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PubMed1999

Structural fragility and inflammatory response of ruptured cerebral aneurysms. A comparative study between ruptured and unruptured cerebral aneurysms.

BACKGROUND AND PURPOSE: Despite technical advances in endovascular and microsurgical treatment, patients with aneurysmal subarachnoid hemorrhage still have a high mortality and morbidity rate. To improve the treatment results in patients with aneurysms, we must better understand the pathophysiology of cerebral aneurysms and the mechanisms leading to their rupture. Therefore, we studied the pathological differences between unruptured and ruptured aneurysms. METHODS: Ruptured (n=44) and unruptured (n=27) aneurysms were obtained at surgery. The aneurysmal endothelium was scored from 0 (normal) to 5 (complete disruption) by using a scanning electron microscope. The aneurysmal wall was evaluated by immunohistochemical methods. The wall structure was scored from 1 (dense collagen and rich, smooth muscle cells) to 5 (hyaline-like structure). The degree of inflammatory cell invasion into the wall was also scored from 0 (very few cells) to 3 (many cells). RESULTS: Ruptured aneurysms manifested significant endothelial damage (score of 3.7 versus 0.8; Mann-Whitney U test, P<10(-3)), significant structural changes of the wall (3.7 versus 1.7, P<10(-5)), and significant inflammatory cell invasion (2.2 versus 0.8, P<10(-4)) compared with unruptured aneurysms. There was a significant correlation between the score for wall structure and the score for inflammatory cell invasion (Rs=0. 63; Spearman rank correlation test, P<10(-5)). The pathophysiology of several symptomatic unruptured aneurysms was similar to that of ruptured aneurysms. CONCLUSIONS: We conclude that the pathophysiology of unruptured, asymptomatic and ruptured aneurysms is different. The wall of ruptured aneurysms was found to be fragile, possibly because macrophage infiltration into the aneurysmal wall resulted in loss of smooth muscle cells and in degradation of matrix proteins.

Aneurysm, Ruptured↗
PubMed2001

Case report: outer sheath rupture may precede complete chordal rupture in fibrotic mitral valve disease.

Rupture mechanics of mitral valve chordae have been difficult to elucidate because most surgical repairs and pathological examinations are performed after the rupture. In an excised anterior leaflet from a fibrotic mitral valve, chordae were observed in an initial phase of rupture. Microscopic sections showed that thinned, nearly ruptured chordal segments were actually chordal cores, containing highly aligned collagen fibers. The outer sheath of elastic fibers, disorganized circumferentially oriented collagen fibers, and endothelial cells that normally surrounds the collagen core apparently had retracted to the extreme ends of the thinned segment, resulting in a bulbous shape, as noted in the chordal rupture literature. In conclusion, these new observations lead us to propose that the rupture of mitral valve chordae is not spontaneous, but may occur over time. The failure of the outer sheath may represent the first phase in a slow, two-part process leading to eventual chordal rupture.

Chordae Tendineae↗
PubMed1985

Spontaneous contained transmural oesophageal rupture clinically resembling intramural rupture. A case report.

Spontaneous rupture of the oesophagus may occur either transmurally or intramurally. The symptoms, signs, clinical course, treatment and prognosis differ in the two types. Transmural rupture is generally regarded as a serious condition, usually requiring operative treatment and having a high morbidity and mortality. Intramural rupture is a much more benign condition, is treated non-operatively and has a good prognosis. A few cases have been documented in which a transmural rupture was contained within the mediastinum; an additional case is described. Under these circumstances the transmural rupture has the clinical features of an intramural rupture. It is suggested that transmural ruptures should be subdivided into those which are not contained (the vast majority) and those which are.

Diagnosis, Differential↗
PubMed1980

Traumatic splenic rupture during 30 years. An analysis of 88 cases with special attention to delayed rupture.

Eighty-eight cases of splenic rupture in non-penetrating abdominal injury are analysed. An increasing frequency was seen during the 30-year period studied (1946--1975). Teenagers and young adults were the most affected age groups. A rising incidence of traffic accidents amd multiple iinjuries was noted. Mortality was 21%. All patients with an isolated splenic rupture survived. The complication rate was low. The high incidence of delayed splenic rupture in earlier reports seems to be more a refleciton of the diagnostic diffulties than an actual delayed rupture. We have put the splenic ruptures into minor immediate, major immediate, and delayed. Minor splenic rupture was seen in 20% of patients undergoing operation, major in 75%, and delayed in only 5%. Three of our patients were operated on with splenorrhaphy with an uneventful postoperative course. In minor splenic ruptures, especially in young patients, splenorrhaphy could be a possible way of treatment but more controlled studies are needed before firm recommendations can be made.

Accidents, Traffic↗
PubMed1999

[Rupture of the pes anserinus superficialis and partial rupture of the patellar ligament. Rare concomitant injures in complex knee injuries].

We present a rare case of combined knee joint lesions in a 25 year old patient. Besides the commonly reported injuries of the knee joint due to directly applied valgus force, forceful quadriceps muscle contraction, external rotation at flexed knee causing combined lesions such as rupture of the anterior cruciate ligament, rupture of the posterior cruciate ligament and rupture of the medial collateral ligament, a rare combination of the above mentioned lesions and a rupture of the lateral meniscus, an osteochondral fracture of the lateral femur condylus, a rupture of the medial patellofemoral retinacula as well as a complete rupture of the superficial pes anserinus and a partial rupture of the patellar ligament was encountered.

Adult↗
PubMed1998

International multicenter term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature Rupture of the Membranes.

OBJECTIVE: Our objective was to determine significant predictors for the development of neonatal infection in infants born to patients with premature rupture of membranes at term. STUDY DESIGN: Multivariate analysis was used to determine the significant predictors of neonatal infection in infants born to women with premature rupture of the membranes who were enrolled in the Term PROM Study. In a randomized, controlled trial, the Term PROM Study recently compared induction of labor with expectant management for premature rupture of membranes at term. RESULTS: The following variables were identified as independent predictors of neonatal infection: clinical chorioamnionitis (odds ratio 5.89, P < .0001), positive maternal group B streptococcal status (vs negative or unknown, odds ratio 3.08, P < .0001), 7 to 8 vaginal digital examinations (vs 0 to 2, odds ratio 2.37, P = .04), 24 to < 48 hours from membrane rupture to active labor (vs < 12 hours, odds ratio 1.97, P = .02), > or = 48 hours from membrane rupture to active labor (vs < 12 hours, odds ratio 2.25, P = .01), and maternal antibiotics before delivery (odds ratio 1.63, P = .05). CONCLUSIONS: Among infants born to patients with premature rupture of membranes at term, clinical chorioamnionitis and maternal colonization with group B streptococci are the most important predictors of subsequent neonatal infection.

Adult↗
PubMed2000

Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site.

OBJECT: The authors describe the clinical, radiological, and pathological findings of ruptured cerebral aneurysms with irregular configurations. METHODS: Eight patients with subarachnoid hemorrhage due to ruptured irregularly shaped aneurysms were examined. The preoperative radiological findings in these cases were compared with the pathological and operative findings of endovascular or open surgery. All of the aneurysms exhibited delayed opacification and delayed washout of contrast medium from the irregularly shaped portion of the aneurysm on digital subtraction angiography and/or helical computerized tomography scanning. Endovascular embolization with platinum coils was attempted in the first four patients who underwent treatment. In three of these patients the aneurysm ruptured again during the endovascular procedure. In the fourth patient an intraaneurysm thrombus was observed during the procedure and clipping was performed. In the subsequent four patients, three underwent clipping without complication and one underwent partial aneurysm embolization because of poor general status. A thrombus adjacent to the aneurysm dome was observed in the patients who underwent open surgery. Pathological examination of the operative specimens revealed a pseudoaneurysm-like cavity in the thrombus that was adherent to the aneurysm. CONCLUSIONS: Ruptured irregularly shaped aneurysms may be accompanied by fragile pseudoaneurysm-like cavities located at the rupture point. Because these aneurysms have a high risk of repeated rupture during an endovascular procedure, advancing microinstruments to the weaker portion of the aneurysm should be avoided.

Adult↗
PubMed2002

[Rupture of previously documented asymptomatic unruptured aneurysms--aneurysm size: risk factor for aneurysm rupture].

The natural history of asymptomatic unruptured aneurysms is not clear. We conducted a follow up study of 100 patients (since 1993) with 122 asymptomatic unruptured aneurysms that had not been operated on. We report five patients with previously documented asymptomatic unruptured aneurysms smaller than 10 mm in diameter that subsequently ruptured. Among the 100 patients, five had suffered subarachnoid hemorrhage (SAH) due to rupturing of an aneurysm. Of the 5 cases, 1 was male and 4 were female, with ages ranging from 59-73 years (mean age, 68 years). The aneurysms were on the MCA in 3, on the BA-SCA in 1, on the IC-PC in 1. The maximal diameter of the aneurysms at diagnosis ranged from 4.5 to 8 mm. The period from discovery to SAH was from 4 to 69 months and the cumulative rate of rupture of the aneurysms was 1.5 percent per year. Four of the 5 cases increased in size after the rupture. In our series, 2 of the 5 cases showed enlargement and the development of an aneurysmal bleb in the follow up MRA and 3D-CTA. The present study demonstrates that five asymptomatic unruptured aneurysms less than 10 mm in diameter subsequently ruptured. We ought to seriously consider the assertion published in the New England Journal of Medicine (Dec. 10, 1998), that unruptured aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture.

Aged↗
PubMed2003

Subsequent rupture after clip on wrap method for ruptured dissecting aneurysm of the distal middle cerebral artery: a case report and review of the literature.

Dissecting aneurysms rarely occur in the middle cerebral artery (MCA). Furthermore, recurrent subarachnoid hemorrhage from ruptured dissecting aneurysms is rare with no published report of subsequent rupture after treatment by the clip on wrap method. The case reported is a 41-year-old man with subarachnoid hemorrhage. Angiography demonstrated aneurysm at the right M2 portion. We performed surgery to prevent rebleeding during the acute stage. Surgery revealed a discolored protrusion of the arterial wall of the lesion. The lesion was clipped on wrapping with Bemsheet. At one month postoperatively, angiography showed neither aneurysmal formation nor stenosis at the right M2, but after 5 months a subsequent rupture occurred. Angiography demonstrated pseudoaneurysm formation at the same portion of the right M2. The lesion was trapped with anastomosis of the superficial temporal artery (STA) to the MCA. He was discharged following a good recovery. The rate of subsequent rupture in ruptured dissecting aneurysm in the MCA is 14.3% in published papers. Acute surgery must be performed to prevent the risk of re-rupture. In our single case report, trapping was effective treatment.

Adult↗
PubMed2006

[Costs evaluation of operation treatment of ruptured and non-ruptured abdominal aortic aneurysm].

UNLABELLED: Abdominal aortic aneurysm operation, performed in the emergency mode, has a much larger mortality than the operation of the aneurysm in scheduled mode. The aim of this study is to compare the treatment costs of the aneurysm operated in the emergency mode and scheduled mode. MATERIAL AND METHODS. 125 patients with abdominal aortic aneurysm were take under consideration, 18 of whom were admitted because of the abdominal aortic aneurysm rupture, and 107 of them were admitted without the signs of rupture. From 107 patients admitted in the scheduled mode, 25 were not qualified to the operation because of: other coexisting illnesses (10), recent stroke (1), not agreeing to the surgical intervention (4) and 10 were observed because of the small diameter of the aneurysm and lack of pain. RESULTS: After receiving the costs from the accountants, we analyzed the costs of treatment in the ruptured and non-ruptured aortic aneurysms. CONCLUSIONS: The total cost of the treatment of ruptured abdominal aortic aneurysm is almost as twice higher as the treatment cost of non-ruptured abdominal aortic aneurysm.

Adult↗
PubMed1984

[Heart wall rupture in acute myocardial infarct. An autopsy study in comparison with infarcts without rupture].

Among 237 patients who died of acute myocardial infarction (4% of the 5,390 autopsies from 1975 to 1979) 43 cases (18%) with a rupture of the cardiac wall were found. These 43 cases of rupture were compared with 43 non-rupture cases of the same period. In difference to the non-rupture cases the average weight of the heart was smaller. Myocardial scars, additional basic diseases and a lung oedema were rarer; an extended region of the infarction and an anamnestically known chronic ischemic heart disease were observed significantly more frequently. In what respect these and other analysed factors are responsible for the rupture mechanism, cannot be clearly estimated. Apart from a continuing hypertension as well as a relatively smaller weight of the heart and the absence of myocardial scars the extension of the area of the infarction as well as the possible effect of granulocytic enzymes in the area of the infarction appear significant for the origin of a heart rupture.

Adult↗
PubMed1975

[Report on 21 uterine ruptures and the influence of single row uterotomy stitching on rupture prevention (author's transl)].

Wound closure by 1 row of interupted sutures provides optimal healing conditions. As a result scar tissue formation is cut down. This general surgical principle is valid in stitching an uterotomy as well. Increasing frequency of cesarian section could end up in a rising number of scar ruptures. This drawback for a subsequent pregnancy should be met by the single row technique. It was applied in 1434 women from 1962 to 1974. All of them had lower segment cesarian sections. Only 3 harmless ruptures occurred in this group. The clinical course of 12 scar ruptures after terraced uterotomy closure was less favourable. In 6 cases a pregnant uterus ruptured without previous operation. Clinical results are compared. This backs the technique practised. In 5 patients the ruptured uterus could be repaired in the same way as in cesarian section. Hysterectomy, however, was the usual treatment. The risk of rupture after classical cesarian section is lowered by the technique described. This applies to the surgical treatment of uterus duplex as well.

Cesarean Section↗
PubMed1995

Postinfarct cardiac free wall rupture: the relationship of rupture site to papillary muscle insertion.

The objective of this study was to examine for any relationship between the sites of papillary muscle insertion in left ventricular free wall (LVFW) and the site of LVFW rupture postinfarct. Twenty-five consecutive patients with LVFW rupture (12 men and 13 women, mean age 72.3 yr, range = 48 to 93) at the University of Ottawa Heart Institute during the period of July 1, 1988 to 1992 were studied. Clinical charts were reviewed, and the Formalin-fixed hearts were re-examined grossly and microscopically. Each patient died of tamponade or after surgery for tamponade. Eight (32%) of the 25 infarcts were anteroseptal or anterior, 11 of 25 (44%) were lateral, and 6 of 25 (24%) were inferior or inferoseptal. Four (16%) of the 25 infarcts were less than 2 days old, 9 of 25 (36%) were 2 to 5 days old, and 12 of 25 (48%) were 5 to 10 days old. A separate pre-existent and healed infarct was noted in 36% of patients; however, rupture adjacent to these areas of old infarct occurred in only 8% of cases. In 15 of 25 (60%) cases, free wall rupture occurred in the lateral wall between and at the level of the two papillary muscles. In a further 5 of 25 (20%) cases, the rupture was beside one of the papillary muscles but in anterior or posterior walls. In 20 of 25 (80%) cases, the endocardial tear associated with the LVFW rupture was within 1 cm of the base of one of the papillary muscles as they inserted in LVFW.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1996

[Partial rupture progressing to complete rupture of the left ventricular anterior papillary muscle after acute myocardial infarction: a case report].

A 71-year old man presented with partial rupture progressing to complete rupture of the left ventricular anterior papillary muscle after acute anterolateral myocardial infarction. The progressive rupture was demonstrated by transthoracic and transesophageal echocardiography. Transthoracic echocardiography showed exaggerated systolic prolapse of the anterior mitral leaflet with grade III mitral regurgitation and partial disruption of the anterolateral papillary muscle, but transesophageal echocardiography during surgery disclosed the progression of the partial rupture to complete rupture. The flail anterior mitral leaflet with severe mitral regurgitation and the head of the ruptured papillary muscle into the left atrium in systole were confirmed. The patient was treated by coronary artery bypass grafting and mitral valve prosthesis using a St. Jude Medical valve with good outcome.

Aged↗
PubMed1997

The rupture type determines the outcome for ruptured abdominal aortic aneurysm patients.

BACKGROUND: The treatment of patients with ruptured abdominal aortic aneurysm (RAAA) poses a significant surgical challenge. To achieve improvement in survival, factors influencing case fatality must be identified and modified. The aim of the present survey was to determine the contribution of preoperative, perioperative and postoperative events in predicting the mortality among AAA patients undergoing an emergency operation. MATERIAL AND METHODS: Fifty-one consecutive patients with ruptured infrarenal abdominal aortic aneurysm and twenty-six patients with 'expanding symptomatic aneurysms' (EAAA) were reviewed retrospectively to determine the relative contributions of preoperative, perioperative and postoperative factors on mortality. RESULTS AND CONCLUSIONS: The 30-day mortality was 47% in the RAAA group and 12% in the EAAA group. The rupture type was the main predictor of the outcome for the RAAA patients, the mortalities being 88% and 29% among patients with free (n = 16) and contained (n = 35) ruptures, respectively. In conclusion, the best way of avoiding poor results in cases of emergency aneurysm repair is to aim at elective operations. After the rupture, the clinical course is mainly determined by the rupture type, which is unfortunately beyond the surgeon's control. Surgical expertise and the avoidance of technical error can significantly affect the survival.

Adult↗
PubMed1981

Blunt traumatic rupture of the heart. Successful repair of simultaneous rupture of the right atrium and left ventricle.

A case is reported of a 48-year-old man who sustained simultaneous rupture of the right atrium and left ventricle following blunt trauma in a motor vehicle accident. Rupture of one or more cardiac chambers in blunt cardiac trauma is not uncommon. However, survival to reach the hospital is rare. The clinical features of cardiac rupture are those of pericardial tamponade or hemorrhage, depending on whether or not the pericardium is intact. Successful management of cardiac rupture in the few reported survivors has depended on a high index of suspicion when signs of tamponade occur after blunt injury. Prompt exploration is essential, as few patients survive longer than 60 minutes after injury. Ready availability of cardiopulmonary bypass is emphasized. Atrial rupture can be managed without bypass, but left ventricular rupture, as in this case, would seem impossible to repair without it.

Accidents, Traffic↗
PubMed2000

Bladder rupture associated with uterine rupture. A report of two cases occurring during vaginal birth after cesarean.

BACKGROUND: Uterine rupture occurs in < 1% of patients undergoing a trial of labor after cesarean section. Associated injury to adjacent organs within the maternal pelvis has likewise been very rarely reported. CASE: Two cases of posterior bladder wall rupture occurred in association with rupture of low transverse uterine incisions. CONCLUSION: Bladder rupture may be associated with uterine rupture during attempted vaginal birth after cesarean. The potential for bladder injury should be included in the patient's antepartum counseling.

Adult↗
PubMed1998

A rare case of spontaneous esophageal rupture (Boerhaave's syndrome) associated with pulmonary rupture.

Spontaneous esophageal rupture (Boerhaave's Syndrome) is a life-threatening condition that requires early diagnosis and effective treatment. The authors describe a rare case of spontaneous rupture of the esophagus associated with pulmonary rupture in a 54-year-old man. The anatomical basis for the occurrence of a spontaneous esophageal rupture associated with pulmonary rupture is discussed.

Esophageal Diseases↗