Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options

Vertebral artery dissection has been recognized as an uncommon cause of ischemic stroke. However, it is less well known as a cause of subarachnoid hemorrhage. Even if dissecting aneurysms of the vertebral artery are rare, their importance arise from their high morbidity and mortality with rebleeding occurring more often than in cases of saccular aneurysms. Dissecting aneurysms of the vertebrobasilar system are a complex entity which requires a rapid and effective treatment to prevent rerupture. The sole stenting technique stands as a promising approach, allowing to occlude the aneurysm while preserving the vessel patency and reconstructing the diseased segment.     

Repair process in spontaneous intradural dissecting aneurysms in children: report of eight patients and review of the literature

Objective  The objective of this study is to present a series of eight pediatric patients (less than 16 years old) with complete spontaneous thrombosis of spontaneous intradural dissecting aneurysms. Material and methods  Since 1989, eight consecutive patients in whom the cerebral aneurysms (four in middle cerebral arteries, one in posterior cerebral artery, three in basilar arteries) were found complete spontaneous thrombosis on follow-up MRI/MRA or conventional angiography. Patient histories and angiographic features were retrospectively reviewed. Results  Complete thrombosis of aneurysms in between first few days to 7 months was found in eight out of 1,587 patients (0.5%) in this recent series. Aneurysm repair was related to multivariate processes. Headache (50%), vomiting, and hemiplegia (37.5%) were common presenting symptoms. Partial or total resolution of the symptoms in a few months was often seen. Associated parent artery occlusions (50%) were also observed. Conclusion  Spontaneous resolution of intradural dissecting aneurysm with or without parent artery occlusion is not uncommon even in the pediatric population. Aneurysm repair is a dynamic and multifaceted entity. Mural hematoma appears to be the most important factor promoting thrombosis and healing of the dissecting intracranial aneurysms.     

Progression of occluded internal carotid artery dissection to giant compressive pseudoaneurysm following gunshot wound

Pseudoaneurysm formation following gunshot wounds is associated with significant morbidity. The natural history and optimal follow-up strategy for penetrating injuries causing dissection remains poorly understood. We report a case of a giant compressive pseudoaneurysm that developed following recanalization of an occlusive internal carotid artery dissection sustained from a gunshot wound. This was detected on routine follow-up imaging six weeks later. The patient subacutely developed dysphagia and hoarseness initially felt to be caused by delayed injury to the laryngeal nerve because computed tomography angiography demonstrated no new pathology. The pseudoaneurysm was successfully treated using a covered stent graft. This case highlights the importance of close angiographic follow-up even in the setting of initial complete vessel occlusion, and the need for a high suspicion for pseudoaneurysm development in the setting of new compressive or neurologic symptoms in patients with potential vascular injury from gunshot wounds to the neck.     

复杂主动脉病变的腔内治疗和杂交手术

目的：总结复杂主动脉病变腔内治疗和杂交手术的疗效和近中期结果。方法：回顾性分析2003年4月—2012年12月间收治的53例复杂主动脉病变患者的临床资料，其中男39例，女14例；年龄31~82岁，平均55岁；主动脉夹层35例，主动脉弓动脉瘤2例，腹主动脉瘤16例；其中5例合并髂动脉瘤。分别采用不同的腔内技术和/或杂交手术治疗。结果：全组患者手术技术成功率100%。术中即刻发生I型内漏8例，2例在其近端加一Cuff后内漏消失，其他患者未作特殊处理。随访1~72个月，平均20.2个月，无移植物移位及器官缺血。随访患者中无I型内漏发生，发生II型内漏2例，未行特殊处理，后自愈；无截瘫病例；1例高龄腹主动脉瘤患者术后1个月死于痰堵塞导致的窒息。结论：腔内治疗和杂交手术治疗复杂主动脉病变具有较好的近、中期疗效，远期疗效有待进一步评估。

     

血管腔内修复术治疗主动脉夹层动脉瘤

目的 探讨血管腔内修复术治疗主动脉夹层动脉瘤的手术指征，术前评估方法、手术操作技巧、并发症防治原则及临床应用前景。方法 对26例行Stanford-B型主动脉夹层动脉瘤腔内修复术患者的临床资料进行分析。全组均为Stanford-B型，其中4例在不同部位有2个以上裂口，术前采用CT血管造影（CTA）或数字减影（DSA）时主动脉夹层动脉瘤进行评估全组均以带膜支架型人工血管在DSA下行腔内修复术。结果 带膜支架型人工血管成功值入26例（100%）术后随访1-18月，无并发症，无内漏，夹层消失。结论 血管腔内修复术治疗Stanford-B型夹层动脉瘤是一种创伤小、恢复快、安全而有效的方法。     

Group B streptococcal endocarditis in a neonate

Summary This is a case of bacterial endocarditis and dissecting aneurysm of the ascending aorta secondary to group B streptococcal (GBS) septicemia in a one-month-old infant girl who presented with meningitis. A large aortic vegetation and a large dissecting aneurysm of the root of the aorta were detected by two-dimensional (2D) echocardiography. Apparently the infant did not have any preexisting cardiac anomaly. She received intravenous ampicillin for six weeks. She also underwent successful surgery for the replacement of the ascending aorta with an aortic homograft. This occurrence reemphasizes the value of 2D echocardiography in detecting vegetations for endocarditis.     

Repeat angiography and magnetic resonance imaging (MRI) of dissecting aneurysms of the intracranial vertebral artery

Summary We here present 4 cases with dissecting aneurysm (DA) of the intracranial vertebral artery, who were followed up by repeat cerebral angiography and MRI. The patients consisted of 2 males and 2 females, and the mean age was 43 years. Two cases were associated with polyarteritis nodosa (PN) and hypertension, respectively. Three of the cases developed subarachnoid haemorrhage (SAH), while the other one suffered from lateral medullary syndrome.In cerebral angiography, pearl and string signs were revealed in all cases, while a double lumen indicating a true diagnostic sign of DA was demonstrated in only one case. Repeat angiography showed that a bleb formation with a bulging of the aneurysmal sac was seen in 2 cases, and an irregularity of the wall in one case. On the other hand in one case, the ectatic part shrank, while the stenotic part was restored.In magnetic resonance imaging (MRI), a hyperintensity mass on T 1-weighted image (T 1-WI) adjacent to flow void suggesting either an intramural haematoma or a linear shape hyperintensity on T1-WI were demonstrated in 3 cases. In the follow up MRI done in 2 cases, a serial change in the intensity from iso-intensity to hyperintensity on T 1-WI was observed in one case suggesting intramural haemorrhage, while an enlargement of the ectatic flow void was seen in the other case.Three of 4 cases were operated on by trapping of the aneurysms. One, who had systemic vascular diseases due to PN, and repeat angiography showed a regression of the aneurysm, was conservatively treated. The outcome was excellent in the 3 surgical cases, whilst the one medically treated case was also excellent without any rebleeding.In conclusion, repeat neuro-imaging procedures are strongly recommended to clarify the possibility of a spontaneous repair of the dissection, and to consider the surgical strategy for the lesion.     

Isolierte spontane Koronararterien-Dissektion

Summary A complete review of the literature on the disease entity isolated spontaneous coronary artery dissection (72 ascertained cases with our own three) is given. The emphasis is placed on differential diagnosis of coronary heart disease, particularly in young patients without typical atherosclerotic risk factors. Isolated spontaneous coronary artery dissection is defined as a spontaneously dissecting hematoma limited to one or more coronary arteries. Women are involved considerably more frequently than men (84% of cases). Mean age at onset of the disease is 41 years (range: 21–70 years). The main site of involvement is the left coronary artery (79% of cases). In one-third of the female patients there is a temporal relationship to pregnancy (peripartum coronary artery dissection). Three types can be differentiated by coronary arteriography. Less than one-third of the patients survive the first 24 h after acute onset of symptoms; attempts at emergency reperfusion of the ischemic myocardium by aortocoronary bypass surgery or thrombolytic therapy have not been successful.

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Abkürzungsverzeichnis ISKD isolierte spontane Koronararterien-Dissektion - RIA Ramus interventricularis anterior - i.c. intrakoronar - LH linkskoronarer Hauptstamm - R rechte Koronararterie - L Lumen - DK Dissektionskanal     

主动脉夹层动脉瘤的CT诊断

目的 讨论螺旋CT对主动脉夹层动脉瘤的诊断准确率及对临床的价值。方法 对11例病人进行CT平扫,其中9例进行CT增强扫描,原始图像在工作站进行MPR图像重建。结果 CT平扫可显示主动脉增宽,主动脉壁的钙化,CT增强扫描及重建可清晰地显示主动脉夹层动脉瘤的内膜瓣的撕裂的形态,动脉瘤的真假腔的形态及大小,内膜瓣的钙化和移位,部分可见破裂口的位置及大小。结论螺旋CT的平扫和增强扫描是诊断主动脉夹层动脉瘤的首选和可靠的检查手段。并且能为外科手术提供更多的信息。     

破裂出血的椎动脉夹层动脉瘤早期血管内治疗经验

目的 探讨早期血管内介入等综合方法 治疗破裂出血的椎动脉夹层动脉瘤的临床效果.方法 根据椎动脉夹层动脉瘤形态选用不同方法 共治疗14例,其中支架辅助弹簧圈技术治疗6例,双支架治疗4例,动脉瘤及载瘤动脉闭塞治疗4例.术后尽早将血性脑脊液排出,同时防治血管痉挛.结果 术中无栓塞及动脉瘤破裂等并发症.除1例Hunt-Hess Ⅴ级患者死亡外,其余13例均恢复良好.平均随访16个月,无再出血.影像随访13例,支架辅助弹簧圈治疗者仅有1例部分再通;2例双支架治疗患者原扩张已消失,另2例扩张部分明显变小.3例动脉瘤及载瘤动脉闭塞无再通.结论 早期血管内介入治疗破裂出血的椎动脉夹层动脉瘤是安全有效的.根据夹层动脉瘤不同的形态特征,可以选择不同的方法 .