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.     

Multiple intracranial aneurysms in sickle cell anemia. Report of two cases

Neurological complications of sickle cell anemia occur in 18% to 29% of patients with homozygous hemoglobin S disease. A review of the literature yielded reports of two cases, both treated conservatively, of multiple intracranial aneurysms occurring in patients with sickle cell anemia. The authors report two cases of subarachnoid hemorrhage secondary to multiple intracranial aneurysms in patients with sickle cell anemia. One of the two patients underwent three craniotomies for ablation of six intracranial aneurysms. The techniques used in the treatment of these patients are presented.     

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.     

颅内多发动脉瘤的显微手术治疗

目的 总结颅内多发动脉瘤显微手术的经验。方法 回顾性分析8例17个颅内动脉瘤的临床资料。结果 对患者随访半个月-10年,按Sundt的随访结果评定标准评定：5例满意,2例好转,1例死亡（为双侧后交通动脉瘤术后1周）。结论 颅内多发性动脉瘤可尽早一期手术,特别是双侧动脉瘤患者,采用冠状切口双侧翼点入路,先夹闭容易出血侧的动脉瘤,再夹闭另外一侧为宜。此入路具有创伤小、暴露好,省时省力等优点。     

Surgical treatment of multiple intracranial aneurysms

Summary Patients with multiple intracranial aneurysms present a great challenge to neurosurgical practice. The presence of one or more additional aneurysms, whether recognized or unrecognized, along with the source of the haemorrhage profoundly changes the outcome. It also alters the timing and strategy of surgery. In this study the experiences gained from 138 cases with a total of 317 aneurysms are discussed. The analysis of the clinical data, our results and the factors influencing the outcome suggest that the risk of clipping all aneurysms simultaneously are less than the risk of a rebleed from an untreated, previously silent sac even in the early postoperative period.     

颅内多发动脉瘤的手术治疗

目的 探讨颅内多发动脉瘤的手术策略并分析临床疗效.方法 回顾性分析2009年1月至2013年12月手术治疗49例颅内多发动脉瘤患者的临床资料.49例患者中,男性12例,女性37例;平均年龄(49±11)岁;35例动脉瘤破裂,14例未破裂;治疗策略有一期手术(一侧入路夹闭所有动脉瘤),二期治疗(分期处理所有动脉瘤)和部分治疗(只处理责任动脉瘤).随访中复查脑CT血管造影(CTA)或数字减影血管造影(DSA),用格拉斯哥预后量表(GOS)评估预后.结果 一期手术32例(65.3％),二期治疗9例(18.4％),部分治疗8例(16.3％).47例随访4 ～ 49个月,平均(22 ±7)个月.术后CTA或DSA均未见动脉瘤复发.根据GOS评分,患者预后良好(4～5分)41例(83.7％),残疾(2～3分)6例(12.2％),死亡(1分)2例(4.1％).结论 在具有娴熟手术技术的前提下选择合适的患者,根据动脉瘤和患者的特征制定个性化的手术策略,能提高颅内多发动脉瘤的手术疗效.     

Management of giant intracranial aneurysms

Summary Based on an own material of 64 cases a survey is given on the management of giant intracranial aneurysms.Essential investigations are as well CT and Magnetic Resonance Scanning as detailed angiographic studies.With regard to the operative handling the following questions are discussed: approach; use of temporary vascular occlusion and related monitoring; preparation of the aneurysm neck for occlusion.In cases without recent subarachnoid haemorrhage morbidity and mortality were less than 10%. It was 15% in cases where recent haemorrhage had occurred.Invited Lecture, presented at the European Congress of Neurosurgery, Moscow, June 23–29, 1991.     

Perioperative considerations for patients with sickle cell disease: a narrative review

Purpose

Approximately 200,000 individuals worldwide are born annually with sickle cell disease (SCD). Regions with the highest rates of SCD include Africa, the Mediterranean, and Asia, where its prevalence is estimated to be 2-6% of the population. An estimated 70,000-100,000 people in the United States have SCD. Due to enhanced newborn screening, a better understanding of this disease, and more aggressive therapy, many sickle cell patients survive into their adult years and present more frequently for surgery.

Source

The authors identified relevant medical literature by searching PubMed, MEDLINE®, EMBASE?, Scopus?, Web of Science, and Google Scholar databases for English language publications appearing from 1972-September 2016. Case reports, abstracts, review articles, and original research articles were reviewed—with particular focus on the pathophysiology and medical management of SCD and any anesthesia-related issues.

Principal findings

Perioperative physicians should be familiar with the triggers of a sickle cell crisis and vaso-occlusive disease. Sickle cell disease affects various organ systems, including the central nervous, cardiovascular, pulmonary, genitourinary, and musculoskeletal systems. Preoperative assessment should focus on end-organ dysfunction. Controversy continues regarding if and when sickle cell patients should receive transfusions and which anesthetic technique (regional or general) confers any benefits. Timely, appropriate, and sufficient analgesia is critical, especially when patients experience a vaso-occlusive crisis, acute chest syndrome, or acute postoperative pain.

Conclusion

Effective management of SCD patients in the perioperative setting requires familiarity with the epidemiology, pathophysiology, clinical manifestations, and treatment of SCD.

     

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.     

Alkaptonuric ochronosis and multiple intracranial aneurysms

Alkaptonuric ochronosis is a heritable disorder of tyrosine metabolism, with various systemic abnormalities related to pigment deposition and degeneration of collagen and other tissues, including the heart and aorta, though no cerebrovascular abnormalities have been reported. The authors report a patient with alkaptonuric ochronosis and multiple intracranial aneurysms presenting with subarachnoid hemorrhage. The ruptured aneurysm was surgically treated, with a satisfactory outcome. In view of the well-known association of other connective tissue disorders with intracranial aneurysms, a potentially causal relationship is suggested between cerebral aneurysms and alkaptonuric ochronosis.     

An unusual case of multiple intracranial aneurysms

Summary A 49-year-old female patient with six intracranial aneurysms, all of which were treated successfully by direct surgery, is reported. She had a major subarachnoid haemorrhage 10 years ago. Because of difficulty in identifying the offending aneurysm she was not surgically treated at that time. The natural progression of intracranial aneurysms, the problem of identifying the lesion in a patient with multiple aneurysms, and an example of excellent recovery of visual function following surgical treatment are discussed.     

A case of multiple mycotic intracranial aneurysms

A patient with multiple mycotic aneurysms associated with infective endocarditis is reported. A 45-year-old man was admitted on February 16, 2001 under the diagnosis of infective endocarditis. After alpha-streptococcus was identified by a blood culture, he was treated with high doses of antibiotics. However, 2 weeks after admission, he suddenly suffered from headache and mild left hemiparesis. A CT showed a parenchymal hematoma in the right parietal lobe. Cerebral angiography demonstrated aneurysms of the bilateral middle cerebral artery and the left posterior cerebral artery. At first, we trapped and resected the ruptured right middle cerebral aneurysm. After the surgery, we tried to treat two unruptured aneurysms by endovascular treatment. During the provocation test for the posterior cerebral artery, the arterial wall was perforated by a guide wire. The parent artery was occluded by coils at this site. Although the aneurysm was still filled by retrograde blood flow, it finally disappeared six months after treatment. The left middle cerebral artery aneurysm could not be treated because the provocation test showed cognitive deficits. The patient recovered from infective endocarditis after four-months of antibiotic therapy; and the unruptured aneurysm had not changed in size for 11 months. Recently, the outcome of patients with intracranial mycotic aneurysm is improved by development of multimodality management. Especially, endovascular therapy may become an effective treatment for unruptured aneurysms, but it is necessary to take risks, such as arterial perforation into consideration.     

Tuberous sclerosis and multiple intracranial aneurysms: case report

A 6-year-old girl with tuberous sclerosis was found to have multiple intracranial fusiform arterial aneurysms. This represents the fifth reported case of this association. The concepts of an arterial dysplasia being present in cases of tuberous sclerosis and of developmental defects being the cause of some intracranial aneurysms are discussed. The need for a prospective study to assess the prevalence of intracranial aneurysms in patients with tuberous sclerosis is suggested.     

Association of persistent hypoglossal artery, multiple intracranial aneurysms, and polycystic disease

A case of multiple intracranial aneurysms associated with a persistent hypoglossal artery and polycystic disease of the liver and kidneys is reported. The persistent hypoglossal artery was seen on the right side, and the left vertebral artery was hypoplastic. There were three aneurysms, each of which was located on bifurcations of right and left middle cerebral artery, and basilar artery. They were successfully treated by direct approach.     

Moyamoya disease associated with intracranial aneurysms

A case of moyamoya disease associated with multiple intracranial aneurysms is reported. The aneurysms were located at the bifurcation of the basilar artery and at the precommunicating segment of the right posterior-cerebral artery. They were found to be unruptured and clipped successfully through a right frontotemporal craniotomy. Outcome of the operation was satisfactory. We propose the operative indication for these cases on the basis of operative and radiological findings, and also discuss characteristic aspects of this disease.