Ruptured de novo intracranial aneurysms

Summary Objective. We describe the actual state of ruptured de novo intracranial aneurysms to contribute to a guideline of follow-up for the patients with treated intracranial aneurysm.Methods. The authors retrospectively investigated 12 cases drawn from 483 consecutive cases of aneurysmal subarachnoid hemorrhage at our institute over a period of 22 years, in which a previously undemonstrated (hence de novo) intracranial saccular aneurysm formed and ruptured after successful treatment of a prior aneurysm.Findings. The 12 cases constitute 2.5% of the 483 patients who left our hospital alive. Eleven cases were females and one was a male with a mean age of 55.7 years (range 29–75) at the first subarachnoid haemorrhage (SAH) and an interval between the first and the second rupture of 10.7 years (range: 2.6–23.8, standard deviation: 6.86, 95% confidence interval: 6.39–15.1). Four cases did not have risk factors such as hypertension, family history, smoking, multiple aneurysms, and moyamoya disease. None of these ruptured de novo aneurysms was at the same location as the original lesion. One-third (4 cases) of the de novo lesions in our series were found on the opposite side to each prior lesion.Interpretation. For not only young but also elder patients with a treated aneurysm (from the fifth decade to the sixth), especially for women, late angiography or alternative modalities of less-invasive examination should be considered. To detect de novo intracranial aneurysms before rupture, the search for a de novo aneurysm should be performed within 6.39 years after a previous examination that shows an aneurysm to be nonexistent, in view of the 95% confidence interval of the mean time to de novo aneurysmal rupture (6.39–15.1 years). If applied this survey, 75% (8 cases of 12 cases) of our de novo aneurysms would be detected before rupture.     

Bleeding patterns from ruptured intracranial aneurysms: An autopsy series of 205 patients

The autopsy records from 205 patients who died from ruptured intracranial aneurysms were reviewed. Special emphasis was placed on the cause of death and the time after rupture that death occurred. One hundred and sixty-eight patients (82%) died within one week of their last aneurysmal rupture. Eighty-eight died within one week of their initial rupture. Massive sub-arachnoid hemorrhage was the cause of death in 53% and localized hematomas in 14%. Eighty patients died within one week following a subsequent rupture. Intracranial hematoma was the cause of death in 87%, with 31% harboring a localized mass potentially amenable to surgical therapy.     

Ruptured intracranial aneurysms in cases of sickle cell anemia

The authors present two cases of ruptured cerebral aneurysms in patients with sickle cell anemia. Only three previous cases with similar presentations have been reported. The various complications of sickle cell anemia and ruptured aneurysms are reviewed. The importance of early aggressive adjunctive medical management, including the use of partial exchange transfusions and surgical intervention, is emphasized.     

Ruptured intracranial aneurysms associated with moyamoya disease: three case reports

Three cases of ruptured intracranial aneurysm associated with moyamoya disease are presented. Endovascular treatments were performed successfully in two patients with major artery aneurysms. One patient with a collateral aneurysm was managed conservatively and follow-up angiography 1 year later demonstrated spontaneous disappearance of the aneurysm. Our experience suggests that although aneurysms associated with moyamoya disease show differences in evolution and location, endovascular treatment of major artery aneurysms is safe and effective, and peripheral aneurysms which cannot be directly accessed for surgery or endovascular embolization may be treated conservatively.     

Ruptured intracranial aneurysms: The preoperative management and the timing of surgery

Summary The authors review 179 consecutive cases of ruptured intracranial aneurysms: 80 out of the first 101 patients underwent aneurysm surgery in a period ranging from 7 days to 2 weeks following subarachnoid haemorrhage (SAH) and patients with all grades of the Hunt and Hess classification were included without discrimination.The total ease mortality rate was 23%. The postoperative mortality rate was 16%.Of the 78 patients in the 2nd group, 44 cases were operated upon. All patients with grades I, II and III and five cases with IV and V underwent aneurysm surgery. The timing of surgery was established on the basis of the various clinical and biochemical data, especially the improvement of meningeal signs, and decreased sensitivity of cerebral vessels to vasconstriction. In this group the angiographic vasospasm and focal neurological deficits, without further clinical damage, were not considered a risk for surgery.The surgical mortality rate was 7%.The evidence presented indicates that both a more selective method of assessing the preoperative neurological function and also an appropriate timing of surgery have improved the surgical morbidity and mortality.     

Ruptured abdominal aortic aneurysms: selecting patients for surgery.

OBJECTIVES: Mortality from ruptured abdominal aortic aneurysm (RAAA) remains high. Despite this, withholding surgery on poor-prognosis patients with RAAA may create a difficult dilemma for the surgeon. Hardman et al. identified five independent, preoperative risk factors associated with mortality and proposed a model for preoperative patient selection. The aim of this study was to test the validity of the same model in an independent series of RAAA patients. METHODS: A consecutive series of patients undergoing surgery for RAAA was analysed retrospectively by case-note review. Thirty-day operative mortality and the presence of the five risk factors: age (> 76 years), creatinine (Cr) (> 190 mumol/l), haemoglobin (Hb) (< 9 g/dl), loss of consciousness and electrocardiographic (ECG) evidence of ischaemia were recorded for each patient. RESULTS: Complete data sets existed for 69 patients (mean age: 73 years, range: 38-86 years, male to female ratio: 6:1). Operative mortality was 43%. The cumulative effect of 0, 1 and 2 risk factors on mortality was 18%, 28% and 48%, respectively. All patients with three or more risk factors died (eight patients). CONCLUSIONS: These results lend support to the validity of the model. The potential to avoid surgery in patients with little or no chance of survival would spare unnecessary suffering, reduce operative mortality and enhance use of scarce resources.     

Rerupture of intracranial aneurysms: a clinicoanatomic study

In a series of 176 prospectively studied patients who survived for at least 24 hours after aneurysmal subarachnoid hemorrhage, 39 had at least one computerized tomography (CT)-proven rebleed within 4 weeks after the first rupture. There were peaks in the incidence of rebleeding at the end of the 2nd and 3rd weeks. Sudden loss of consciousness occurred in 35 patients, preceded in one-third of them by headache. A sudden increase in headache was a symptom of rebleeding in only one patient. Loss of brain-stem reflexes was recorded in 13 patients, respiratory arrest in six, and both symptoms in eight patients. Apnea was temporary in 11 patients. Rebleeding occurred as gross intraventricular hemorrhage in 20 patients, as a space-occupying hematoma in four, as both types of hemorrhage in three, and as a purely subarachnoid hemorrhage in 12. The location of the rebleed could not be inferred from the clinical features. Rebleeding was fatal in 51% of cases (two of 12 patients with a purely subarachnoid hemorrhage, and 18 of the other 27 patients (p less than 0.005)). The risk of rebleeding could not be predicted from the patients' clinical condition on admission or from the amount of subarachnoid blood identified on the initial CT scan. The risk of further rebleeding was significantly increased in survivors of a first rebleed (47%: p less than 0.01). Only seven (18%) of the 39 patients with rebleeding had survived at 3 months after the initial hemorrhage.     

Ruptured abdominal aortic aneurysms: a study of incidence and mortality

The incidence of ruptured abdominal aortic aneurysms (AAA) during 1980 in the Stockholm county and the clinical fate of the patients were evaluated. Eighty-eight patients with ruptured AAA were found, an incidence of 0.06 per thousand. The overall mortality was 94 per cent. Sixty-four patients reached hospital, twenty-three received a correct diagnosis; thirteen were operated upon and five survived. Autopsy or operation revealed that most ruptures were retroperitoneal (88 per cent) and that only two aneurysms (2 per cent) extended above the renal arteries. It is concluded that the high mortality rate following rupture is more dependent upon failure to operate than on operative mortality.     

Ruptured intracranial aneurysms. The influence of sex and fibromuscular dysplasia upon prognosis

From a statistical analysis of a series of 214 cases of ruptured intracranial aneurysms, it was demonstrated that only four parameters among those collected on the admission day, are predictive of the final functional result: sex (p less than 0.001); age (p less than 0.02); clinical grade (p less than 0.001) and angiographic spasm (p less than 0.01). The surprisingly poor prognosis in women was explained by the higher frequency of spasm (p less than 0.005). Aneurysms in women predominated on the intracranial carotid artery (38%) and were frequently multiple (12%). A further angiographic study on 87 cases was then carried out including a systematic investigation of the cervical part of the vessels; it permitted one to identify angiographic features of fibromuscular dysplasia (FMD) on the cervical vessels in 20 cases. In those cases it was also observed that there was a marked female predominance (F/M = 5.6), a frequent localization on the internal carotid artery (50%), a high rate of multiple aneurysms (60%) and a poor prognosis related to spasm (50%). Therefore, intracranial aneurysms appear far more frequently than usually reported, to be related to FMD. The worse prognosis of ruptured intracranial aneurysms in females can be, at least partly explained by the association with FMD and the frequent occurrence of spasm. A careful investigation of patients exhibiting features of FMD in order to detect intracranial aneurysms before rupture, is suggested.     

Ruptured cerebral aneurysms missed by initial angiographic study

The authors reviewed the computed tomographic (CT) scans of patients with subarachnoid hemorrhage whose initial angiograms were negative, to investigate the validity of CT scans in predicting the presence of an angiographically missed aneurysm in such patients. During the past 14 years, additional angiograms have been obtained for 38 of the 45 patients with subarachnoid hemorrhage whose initial angiograms disclosed no aneurysm. Aneurysms were found in 8 patients; 7 on the anterior communicating artery and 1 at the junction of the internal carotid and posterior communicating arteries. CT scans were taken within 4 days after subarachnoid hemorrhage in 31 patients. Analysis of these scans showed that the second angiogram revealed 1) an aneurysm in 21% of the patients with a thin layer of subarachnoid blood and in 63% of those with a thick layer; 2) no aneurysm in the patients without subarachnoid blood; and 3) an aneurysm of the anterior communicating artery in 70% of the patients who showed a considerable amount of blood in the basal frontal interhemispheric fissure. These results suggest that if CT scans show thin or thick subarachnoid blood, angiographic study should be repeated early in the course. If a considerable amount of blood is shown in the basal frontal interhemispheric fissure, it is highly probable that an aneurysm is hidden on the anterior communicating artery, even if the angiogram is negative for an aneurysm.     

Unruptured intracranial aneurysms in haemodialysis patients

SUMMARY:   While the mortality rate of subarachnoid haemorrhage is very high in haemodialysis (HD) patients, the prevalence of unruptured intracranial aneurysms in HD patients has not yet been elucidated. We performed cerebral magnetic resonance angiography (MRA) on 123 HD patients who did not have symptomatic cerebrovascular disease, and on 52 control subjects. On the basis of these images, the prevalence of unruptured intracranial aneurysms was evaluated. Unruptured aneurysms were found in three HD patients (2.4%). There were no aneurysms found in the healthy control group. There was no significant difference in the prevalence of unruptured aneurysms between HD patients and healthy controls. Therefore, the incidence of intracranial aneurysms is not associated with chronic renal failure.     

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.     

Ruptured thoracic aortic aneurysms: A study of incidence and mortality rates

Purpose: The purpose of this study was to determine the incidence and mortality rate of ruptured thoracic aortic aneurysm (TAA) in a well-defined population.Methods: Retrospective analysis of compiled data from multiple registries in Stockholm, Sweden was performed.Results: Eighty-two and 76 cases were identified from 1980 and 1989, respectively, for an equal incidence of 5 per 100,000. Forty-one percent of the patients were alive on arrival at an emergency hospital, but the overall mortality rate was 97% to 100%.Conclusions: The mortality rate of ruptured TAA is high. To decrease this high mortality rate, efficient screening methods for the diagnosis of TAA must be worked out, characteristics indicating high risk of rupture must be identified, and efforts should be made to increase the number of operations for ruptured TAA. (J VASC SURG 1995;21:985-8.)     

Ruptured cerebral aneurysms in patients with systemic lupus erythematosus

Two cases of ruptured aneurysms in the cerebral arteries in patients with established systemic lupus erythematosus are presented. A 32-year-old woman with a 3-year history of systemic lupus erythematosus was found to have a ruptured cerebral aneurysm at the top of the basilar artery. Another 38-year-old woman with a 4-year history of lupus erythematosus had a ruptured aneurysm in the anterior communicating artery. Both were treated surgically. Cerebral aneurysms associated with systemic lupus erythematosus are reviewed in the literature and the pathogenesis of these aneurysms is discussed.