examination, and their size was generally between 3 and 6 mm. Twenty-eight aneurysms presented with various neurological signs and symptoms (headaches, facial pain on 9 occasions, ischaemic vascular accidents on 7 occasions, ocular signs on 8 occasions and generalized epilepsy on 4 occasions), with a range in size from 7 to 10 mm. The clinical and autopsy series published in the literarure show the usefulness of surgery when certain factors come together and increase the risk of rupture: middle-aged patients (between 40 and 65), arterial hypertension, aneurysm located on the anterior part of the circle of Willis and with a diameter close to the critical size (10 mm) for rupture.     

High plasma microfibrillar-associated protein 4 is associated with reduced surgical repair in abdominal aortic aneurysms

ObjectiveIdentifying biomarkers for abdominal aortic aneurysms (AAA) could prove beneficial in prognosis of AAA and thus the selection for treatment. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein that is highly expressed in aorta. MFAP4 is involved in several tissue remodeling-related diseases. We aimed to investigate the potential role of plasma MFAP4 (pMFAP4) as a biomarker of AAA.MethodsPlasma samples and data were obtained for 504 male AAA patients and 188 controls in the Viborg Vascular (VIVA) screening trial. The pMFAP4 levels were measured by Alphalisa. The Mann-Whitney U test assessed differences in pMFAP4 levels between the presence and absence of different exposures of interest. The correlation between pMFAP4 and aorta growth rate were investigated through spearman's correlation analysis. Immunohistochemistry and multiple logistic regression adjusted for potential confounders assessed the association between pMFAP4 and AAA. Multiple linear regression assessed the correlation between pMFAP4 and aorta growth rate. Cox regression and competing risk regression were used to investigate the correlation between AAA patients with upper tertile pMFAP4 and the risk of undergoing later surgical repair.ResultsA significant negative correlation between pMFAP4 and aorta growth rate was observed using spearman's correlation analysis (ρ = −0.14; P = .0074). However, this finding did not reach significance when applying multiple linear regression. A tendency of decreased pMFAP4 was observed in AAA using immunohistochemistry. Competing risk regression adjusted for potential confounders indicated that patients with upper tertile pMFAP4 had a hazard ratio of 0.51 (P = .001) for risk of undergoing later surgical repair.ConclusionsHigh levels of pMFAP4 are associated with a decreased likelihood of receiving surgical repair in AAA. This observation warrants confirmation in an independent cohort.     

我国腹主动脉瘤腔内修复技术发展现状和展望

近30年来,我国的主动脉腔内修复手术(EVAR)技术发展迅速,凭借其创伤小、恢复快、严重并发症少等优势在腹主动脉瘤(AAA)的手术治疗中得到了广泛应用.随着各类新型技术和支架等耗材的不断出现,诸多解剖条件复杂的AAA不再是EVAR的禁忌证.EVAR未来发展离不开临床医学、基础医学、材料科学、生物工程、3D打印甚至人工智...     

Development of new intracranial saccular aneurysms

Newly formed aneurysms developing from a cerebral vessel which had appeared to be normal in a previous angiographic study are very rare. Four cases of angiographically documented newly developed saccular aneurysms are described in this report. In all four patients, the new aneurysms were symptomatic, causing subarachnoid hemorrhage (SAH). Repeat angiography, performed after the second SAH, revealed new aneurysms that were not demonstrated on initial angiograms after the first SAH. They were clipped with good postoperative course. Our observations and literature data suggest that some patients with SAH need further neuroradiological followup. The presence of the risk factors and age of the patient should be taken into consideration.