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PubMed2006

Aortic aneurysm, thoracoabdominal aneurysm, juxtarenal aneurysm, fenestrated endografts, branched endografts, and endovascular aneurysm repair.

The development of endovascular devices to treat aneurysms that abut or involve the visceral vessels has occurred in an effort to reduce the significant procedural morbidity and mortality associated with conventional repair. To accomplish this, three systems have been trialed. The first technique was developed to treat juxtarenal aneurysms and involves the placement of customized fenestrations strategically placed within the fabric of the graft. These are aligned with the ostia of the visceral vessels incorporated by the repair and supplemented by the placement of a balloon expandable stent. In a similar fashion, aneurysms that involve the visceral vessels can be treated with a fenestrated graft where the fenestration is reinforced with a nitinol ring. This is then mated with a balloon-expandable stentgraft, allowing the devices to seal at the level of the nitinol ring. An alternative means of incorporating the visceral vessels is to use directional branches where one or more additional limbs (typically 8 mm) are anastomosed to the aortic graft, through which access into the visceral vessel is attained. Mating stentgrafts for the later design can be of a self-expanding or balloon expandable nature. The experience with fenestrated devices is mature and associated with a low perioperative mortality (<2%) without many long-term complications. The treatment of thoracoabdominal aneurysms with branches has provided us with optimism regarding the technique, but results are only short term in nature. Further device development is ongoing and dissemination of this technology is now occurring in Europe, Australia and Canada.

Aneurysm↗
PubMed2006

Epidemiology of the size distribution of intracranial bifurcation aneurysms: smaller size of distal aneurysms and increasing size of unruptured aneurysms with age.

OBJECTIVE: To explore the epidemiology of the size distribution of intracranial bifurcation aneurysms at different locations and to specifically test the hypothesis that distal vessels develop, on average, smaller aneurysms. METHODS: A database detailing all aneurysm cases admitted to Massachusetts General Hospital from 1991 to 2003 was reviewed. Aneurysms were classified by location and size. The distribution of aneurysms by sizes at differing origin sites was then compared. RESULTS: We identified 1673 aneurysms for study; 854 were ruptured and 819 were unruptured; 58 lesions were classified as distal middle cerebral artery and anterior cerebral artery, of which 26 were unruptured and 32 were ruptured. Analysis of the kernel density estimates for the distribution of aneurysm sizes revealed that aneurysms at distal locations and the posterior-inferior cerebellar artery location were smaller than those at other locations in the circle of Willis. The mean size of ruptured distal aneurysms at 5.7 mm (95% confidence interval 4.8-6.5), or ruptured posterior-inferior cerebellar artery aneurysms at 7.1 mm (95% confidence interval 6.3-7.8) was smaller than the average size for basilar, middle cerebral artery, or ICA aneurysms occurring proximally in the Circle of Willis. The decrease in the mean size of the distal lesions is caused by a relative paucity of aneurysms above 10 mm in size. Although ruptured aneurysms showed no change in size with age, unruptured lesions at most intracranial locations increased in size with age. CONCLUSION: The distribution of aneurysm sizes differs according to location in the intracranial vasculature in this single institution series. Smaller aneurysm sizes are observed for "distal" aneurysms than at other locations in the Circle of Willis. We hypothesize that this may be related to Laplace's Law, which states that the "critical" size for aneurysm rupture is related to the parent artery wall thickness. The larger size of unruptured aneurysms in older patients in this study may reflect referral bias or a biological model in which a subset of smaller "unstable" aneurysms are prone to rupture. Because distal aneurysms present at smaller sizes compared with aneurysms originating proximally on the Circle of Willis, prospective studies that focus on the rupture risk of this subset of intracranial aneurysms are appropriate for future investigation.

Age Factors↗
PubMed2002

Evaluation of the stability of aneurysms after embolization using detachable coils: correlation between stability of aneurysms and embolized volume of aneurysms.

BACKGROUND AND PURPOSE: The long-term outcome of aneurysmal coil embolization has not been determined. We retrospectively analyzed the results of our cases treated with detachable coils and evaluated the long-term stability of embolized aneurysms. METHODS: This study involved 100 aneurysms in 93 patients who underwent follow-up angiography > or = 3 months after initial treatment between December 1993 and December 1999. The percentage of the coil volume occupying the aneurysm lumen (embolized volume) was used as an index to evaluate the stability of embolized aneurysms. The reliability of the embolized volume was also evaluated by comparing angiographic percentage occlusion. RESULTS: Follow-up angiographic assessment was conducted 12 +/- 8.5 months after initial treatment. Angiographic evaluation of percentage occlusion at initial treatment did not always predict long-term stability of embolized aneurysms. Of 49 aneurysms judged as being totally occluded at initial treatment, 44 remained unchanged and five showed recanalization. The embolized volume of unchanged aneurysms was 30.8 +/- 10.2%, and that of recanalized aneurysms was 19.9 +/- 10.6%. There was a significant difference between these two groups (P=.03). Of 29 subtotally occluded aneurysms, nine had further thrombosis (embolized volume = 31.8 +/- 12.7%), nine remained unchanged (embolized volume = 23.2 +/- 10.3%), and 11 had recanalization (embolized volume = 14.1 +/- 6.1%). The mean embolized volume of 11 recanalized aneurysms was significantly lower than in the thrombosed group and the unchanged group (P=.002 and P <.001, respectively). Large aneurysms tended to have recanalization more frequently (59%) than did small aneurysms (15%). CONCLUSION: There is a significant correlation between embolized volume and stability of embolized aneurysms. Embolized volume is a more objective index than is subjectively angiographic percentage occlusion. In addition to angiographic assessment, measurement of embolized volume could be useful to predict angiographic changes of aneurysms.

Adult↗
PubMed1993

De novo aneurysm formation and aneurysm growth following therapeutic carotid occlusion for intracranial internal carotid artery (ICA) aneurysms.

We herein report the long term results of 27 intracranial internal carotid artery (ICA) aneurysms treated by indirect surgery such as a trapping of the aneurysm or carotid ligation either with or without EC-IC bypass. These patients were then followed for a mean period of 10 years. Seventy-four percent of the aneurysms were categorized as either being giant or large. Late complications were observed in 7 patients. A rupture of newly formed aneurysms at the anterior communicating artery occurred in 2 cases 8 or 9 years after either trapping or performing a ICA ligation, respectively. In these patients, previous angiography could not reveal any abnormalities at the anterior communicating artery. A rupture of a contralateral ICA aneurysm was seen in a patient whose ipsilateral ICA was ligated for a ICA aneurysm 22 years previously. An enlargement of the contralateral giant cavernous ICA aneurysm became symptomatic 6 years after a partial ligation of the ICA combined with an EC-IC bypass for a giant cavernous carotid artery aneurysm on the other side. Two cases of sudden death occurred in a young patient and an elderly patient with a small anterior communicating artery aneurysm, 9 and 19 years respectively, after trapping of the ICA aneurysms, although the cause could not be definitely ascertained. Rebleeding occurred in one patient who died 8 years after a carotid ligation and a partial clipping of the ICA aneurysm. Haemodynamic stress may therefore play a major role in inducing new aneurysms or growing aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid Artery Diseases↗
PubMed2004

Intracranial pseudoaneurysm due to rupture of a saccular aneurysm mimicking a large partially thrombosed aneurysm ("ghost aneurysm"): radiological findings and therapeutic implications in two cases.

Intracranial pseudoaneurysm formation due to ruptured non-traumatic saccular aneurysm is extremely rare. We experienced two cases of large pseudoaneurysm formation due to rupture of a saccular aneurysm. The neuroradiological ghost-like appearance of the aneurysms led to misdiagnoses as large partially thrombosed aneurysm. Two cases of large intracranial pseudoaneurysm formation due to rupture of a saccular aneurysm occurred in a 77-year-old comatose woman with an aneurysm on the anterior wall of the internal carotid artery and a 73-year-old comatose woman with an anterior cerebral artery (azygos) aneurysm. Both patients suffered subarachnoid hemorrhage associated with intracerebral and intraventricular hematomas. Angiography showed peculiar "ghost-like" appearance of the aneurysm including delayed filling, changing shape, retention of the contrast material after the venous phase, and unclear location of neck. Neck clipping surgeries were performed, but were difficult because of the preoperative misdiagnosis as large partially thrombosed aneurysm. The entity of "ghost aneurysm" caused by rupture of a saccular aneurysm should be considered in the clinical diagnosis.

Aged↗
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↗
PubMed1997

[A case report of primary repair for thoracic and thoracoabdominal and iliac artery aneurysms associated with severe visceral artery occlusive diseases--a redo operation for thoracoabdominal aortic aneurysm after infrarenal abdominal aortic aneurysm repair].

Abdominal aortic aneurysms can now be successfully repaired with low mortality and few early complications. On the other hand, the cases that required operations for recurrent aneurysms have been increased during long term follow-up period. In such cases, there are many difficulties for operative procedures compared to their first operations and many risk factors. A case of successful operation for the thoracoabdominal aortic aneurysm associated with severe stenotic lesions of the visceral arteries and descending thoracic aneurysm and left common iliac artery aneurysm are reported. A 74-year-old man who underwent operation for infrarenal abdominal aortic aneurysm and left nephrectomy 7 years and 9 months ago at our institution developed an aneurysm just above the proximal anastomosis with severe stenotic lesions of the visceral arteries. At the same time, descending thoracic aortic aneurysm and left common iliac artery aneurysm were associated. And he had ischemic heart disease. Under selective perfusion of the visceral arteries, graft replacement of these aneurysms and reconstruction of superior mesenteric artery and right renal artery were done. The patient had good post operative course and started oral feeding at 3 post operation day. He returned to his occupation and is doing well with no trouble one and half year after operation.

Aged↗
PubMed1994

A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm, with associated bronchial artery aneurysms: report of a case.

A 57-year-old woman who went into shock following an acute left hemothorax was operated on after stabilization under the diagnosis of a ruptured aortic aneurysm. A left fifth intercostal thoracotomy was done which revealed approximately 500 ml of bloody effusion in the extrapleural space and 2,000 g of clotted blood in the pleural cavity. While the aneurysm was initially thought to have originated in the isthmic or descending aorta, intraoperative findings revealed a swollen hematomatous thymus adherent to the aorta. A ruptured thymic branch aneurysm, 3 cm in diameter, was subsequently found in the resected hematomatous thymus. Histological examination also revealed several small aneurysms in the tortured bronchial arteries. Postoperative angiography showed a saccular aneurysm, 1.5 cm in diameter, and several smaller aneurysms in the bronchial artery of the left lung. The aneurysm was successfully treated by a transcatheter arterial embolization, and the patient has had no further symptoms since then. To our knowledge, there has been no other case of a ruptured thymic artery aneurysm reported in the literature, and only a few cases of bronchial artery aneurysms have been documented.

Aneurysm↗
PubMed1981

Intracranial aneurysms: characteristics of aneurysms by site, with special reference to anterior communicating artery aneurysms.

Data are presented from an unselected series of 212 aneurysm patients for aneurysms at three major sites: the internal carotid-posterior communicating artery junction, the anterior communicating artery, and the middle cerebral artery. More than 70% of the anterior communicating artery aneurysms occurred as single aneurysms; less than 30% of the middle cerebral artery aneurysms were single. Anterior communicating artery aneurysms showed a right-side predominance in males but not in females. Both males and females had significantly higher mean systolic and diastolic blood pressures for left-sided anterior communicating artery aneurysms than for right-side aneurysms. A brief review of factors relevant to anterior communicating artery aneurysms is presented.

Carotid Artery Diseases↗
PubMed1993

[Familial aneurysms, multiple aneurysms and "de novo" aneurysms. Apropos of 2 cases].

The authors report the case of two sisters: each suffered from two intracranial hemorrhages caused by aneurysmal rupture at an interval of respectively 8 and 5 years. In the first case, the first subarachnoid hemorrhage (SAH) was related to a left middle cerebral artery aneurysm and the second, 8 years later, to the rupture of one of three right aneurysms (anterior communicating, supraclinoid internal carotid and middle cerebral arteries). But the "de novo" character of the right aneurysms could not be established. In the second case, the first SAH was related to an aneurysm of the right middle cerebral artery, with the left one appearing normal on the initial angiography. The second SAH, 5 years later, was related to a "de novo" left aneurysm. These two observations of familial, multiple and "de novo" intracranial aneurysms suggest a genetic basis for the pathogenesis of the arterial dysplasia. As in the literature, these hypothetical congenital factors could not be identified in both cases, but their probability justifies further investigations. If this factor exists, can we hope for a total recovery of the aneurysmal disease?

Adult↗
PubMed1992

Present management of hepatic artery aneurysms. Symptomatic left hepatic artery aneurysm; right hepatic artery aneurysm with erosion into the gallbladder and simultaneous colocholecystic fistula--a report of two unusual cases and the current state of etiology, diagnosis, histology and treatment.

A left hepatic artery aneurysm has an incidence of 0.8% among the splanchnic artery aneurysms. 20% of splanchnic artery aneurysms are hepatic artery aneurysms. Atherosclerosis (32%) is the most prevalent etiology, followed by trauma (22%) and inflammatory lesions (10%). The average age is 40 (10-83) years, the male to female ratio 2:1. In 64-80% of cases rupture of the aneurysm is the first clinical manifestation. The mortality is then about 35%. The case of a 64 years old female with a symptomatic aneurysm of the left hepatic artery and the case of a 70 years old female, who underwent emergency laparotomy for acute colorectal hemorrhage, with a right hepatic artery aneurysm, which perforated into the gallbladder, with simultaneous colocholecystic fistula is reported and the etiology, histology, and present diagnostic and therapeutic management of hepatic artery aneurysms is discussed.

Aged↗
PubMed1994

Nonruptured abdominal aortic aneurysm: six-year follow-up results from the multicenter prospective Canadian aneurysm study. Canadian Society for Vascular Surgery Aneurysm Study Group.

PURPOSE: Based on the prospective analysis of data on 680 patients undergoing surgery for nonruptured abdominal aortic aneurysm (AAA) and recorded in the Canadian Society for Vascular Surgery Aneurysm Registry, this study determines the late survival rate by comparison to an age- and sex-matched population, the causes of late death, the effect of heart-related death on late survival, and the prognostic variables that are associated with late survival. METHODS: To identify the variables that were associated with survival, statistical methods included Kaplan-Meier analysis and Cox regression analysis. The Canadian Society for Vascular Surgery Aneurysm Registry provided ongoing current follow-up of patients. RESULTS: The survival rate was 94.6% at 1 month, 90.7% at 1 year, 87.1% at 2 years, 81.0% at 3 years, 74.0% at 4 years, 67.7% at 5 years, and 60.2% at 6 years. The late survival rate of patients with AAA is significantly less than the age- and sex-matched normal population (60.2% versus 79.2%). In the AAA group, heart-related causes of late death (44.4% versus 34.1%) and cerebrovascular causes (8.3% versus 5.8%) were more frequent. The calculated 5-year heart-related mortality rate is 14.3%. This is higher than the heart-related mortality rate for the age- and sex-matched population, which is 6.4%. Hence, the risk of heart-related death for patients who have undergone AAA repair is increased by 1.6% per year. Vascular complications from aortic aneurysm repair or recurrent aneurysmal disease were an uncommon cause of late death: ruptured thoracic aneurysm, 1.5%; ruptured aortic false aneurysm, 1.5%; and aortoenteric fistula, 0%. This incidence appears to be less than reported in earlier series. By Cox regression analysis, the variables that were significant predictors of a lower late survival rate were increased age, preoperative electrocardiogram indicating a previous myocardial infarction, and elevated serum creatinine levels. CONCLUSIONS: Because cardiac complications accounted for 68.8% (22/32) of the 4.7% in-hospital mortality rate (i.e., a heart-related mortality rate of 3.2%), it seems reasonable to develop a strategy to reduce the cardiac operative risk by identifying and treating patients at high risk before operation. However, it is doubtful that a preoperative program that screens and treats all patients can be cost-effective in preventing late heart-related deaths.

Aged↗
PubMed2004

Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks.

OBJECTIVE: Our objective was to study intra-aneurysm pressure after endovascular aneurysm repair (EVAR) in shrinking, unchanged, and expanding abdominal aortic aneurysms (AAAs) with and without endoleaks. METHODS: Direct intra-aneurysm sac pressure measurement (DISP) by percutaneous translumbar puncture of the AAA under fluoroscopic guidance was performed 46 times during the follow-up of 37 patients (30 men; median age, 73 years [range, 58-82 years]; AAA diameter: median, 60 mm [range, 48-84 mm]). Three patients were included in two different groups because DISP was performed more than once with different indications. Tip-pressure sensors mounted on 0.014-inch guidewires were used for simultaneous measurement of systemic and AAA sac pressures. Mean pressure index (MPI) was calculated as the percentage of mean intra-aneurysm pressure relative to the simultaneous mean intra-aortic pressure. RESULTS: Median MPI was 19% in shrinking (11 patients), 30% in unchanged (10 patients), and 59% in expanding (9 patients) aneurysms without endoleaks. Pulse pressure was also higher in expanding (10 mm Hg) compared with shrinking (2 mm Hg; P <.0001) AAAs. Four of the nine patients with expanding AAAs underwent five repeated DISPs later in the follow-up, and MPIs were consistently elevated. Seven of the 10 patients with unchanged AAAs without endoleaks underwent further computed tomography follow-up after DISP; 2 expanded (MPI, 47%-63%), 4 shrank (MPI, 21%-30%), and 1 remained unchanged (MPI, 14%). Type II endoleaks (6 patients, 7 DISPs) were associated with wide range of MPI (22%-92%). Successful endoleak embolization (n = 4) resulted in pressure reduction. CONCLUSIONS: Intra-aneurysm sac pressure measurement is an important adjunctive for EVAR evaluation, possibly allowing early detection of failures. High pressure is associated with AAA expansion and low pressure with shrinkage. Type II endoleaks can be responsible for AAA pressurization, and successful embolization appears to result in pressure reduction.

Aged↗
PubMed2004

Systemic lupus erythematosus with hepatic aneurysm, valsalva sinus aneurysm and associated polyangiitis: aneurysmal wall remodeling with dense fibrosis and calcification mediated by residual smooth muscle cells.

Isolated case reports have demonstrated the combination of hepatic aneurysm and systemic lupus erythematosus (SLE). The author experienced a rare autopsy case of a 36-year old Japanese male with SLE, a hepatic aneurysm, a Valsalva sinus aneurysm and associated polyangiitis. In the histopathological and ultrastructural examinations of the postmortem organs, most of the angiitis lesions were in the scar phase associated with the histopathological features of collagenous fibrosis with the diminution of the smooth muscle cells and elastic fibre layers. Massive calcification was seen on the wall and obliterative changes in the lumen with calcified thrombi. In the dense collagenous stroma of the aneurysmal wall, residual atrophic smooth muscle cells with immunohistochemical (HHF35+, alpha-smooth-muscle actin+, vimentin+ and desmin almost-) and ultrastructural features (spindle-shaped cells with a few rER and rich intracytoplasmic filaments with peripheral dense patches) were assumed to be involved in the histogenesis of the aneurysmal wall. Massive calcification and degeneration or dynamic remodeling of the extracellular matrices in the aneurysmal wall might be mediated by the residual smooth muscle cells. It was suspected that the generalized polyangiitis as a complication of SLE might have involved the intrahepatic arteries and Valsalva sinus wall and subsequently generated the aneurysm.

Adult↗
PubMed1991

[CT of abdominal aortic aneurysms--aneurysmal size and thickness of intra-aneurysmal thrombus as risk factors of rupture].

In order to seek for the factors to suggest a risk of rupture of abdominal aortic aneurysms (AAA), we measured the largest diameter of AAA and the thickness of intra-luminal thrombus on CT in 72 patients. The mean aneurysmal size was 64 mm in diameter in 9 patients with ruptured aneurysm and 61 mm in diameter in 63 patients with non-ruptured aneurysm respectively (p less than 0.90). The rupture of AAA was seen in 3 of 30 patients with AAA of the small size (less than 50 mm in diameter), in 3 of 16 patients with AAA of the intermediate size (51-66 mm in diameter) and in 3 of 26 patients with AAA of the large size (more than 70 mm in diameter), respectively. The mean intra-luminal thrombus was 9 mm in 9 patients with ruptured aneurysm and 19 mm in thickness in 63 patients with non-ruptured aneurysm respectively (p = 0.05). We concluded from the above results that the aneurysmal size was not important, but the thickness of intra-luminal thrombus was useful for suggestion of a risk of rupture of AAA.

Adult↗
PubMed1995

[Anastomotic pseudoaneurysm, true para-anastomotic aneurysm and recurrent aneurysm following surgery for abdominal aortic aneurysm. Is a unifying theory possible?].

BACKGROUND. Recurrent aneurysms (RA) and true para-anastomotic aneurysms (TPA) are currently reported as anecdotal findings during occasional follow-up of subjects previously operated for abdominal aortic aneurysm (AAA). In several instances concomitant false anastomotic aneurysms (FAA) are found, not attributable to infection nor to suture or graft degradation. PURPOSE. To discuss the possibility that RA of inborn arteries, TPA, and non infectious FAA, when concomitantly present in the same subject, may reflect a peculiar late presentation of multiarterial aneurysmal disease. MATERIAL. Three cases of occasionally discovered concomitant RA, TPA, and FAA in subjects previously operated for AAA are reported. The finding of new aneurysms and FAA in subjects previously operated for AAA may be theoretically justified by the currently recognized pathogenetic mechanisms, molecular, enzymatic or genetically determined, implicated in the formation of AAA. This points out the need for a correct surgical management of AAAs and for accurate accomplishment of follow-up programmes supported by ultrasound echography of graft-arterial anastomoses and of the arteries at risk of aneurysmal disease.

Aged↗
PubMed1995

Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study.

OBJECTIVES: This report examines the frequency, type, and prognostic factors of medical (nonneurologic) complications after subarachnoid hemorrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality and morbidity rates after aneurysmal subarachnoid hemorrhage are evaluated. DESIGN: A study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonist, nicardipine, after subarachnoid hemorrhage. SETTING: Patients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada. PATIENTS: A total of 457 patients with subarachnoid hemorrhage, > or = 18 yrs of age, were randomly assigned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an angiographically documented saccular aneurysm. MEASUREMENTS AND MAIN RESULTS: The frequency rates of symptomatic vasospasm, rebleeding, and total mortality rate after subarachnoid hemorrhage at 3-month follow-up were 46%, 7%, and 19%, respectively. The frequency of having at least one severe (life-threatening) medical complication was 40%. The proportion of deaths from medical complications was 23%. This value was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac arrhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurred in 23% of the patients, with a 6% occurrence rate incidence of severe pulmonary edema. There was a wide variation from center to center, with the greatest frequency on days 3 through 7. There was a nonsignificant association of pulmonary edema with the use of hypertensive hypervolemic therapy (p = .10), and a significant association with the timing of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepatic enzymes with no clinical accompaniment (4% frequency of severe hepatic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening severity. There was an association (p = .001) with antibiotic therapy. CONCLUSIONS: Potentially preventable medical complications after ruptured cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical complications equals those deaths from either direct effects, rebleeding, or vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, was not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias, were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.

Adult↗
PubMedDate not supplied

International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion.

BACKGROUND: Two types of treatment are being used for patients with ruptured intracranial aneurysms: endovascular detachable-coil treatment or craniotomy and clipping. We undertook a randomised, multicentre trial to compare these treatments in patients who were suitable for either treatment because the relative safety and efficacy of these approaches had not been established. Here we present clinical outcomes 1 year after treatment. METHODS: 2143 patients with ruptured intracranial aneurysms, who were admitted to 42 neurosurgical centres, mainly in the UK and Europe, took part in the trial. They were randomly assigned to neurosurgical clipping (n=1070) or endovascular coiling (n=1073). The primary outcome was death or dependence at 1 year (defined by a modified Rankin scale of 3-6). Secondary outcomes included rebleeding from the treated aneurysm and risk of seizures. Long-term follow up continues. Analysis was in accordance with the randomised treatment. FINDINGS: We report the 1-year outcomes for 1063 of 1073 patients allocated to endovascular treatment, and 1055 of 1070 patients allocated to neurosurgical treatment. 250 (23.5%) of 1063 patients allocated to endovascular treatment were dead or dependent at 1 year, compared with 326 (30.9%) of 1055 patients allocated to neurosurgery, an absolute risk reduction of 7.4% (95% CI 3.6-11.2, p=0.0001). The early survival advantage was maintained for up to 7 years and was significant (log rank p=0.03). The risk of epilepsy was substantially lower in patients allocated to endovascular treatment, but the risk of late rebleeding was higher. INTERPRETATION: In patients with ruptured intracranial aneurysms suitable for both treatments, endovascular coiling is more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continues for at least 7 years. The risk of late rebleeding is low, but is more common after endovascular coiling than after neurosurgical clipping.

Activities of Daily Living↗