Mycotic aneurysm of the superior mesenteric artery in a young woman

Aneurysm of the superior mesenteric artery (SMA) is rare. We, in this study, present the case of a 21-year-old woman with a history of heroin abuse who was admitted to our hospital for infective endocarditis complicated by floating vegetation at the posterior mitral valve. After receiving 2-week antibiotic treatment, the patient had acute abdominal pain. Computed tomography demonstrated an aneurysm at the SMA. The mycotic aneurysm was resected and the mitral valve was repaired successfully. This report reviews the pathophysiology of mycotic aneurysms of the SMA and role of computed tomography in the differential diagnosis of this condition from acute mesenteric ischaemia.     

Sonographic diagnosis and successful nonoperative management of sealed perforated duodenal ulcer

We encountered a case of sealed perforated duodenal ulcer in a 75-year-old woman with rheumatoid arthritis and chronic renal failure. Abdominal sonography showed a bright linear echo within the thickened anterior wall of the duodenal bulb and the presence of free air at the anterior surface of the liver. We found no signs of direct communication between the duodenal lumen and the peritoneal cavity or any free fluid. On follow-up sonography performed every 2 days during the first week of the patient's hospitalization, no free fluid was found in the abdomen. The use of sonography to diagnose this patient's sealed perforated duodenal ulcer and to monitor the ulcer for the appearance of free fluid allowed us to provide successful nonsurgical management to this patient. We believe that the use of abdominal sonography in all patients suspected of having a perforated duodenal ulcer may help increase the diagnostic accuracy of this modality and may reduce the need for surgery in such patients.     

New directions in nonoperative management of coronary artery disease

This review has discussed several nonoperative approaches designed to restore or maintain coronary artery patency in patients with coronary artery disease. Information obtained during the last decade concerning the use of thrombolytic, anticoagulant, and antiplatelet drugs and the development of the technique of PTCA have dramatically changed the clinical management of patients with coronary artery disease. It is likely that the application of these therapies will continue to evolve during the next several years as new pathophysiological insights are obtained and large ongoing or planned clinical trials testing current hypotheses are completed.     

Sonographic diagnosis of inferior mesenteric artery aneurysm and marginal artery of Drummond

We report the case of a patient in whom sonographic examination revealed an aneurysm of the inferior mesenteric artery with severe proximal stenosis and poststenotic dilatation--the enlargement of the proximal portion of the artery of Drummond. This collateral pathway should be kept in mind when studying bowel ischemia, especially when stenosis is present or when there is occlusion of the superior mesenteric artery.     

Mycotic aneurysm of the left ventricle: echocardiographic diagnosis.

We report an unusual case of myocardial mycotic aneurysm of the left ventricle resulting from a healed myocardial abscess caused by an aortic regurgitant jet lesion. The diagnosis was made during intraoperative transesophageal echocardiography and confirmed by surgical inspection. The echocardiographic features are described.     

Mycotic aneurysm of the abdominal aorta:CT findings in three patients

We present three cases of mycotic aneurysms of the abdominal aorta that were initially diagnosed with computed tomography (CT). The accuracy of CT as the first imaging technique in the diagnosis of this condition is reviewed in light of our results and those reported in the literature. Received: 7 November 1995/Accepted: 6 December 1995     

Aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery

Aneurysms of the pancreaticoduodenal artery are rare and may be associated with celiac artery stenosis or occlusion. Twenty-eight patients are reported in the literature. The diagnostic findings and therapeutic alternatives of four additional patients form the basis of this report. One patient with ruptured pancreaticoduodenal aneurysm was successfully treated by transcatheter embolization, and one patient was treated surgically; both patients had an uneventful recovery. In the remaining two patients, the aneurysms were left untreated. One patient died 1 year later of an unrelated cause, and the other patient is symptomfree after 2 years.     

Hemosuccus pancreaticus secondary to intraductal rupture of a primary splenic artery aneurysm: diagnosis by ERCP and successful management by interventional radiology

This report describes the case of a 65-year-old man with a prolonged history of gastrointestinal bleeding of unknown origin. During a 2-year period, he underwent 28 endoscopic procedures, three angiographies with or without heparin provocation, a nuclear scan, and abdominal magnetic resonance imaging, none of which were diagnostic. A blind ileocecal resection was also carried out. A diagnosis of hemosuccus pancreaticus secondary to a ruptured primary splenic artery aneurysm was obtained by endoscopic retrograde cholangiopancreatography, and successful interventional radiographic embolization of the splenic artery aneurysm was conducted. During a 17-month follow-up period, no relapse of gastrointestinal bleeding was observed.     

Adrenal myelolipoma: rationale for nonoperative management

With increasing use of computerized tomography and ultrasonography, asymptomatic lesions of the adrenal gland are frequently detected. One such tumor is the adrenal myelolipoma, composed of adipose and hemic elements histologically resembling bone marrow. This tumor can be diagnosed by its characteristic appearance on CT scan, and fine-needle biopsy guided by CT can be used to obtain a tissue diagnosis. Because patients with adrenal myelolipoma typically have recurrence of symptoms after resection, surgical intervention is not indicated unless an enlarging tumor impinges on surrounding structures.     

Mycotic aneurysm caused by group B streptococcus: a cautionary tale of management problems and a rare organism

We report a case of mycotic aneurysm of the femoral artery which highlights the diagnostic features and management problems of the condition. Our patient required emergency ligation of the artery for life-threatening haemorrhage and subsequently his leg was not viable. The alternative treatment options of simple ligation and excision versus ligation, excision and immediate bypass grafting of the artery are discussed. The causative organism, beta-haemolytic group B streptococcus (S. Agalactiae), is an extremely rare cause of embolic mycotic aneurysm. This rarity is unexplained and is surprising since this organism is a well-known cause of infective endocarditis, which can be complicated by mycotic aneurysms. Mycotic aneurysms may become more common because of the rise of intravascular drug abuse, which combines the risk factors of vessel trauma, endocarditis and immunosuppression, notably from HIV infection.     

Herniated nucleus pulposus with radiculopathy in an adolescent: successful nonoperative treatment

The following report describes a 17-year old girl with a central herniated nucleus pulposus (HNP) at L4-5. The diagnosis of lumbar disk herniation was based on findings from magnetic resonance imaging (MRI). A decision to use conservative treatment was unanimously agreed upon by a team of orthopedists, a neurosurgeon, and an internist. This report follows the patient's course from the onset of pain through the completion of the nonoperative treatment and shows that HNP of a lumbar intervertebral disk with radiculopathy can be treated successfully with aggressive nonoperative care.     

Splenic injuries in adults: selective nonoperative management

Although nonoperative management is the standard initial treatment in children with splenic injury, this therapeutic option has been exercised infrequently in adults. Over the past two years we have hospitalized and observed 11 hemodynamically stable adults with splenic trauma and no other significant injury. Ten patients sustained blunt trauma localized to the left upper quadrant, and one patient was stabbed in the left flank. Eight patients were normotensive on hospital arrival, while three had an initial systolic blood pressure of 90 to 98 mm Hg. All patients remained normotensive after receiving 2 liters of crystalloid fluid IV. Nine patients had an initial hemoglobin level of 11.1 to 14.0 gm/dl, and two a level of less than 10 gm/dl. Liver-spleen scan done in ten patients yielded true-positive results in eight, false-positive results in one, and false-negative results in one. In the 11th patient, a celiac arteriogram showed a splenic defect. Three patients had laparotomy 27 to 43 hours after hospitalization, owing to a decreasing hemoglobin concentration; one required partial splenectomy. Eight patients were successfully managed nonoperatively; only one required blood transfusion, and all tolerated oral alimentation by the second hospital day. All patients were discharged by the 12th hospital day. Nonoperative management can be successfully applied to adults with isolated splenic trauma.     

Treatment of a ruptured aneurysm involved in a double origin of the posterior inferior cerebellar artery

Double origin of the posterior inferior cerebellar artery (DOPICA) is a rare anatomical variation, and can be associated with intracranial aneurysm formation. We describe a 66-year-old woman case of a ruptured aneurysm involved in a DOPICA. We performed aneurysmal coil embolization for the ruptured aneurysm involved in the cranial channel of DOPICA, but the aneurysm relapsed two months later. We subsequently performed internal trapping of the cranial channel because of well visualization of the distal flow by the balloon occlusion test. Endovascular trapping of a channel is one of the effective treatments of an aneurysm involved in DOPICA.