Spontaneous rupture of renal angiomyolipoma with tuberous sclerosis during long-term follow-up: a case report]

We present a case of spontaneous rupture of bilateral renal angiomyolipoma (AML) with tuberous sclerosis. A 46-year-old woman was admitted with sudden onset of severe left flank pain. She had been diagnosed to have bilateral AML with tuberous sclerosis 15 years earlier. Four years after the initial diagnosis, spontaneous rupture of right renal AML occurred and right renal embolization of the right renal artery was performed. The treatment for the left renal AML was not performed. Eleven years later in 2000, spontaneous rupture of contralateral renal AML occurred and left renal embolization of the left renal artery was performed. We evaluated the efficacy of selective arterial embolization in right AML and the change of the tumor size during a 10-year follow up after embolization. The right AML had decreased 86% in 11 years. Selective arterial embolization is an effective and safe treatment for AML. We evaluated the natural history of left AML and calculated the doubling time to be about 1,370 days for the first period of 4 years and about 2,075 days for the second period of 11 years. Although the growth change was very slow, we should observe the tumors carefully on computed tomography or ultrasound to prevent life-threatening hemorrhage.     

Delayed rupture of the spleen: Case report

We present a case of delayed rupture of the spleen with perisplenic hematoma in a fifty-five year old male which coincides with the observation expressed by Zabmski and Harkins²⁴ that “delayed splenic rupture is most common in males in the third decade of life.”This patient had recuperated from the shock of his late acute internal hemorrhage suffered thirteen days prior to surgery, and was operated upon eight months plus days after his unrecalled injury through a mistaken diagnosis of carcinoma of the stomach. The history and symptoms were all confusing and this case illustrates the difficulties in diagnosis and shows how insidious and treacherous this syndrome may be. He would unquestionably have gone on for a variable period before another possibly fatal hemorrhage occurred. Such a case helps explain the very prolonged cases reported in the literature.The postoperative course was complicated by pneumonia from which this patient recovered.His chief complaints during his early observation were those of hypertension with dizziness headaches, and fullness of the head, and anorexia, weight loss, weakness, cough, and precordial pain; later were added nocturia, epigastric and left hypochondriac pain, and nausea.The unusual symptoms in this case at variance with the accepted literature on the subJect of delayed rupture of the spleen are a hypertension (of 220/120) and a nocturia (of four to five times). This is difficult to explain except on the basis of the mass exerting pressure on the left kidney or/and left renal artery. Following surgery his nocturia ceased and his blood pressure dropped to 140/76.The incidence of delayed rupture of the spleen in our five-year series of thirteen cases including this case, is two cases of delayed hemorrhage and eleven cases of acute hemorrhage (2 in 13). Of this group four cases including the present one, were isolated and uncomplicated cases of splenic rupture.     

注射毒品所致的股动脉假性动脉瘤的治疗：附45例报告

目的：探讨注射毒品所致的股动脉假性动脉瘤的外科治疗方法及效果。方法：对45例注射毒品所致的股动脉假性动脉瘤患者临床资料进行回顾性分析。其中27例进行血管重建,包括20例直接采用ePTFE人工血管移植,4例自体大隐静脉移植,3例覆膜支架腔内隔绝;18例直接采用单纯股动脉三头结扎。分析患者的近期治疗效果及随访资料。结果：所有患者均保肢成功。血管结扎术后3例分别于6个月、2年、3年出现间歇性跛行3例,2例分别于术后1年和2年出现肌肉萎缩乏力;血管重建术后近期2例出现人造血管感染和术后再出血4例。结论：患者一般情况允许时,应尽可能行假性动脉瘤切除+人工血管解剖旁路移植,但需预防近期术后再出血及感染发生;若患者一般情况差,不耐受大手术,或局部感染严重,单纯股动脉三头结扎是可行的方法,但需预防远期肌肉萎缩等并发症;覆膜支架腔内隔绝适合无明显感染且动脉瘤未破裂的患者。

     

A case of left occipital lobe hemorrhage in a patient with progressive systemic sclerosis: evaluation of cerebral angiography and histology

Involvement of the central nervous system is uncommon in progressive systemic sclerosis, with only 2 reported cases associated with intracerebral hemorrhage detected by neuroimaging. A 55-year-old woman with a 10-year history of scleroderma presented with left occipital lobe hemorrhage manifesting as headache and vomiting. She had no signs of hypertension, diabetes mellitus and hyperlipidemia. CT and MRI, on admission, showed left occipital lobe hemorrhage with ventricular rupture and acute left subdural hematoma. Serial cerebral angiography was performed on day 0, day 7 and day 14, and found no evidence of aneurysm, arteriovenous multiformation or tumor stain in the left occipital lobe. However, the bilateral anterior cerebral arteries showed increasing segmental narrowing suggestive of vasculitis. Histological examination of a section from the brain cortex adjacent to the hemorrhage revealed no evidence of vasculitis, fibrinoid degeneration or amyloid deposition. Focal vasculitis may have occurred secondary to the homorrhagic lesion.     

Spontaneous rupture of a left gastroepiploic artery aneurysm in a patient with autosomal-dominant polycystic kidney disease

Autosomal-dominant polycystic kidney disease (ADPKD) has been known to be associated with a variety of vascular diseases. We present a hemodialysis patient with ADPKD who died of a massive intraperitoneal hemorrhage caused by the spontaneous rupture of a left gastroepiploic artery aneurysm. A 64-year-old male was admitted to our hospital with acute upper abdominal pain and hemorrhagic shock. An abdominal angiography showed three aneurysms and the source of hemorrhage was assumed to be the left gastroepiploic artery aneurysm. The patient died of severe metabolic acidosis and disseminated intravascular coagulation (DIC) on the second hospital day. At autopsy, there was massive bleeding into the abdominal cavity, and pathological examination of the left gastroepiploic artery aneurysm revealed a dissecting aneurysm. This is the first case describing a rupture of a gastroepiploic aneurysm in a patient with ADPKD.     

腹部手术后腹腔干分支假性动脉瘤消化道瘘的临床分析：附5例分析

目的:总结分析腹部手术后腹腔干分支假性动脉瘤消化道瘘导致的迟发性消化道大出血的诊断和治疗。方法:回顾性分析自2013年1月—2014年9月腹部肿瘤术后上消化道大出血经造影证实腹腔干分支假性动脉瘤消化道瘘的5例患者的临床资料。结果:5例患者消化道出血时间平均为术后53.6 d;假性动脉瘤位于脾动脉2例,位于肝总动脉2例,位于左肝动脉1例;造影后行栓塞治疗4例,行覆膜支架置入1例。无术后严重并发症及围手术死亡病例。随访时间6~16个月,无再次假性动脉瘤破裂出血,肝总动脉覆膜支架置入患者于8个月猝死,原因未明。结论:腹腔干分支假性动脉瘤消化道瘘是腹部手术后罕见而又致命的并发症,应提高该病的认识,其诊断及治疗首选动脉造影及血管腔内治疗,避免医源性损伤可能是减少该病发生的关键。     

Vascular complications of transurethral incision of post-traumatic urethral strictures

Retrograde or antegrade transurethral incision of urethral strictures that have formed after complete rupture of the membranous urethra has been advocated to restore urethral continuity. With this technique we encountered vascular complications in 2 patients, which consisted of opening of a patent vessel entrapped in the fibrous tissue of the stricture. The opened vein in 1 patient healed without bleeding. The opened artery in the other patient did not heal with catheter drainage and pressure dressings, resulting in recurrent severe hemorrhage that necessitated stage 1 urethroplasty with ligation of the artery. The entrapment of a patent vessel in fibrous scar tissue resulting from complete urethral rupture is believed to be responsible for these complications.     

Midaortic syndrome in childhood associated with a ruptured cerebral aneurysm: a case report

BACKGROUND: We present a patient with a midaortic syndrome who presented with subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm.CASE DESCRIPTION: A 14-year-old boy with midaortic syndrome was admitted to our hospital because of subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. He also developed acute renal failure due to previously controlled hypotension. After blood dialysis, successful clipping of the aneurysm was performed. The postoperative course was complicated by malignant renovascular hypertension due to midaortic syndrome. Medical treatment failed to control his hypertension; left primary nephrectomy improved his condition.CONCLUSION: Although midaortic syndrome is rare, it may be significant as a cause of cerebral hemorrhage in childhood.     

血管腔内支架植入术的临床应用

目的 评价应用血管内支架治疗血管性疾病的临床价值。方法 对36例患有血管性疾病的患者施行了血管内支架植入术，包括胸主动脉夹层动脉瘤24例，腹主动脉真性动脉瘤3例，腹主动脉夹层动脉瘤1例，颈动脉动静脉瘘1例，左锁骨下动脉狭窄1例，左锁骨下动静脉瘘1例，髂动脉假性动脉瘤4例及股动脉狭窄1例。除1例左锁骨下动脉狭窄患者、1例股动脉狭窄患者使用了裸支架外，其余34例患者均采用带膜支架进行血管内治疗。结果 术中所有患者均未出现特殊不适，术后随访期间未见明显合并症发生。所有患者均完全消除了临床症状。结论 应用血管内支架治疗血管性疾病是一种实用且效果较好的治疗方法。     

Spontaneous Iliac Vein Rupture: Case Report and Comprehensive Review of the Literature

Iliac vein rupture is a rare cause of retroperitoneal hemorrhage. It is occasionally lethal, with no clear precipitating factors. We report a case of spontaneous left common iliac vein rupture in a 56-year-old man with a history of deep vein thrombophlebitis (DVT). To date, 32 cases have been reported in the literature. The 32 existing cases and the case presented here were analyzed. A comparative review was performed for chief complaints, basic demographics, potential predisposing factors, treatment modalities, and outcomes. Possible etiological factors to explain this phenomenon were formulated. The patient presented with abdominal pain of 4 hr duration and a near-syncope episode. In the emergency room, he was found to be in hypovolemic shock that was responsive to crystalloids. An urgent exploratory laparotomy was performed for a suspected iliac artery rupture. An uncontrollable hemorrhage from a spontaneous posteromedial tear of the left common iliac vein resulted in intraoperative death. Interestingly, 85% of reported cases occurred in women with an overall average age of 60.6 ± 13.4 years; 94% of cases were left-sided; 79% reported clinical or histological evidence of DVT or thrombophlebitis; 94% were treated operatively, with a survival rate of 71%. Only one reported case was treated conservatively, with success, and one reported case of endovascular repair resulted in significant morbidity. Iliac vein rupture is an uncommon diagnosis associated with trauma and even rarer when it is spontaneous. We report the thirty-third documented case in the literature since 1961. There is a clear predominance in females and on the left side and a probable association with thrombophlebitis. Our calculated operative success may be overestimated due to a biased literature reporting of favorable outcomes.     

医源性肾动脉损伤性出血的介入诊疗

目的探讨超选择性动脉造影与栓塞治疗医源性肾动脉损伤性出血的临床价值。方法对11例肾穿刺活检或经皮肾镜取石术后大量肉眼血尿患者实施超选择性肾动脉造影与栓塞术,栓塞材料采用明胶海绵与弹簧圈。结果 11例中,假性动脉瘤2例,动-静脉瘘2例,假性动脉瘤合并动静脉瘘5例,动脉-肾盏瘘2例;损伤血管为肾脏后段、下段动脉及其叶间动脉分支,单支血管损伤10例,多支血管损伤1例。单纯采用明胶海绵栓塞4例,单纯采用弹簧圈栓塞4例,二者联合栓塞3例,其中1例为明胶海绵栓塞24h后复发尿血改用弹簧圈栓塞。栓塞后10min造影示出血征象消失,1~3天后患者血尿逐渐消失,未发生严重并发症。结论动静脉瘘为医源性肾动脉损伤的主要表现,以单发病变多见;超选择性动肾脉造影可迅速明确诊断,超选择性肾动脉栓塞微创、安全、有效,应作为治疗医源性肾动脉损伤性出血的首选方法。     

Unilateral middle cerebral artery stenosis in an adult with Down's syndrome--case report

A 29-year-old male with Down's syndrome presented with severe headache and vomiting. Computed tomography demonstrated subarachnoid hemorrhage. Left carotid angiography showed severe stenosis of the middle cerebral artery 2 cm distal to its origin, as well as abnormal hyper-vascularization near the stenosis site similar to that seen in moyamoya disease. Right carotid angiography showed no abnormalities. However, slight stenosis of the distal part of the bilateral vertebral arteries was noted. There was no aneurysm. We judged that the subarachnoid hemorrhage had been caused by rupture of the moyamoya-like vessel. Some patients with Down's syndrome have anatomical vascular abnormality and vascular fragility. The cerebral vascular abnormality found in this case may be part of the systemic vascular abnormalities associated with Down's syndrome. The vascular changes in some adult patients with Down's syndrome may be a sign of premature aging, and long-term studies with periodic vascular examination of patients with Down's syndrome need to be performed.     

Serial angiography and endovascular treatment of dissecting aneurysms of the anterior cerebral and vertebral arteries. Case report.

This 47-year-old man was admitted to the hospital with disturbance of consciousness due to subarachnoid hemorrhage caused by a ruptured dissecting aneurysm of the left anterior cerebral artery (ACA). Conservative treatment resulted in improvement in the patient's consciousness; however, repeated rupture occurred during the chronic stage. Endovascular coil embolization of the parent artery was successful. Serial angiography demonstrated all stages in the development of the aneurysm. Follow-up angiography demonstrated an incidental dissecting aneurysm of the right vertebral artery. This aneurysm was also treated by endovascular embolization. No new neurological deficit appeared during or after the treatment. Multiple dissecting aneurysms are rare, especially those involving both supra- and infratentorial regions. A ruptured dissecting aneurysm of the ACA is also an uncommon vascular disorder. This case shows that rebleeding may occur, even during the chronic stage, and thus appropriate treatment for the prevention of subsequent bleeding is essential. Incidental dissecting aneurysms can be treated using the endovascular technique, but further study is necessary.     

Dural arteriovenous malformation in the falx with subarachnoid hemorrhage

A case of falx dural arteriovenous malformation was reported. A 62 year old man was admitted to Nakamura City Hospital on August 15, 1989, with severe headache as his chief complaint. On admission, his consciousness was lethargic. CT scan showed subarachnoid hemorrhage with ventricular perforation and hematoma of the corpus callosum. Angiograms demonstrated a dural arteriovenous malformation (DAVM) in the frontal falx, which was fed by bilateral middle meningeal arteries and the left anterior falx artery and drained into the superior sagittal sinus via the dural vein. Bifrontal craniotomy was performed. At first, bilateral middle meningeal arteries were coagulated, and the frontoparietal dura was excised widely. Then, the falx was cut at the crista galli. The DAVM was found in the falx, including a vascular sac embedded in the brain tissue. The DAVM was coagulated as much as possible. Carotid angiograms revealed complete disappearance of the DAVM, 4 months after the operation. Although angiograms performed after only one month still showed a small residual DAVM. On reviewing the literature we found only 5 patients with the DAVM in the falx. In 6 cases including our own, intracranial hemorrhage occurred in 4 cases (3 cases were subarachnoid hemorrhage). Vascular sacs were seen in 4 cases, and drainage to the pial vein was noted in 3 cases. It seemed to be rare that the DAVM drained into the dural vein. In our particular case, operative findings showed the DAVM drained into the dural vein without the pial vein, and intracranial hemorrhage was attributed to rupture of the vascular sac.     

Angiographic demonstration of acute phase of intracranial arterial spasm following aneurysm rupture. Case report

A case documenting the acute phase of intracranial arterial spasm following rupture of an aneurysm arising from the left internal carotid artery is reported. The patient deteriorated due to recurrent hemorrhage while undergoing angiography 12 hours after the initial aneurysm rupture. The acute deterioration was accompanied by dilatation of the ipsilateral pupil and occurred during injection of contrast material. There was delayed filling of the middle cerebral artery complex along with this narrowing. The arterial narrowing was confirmed to have completely disappeared on an angiographic series performed 14 minutes after the first series of films. The etiology of the acute vasospasm is discussed.     

Splenic artery rupture in pancreatic pseudocyst

Hemorrhage is one of the most threatening complication of pancreatic pseudocyst. It results from erosion of adjacent vessels. Splenic, gastroduodenal, pancreaticoduodenal and middle colic vessels are predominantly involved. Hemorrhage may present different feature: intra and/or extraperitoneal collection, gastrointestinal bleeding. The authors report the rupture of splenic artery into pseudocyst, with the formation of pulsating pseudoaneurysm, increasing progressively until the final rupture. For the diagnosis the authors utilized: ultrasounds (US) which showed the cyst but not its nature and content; the CT scan which disclosed haematic contents; finally the US Color Doppler which proved the dynamic feature of hemorrhage. This technique allows to identify the arterious or venous source of bleeding and the possible presence of arteriovenous fistula. Arteriography was not performed due to circumstances, although it would permit bleeding vessel embolization and the control of hemorrhage. This procedure is not ever achievable, and doesn't exclude the possibility of rebleeding. On surgery, since the intraoperative rupture of the pseudoaneurysm occurred with severe hypovolemic shock, only a timely posterior mesogastric mobilization and the medially displacement of spleen-body-tail pancreatic complex, allowed to clamp the mass and the hemostasis. When such lesion are approached, it is mandatory to be prepared to carry on this maneuver: the severity of bleeding cannot allow intracystic ligature of bleeding vessel.     

Surgical management of papillary muscle rupture following acute myocardial infarction

Papillary muscle rupture is a rare but severe complication of acute myocardial infarction. Two cases successfully underwent mitral valve replacement and concomitant coronary artery bypass grafting (CABG) for acute myocardial infarction with the anterior papillary muscle rupture in cardiogenic shock. Each of them needed preoperative massive inotropic infusion, respiratory support and intraaortic balloon pumping assist. The first case was a 76-year-old female. Double vessel disease (seg 7 : 90%, seg 11 : 100%) was revealed by coronary angiography and rupture of the papillary muscle was confirmed by transesophageal echocardiography. The second case was a 69-year-old female. Double vessel disease (seg 2 : 90%, seg 11 : 100%) was revealed and severe mitral regurgitation due to prolapse of the anterior leaflet was confirmed by transthoracic echocardiography. To assess the diagnosis of postinfarction papillary muscle rupture, transthoracic and/or transesophageal echocardiography is mandatory. Coronary angiography is also desirable because concomitant myocardial revascularization may improve the prognosis.     

A case of acute subdural hematoma associated with convexity meningioma

A 61-year-old normotensive woman was admitted to our hospital with complaints of severe headache and nausea. She has had a limp due to the poliomyelitis in her childhood. Three days before admission, she had a headache without unconsciousness. On admission, she was almost alert. Her vital signs were normal. A mild monoparesis of the atrophic right lower extremity was evident. This impairment was due to her past poliomyelitis. There were no other motor palsy, sensory loss, nuchal rigidity, and papilledema. A plain CT scan showed a crescent high density zone adjacent to a round high density mass in the left convexity. A cerebral angiogram showed a vascular left temporoparietal mass supplied by a middle meningeal artery. A craniotomy was then immediately performed. The well encapsulated tumor was totally resected, and the adjacent subdural hematoma was also evacuated. Histologically, the tumor was transitional meningioma with areas containing thin-walled vessels and focal necrosis. Postoperative course was uneventful. The origin of hemorrhage in this case would seem to be the thin-walled blood vessel with loss of vessel support. The clinical significance and the mechanism of the hemorrhage from the meningioma were discussed.     

Unbranched-site aneurysm of intracranial internal carotid artery]

Most intracranial saccular aneurysms arise from the angle between a parent vessel and an arterial branch. Saccular aneurysms without relation to any arterial branch are rare. During the last 24 years, 210 patients with intracranial internal carotid artery (ICA) aneurysms were directly operated on at our institution. We found eight saccular aneurysms arising from intracranial ICA without relation to any arterial branch. So we call them unbranched-site aneurysms of intracranial ICA, and describe their unique characteristics. Of the eight cases with unbranched-site aneurysm of intracranial ICA, three were men and five were women. The age ranged from 31 to 61 years with an average age of 48. Seven cases suffered a subarachnoid hemorrhage due to ruptured unbranched-site aneurysm, and the other case had been admitted to our department because of accompanying ruptured left internal carotid-posterior communicating aneurysm. All cases of unbranched-site aneurysm presented intraoperative and/or angiographic findings of arteriosclerosis, and five of the patients had a past history of hypertension. Of the four unbranched-site aneurysms at the C2 portion of ICA, two arose from the lateral wall, one arose from the superior wall and the other arose from the infero-lateral wall of ICA. Of the four unbranched-site aneurysms at the C1 portion of ICA, three arose from the superior wall and the other arose from the supero-medial wall of ICA. Radical operation was performed in all cases and intraoperative rupture occurred in two cases. It was suggested that arteriosclerotic change in the arterial wall, and local hemodynamic stress played important roles in the development of unbranched-site aneurysms of intracranial ICA.