Manejo ultra temprano del aneurisma cerebral roto. Reporte de caso y revisión de la literatura / Ultra-early management of ruptured brain aneurysm. A case report and literature review

Introducción : Los aneurismas intracraneales representan el 85% de casos de hemorragias subaracnoideas, dentro de las cuales las no traumáticas tienen una alta tasa de mortalidad (40-60%). En el manejo endovascular y microquirúrgico de esta enfermedad, el debate ha sido siempre intenso respecto a si el tratamiento temprano produce un beneficioso resultado funcional y reduce la morbi-mortalidad del paciente. Caso Clínico : Paciente mujer de 54 años, admitida con cefalea súbita y cuadro neurológico que cursó con rápido deterioro. La tomografía mostró hemorragia subaracnoidea por ruptura aneurísmica del complejo comunicante anterior; fue sometida a microcirugía dentro de las primeras 24 horas y transferida luego a UCI, sin complicaciones. Discusión : El tiempo de resolución, sea mediante clipaje microquirúrgico o tratamiento endovascular es tema de intensos debates. Las guías actuales señalan la necesidad del manejo más temprano posible de la patología. Conclusión : En nuestro caso, se obtuvo un buen resultado funcional debido a varios factores uno de ellos el ingreso precoz a cirugía. La actualización de las guías y nuevos estudios ayudarán a mejorar el conocimiento de la enfermedad y protocolos hospitalarios adecuados a la realidad clínica ayudarán a reducir su tiempo de resolución.

SUMMARY Introduction : Intracranial aneurysms account for 85% of all subarachnoid hemorrhages. Non-traumatic SAH has a high mortality rate (40-60%). Regarding the microsurgical and endovascular management for this pathology, there has been intense debate on whether early action is beneficial in terms of functional outcome and reduction of morbi-mortality. Clinical case : A 54-year-old woman admitted with a sudden, severe headache and a rapidly deteriorating neurological state at baseline, and with deterioration at the next hour. Tomography showed a subarachnoid hemorrhage due to ruptured aneurysm of the anterior communicating artery; the patient underwent surgery within the first 24 hours, with subsequent ICU management without complications. Discussion : The resolution time of this condition, either by micosurgery or endovascular management is a matter of intense debate. International guidelines point out the need of an earliest possible treatment. Conclusion : In our case, a good functional result was obtained due to several factors, one of which was early admission to surgery. The updating of guidelines and new studies will help to better understand the pathophysiology of SAH, and the creation of hospital protocols adapted to clinical realities will assist to reduce the resolution time of this pathology.

Rotura aneurismática de la arteria hepática común / Ruptured common hepatic artery aneurysm

RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.

ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.

Microsurgery versus embolization: different risk factors for short- and long- term outcomes of patients with ruptured aneurysms

Purpose: To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results: Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions: Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Successful endovascular repair with coil embolization of ruptured right internal thoracic artery aneurysm / Reparo endovascular bem-sucedido de aneurisma da artéria torácica interna direita roto com embolização com molas

Abstract Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.

Resumo Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.

Perfil clínico de los pacientes con aneurisma cerebral atendidos en el Hospital Carlos Andrade Marín / Clinical profile of patients with cerebral aneurysms treated at Carlos Andrade Marín Hospital

INTRODUCCIÓN. En Ecuador, las enfermedades cerebrovasculares son la tercera causa de muerte en la población general; existen pocos datos en la literatura médica sobre la hemorragia subaracnoidea aneurismática y aneurismas no rotos, por lo que fue fundamental describir un perfil clínico. OBJETIVO. Caracterizar la clínica de los pacientes con diagnóstico de aneurisma cerebral. MATERIALES Y MÉTODOS. Estudio observacional descriptivo. Población de 450 y muestra de 447 pacientes con diagnóstico de aneurisma cerebral atendidos en la Unidad de Neurología del Hospital Carlos Andrade Marín, periodo enero 2010 a diciembre 2018. Los datos clínicos e imagenológicos fueron recolectados a través de la revisión de historias clínicas digitales obtenidas del sistema informático MIS/AS400, y se analizaron en el programa estadístico International Business Machines Statistical Package for the Social Sciences, versión 23. RESULTADOS. Se identificaron 605 aneurismas en 447 pacientes. El 80,5% (360; 447) presentó aneurismas rotos, de éstos el 81,4% (293; 360) tuvo un solo aneurisma. El factor de riesgo más frecuente fue la hipertensión arterial con el 44,3% (198; 447), las manifestaciones observadas fueron: hemorragia subaracnoidea con el 98,9% (356; 360) en aneurismas rotos; y cefalea con el 65,5% (57; 87) en aneurismas no rotos. DISCUSIÓN. Se encontró datos relevantes no coincidentes con la literatura científica mundial, como el bajo número de aneurismas asintomáticos y no rotos, comparados con su contraparte. CONCLUSIÓN. Se evidenció que los aneurismas intracraneales produjeron una amplia gama de manifestaciones clínicas, que fluctuaron desde la hemorragia subaracnoidea como la más frecuente en el grupo de aneurismas rotos, hasta pacientes completamente asintomáticos en el grupo de aneurismas no rotos.

INTRODUCTION. In Ecuador, cerebrovascular diseases are the third leading cause of death in the general population; there are few data in the medical literature on aneurysmal subarachnoid hemorrhage and unruptured aneurysms, so it was essential to describe a clinical profile. OBJECTIVE. To characterize the clinical profile of patients diagnosed with cerebral aneurysm. MATERIALS AND METHODS. Descriptive observational study. Population of 450 and sample of 447 patients with a diagnosis of cerebral aneurysm seen in the Neurology Unit of the Carlos Andrade Marín Hospital, period January 2010 to December 2018. Clinical and imaging data were collected through the review of digital medical records obtained from the MIS/AS400 computer system, and were analyzed in the statistical program International Business Machines Statistical Package for the Social Sciences, version 23. RESULTS. A total of 605 aneurysms were identified in 447 patients. A total of 80,5% (360; 447) had ruptured aneurysms, of which 81,4% (293; 360) had a single aneurysm. The most common risk factor was hypertension with 44,3% (198; 447), the manifestations observed were: subarachnoid hemorrhage with 98,9% (356; 360) in ruptured aneurysms; and headache with 65,5% (57; 87) in unruptured aneurysms. DISCUSSION. We found relevant data not consistent with the world scientific literature, such as the low number of asymptomatic and unruptured aneurysms, compared with its counterpart. CONCLUSION. It was evidenced that intracranial aneurysms produced a wide range of clinical manifestations, ranging from subarachnoid hemorrhage as the most frequent in the group of ruptured aneurysms, to completely asymptomatic patients in the group of unruptured aneurysms.

Tratamiento endovascular del aneurisma esplénico incidental y en la urgencia / Endovascular treatment of incidental and emergency splenic aneurysm

Resumen Los aneurismas esplénicos verdaderos son dilataciones saculares que involucran todas las capas de la arteria esplénica. Se presentan más frecuentemente en mujeres, en el embarazo y pacientes con hipertensión portal. Son habitualmente asintomáticos y diagnosticados incidentalmente durante el estudio de otra afección abdominal. Hasta un 10% se puede presentar con ruptura, lo que supone un escenario con una alta morbilidad y mortalidad. El tratamiento de los aneurismas esplénicos es aún un tema de controversia y existen variadas modalidades terapéuticas. Presentamos dos casos de pacientes con aneurismas esplénicos: uno de ellos que se manifestó con rotura y el otro por un diagnóstico incidental. Ambos fueron resueltos mediante embolización endovascular con resultados óptimos. Esta modalidad terapéutica poco difundida para el tratamiento de aneurismas esplénicos gigantes o rotos, nos permitió resolver el cuadro de forma segura y efectiva, con mínima morbilidad y mortalidad.

Abstract True splenic aneurysms are saccular dilations of all the layers of the splenic artery, more common in women, pregnancy and portal hypertension. They are usually asymptomatic and diagnosed incidentally during the study of other abdominal diseases. Up to 10% may present with rupture, which implies a high morbidity and mortality. Treatment of splenic aneurysms is still a subject of controversy and there is a great variety of therapeutic modalities. We present two cases of patients with splenic aneurysms: one who presented with rupture and the other one incidentally diagnosed. Both were treated with endovascular embolization achieving optimal results. Although the utility of this therapy has not been assessed for giant or ruptured aneurysms, it allowed us to solve these scenarios in a secure and effective way, with minimum morbidity and mortality.

Resultado imediato do tratamento endovascular com stents paralelos do aneurisma roto justarrenal / Immediate outcome of endovascular treatment of ruptured juxtarenal aneurysm with parallel stents

Resumo A ruptura do aneurisma de aorta abdominal é um evento com alta mortalidade, e o seu tratamento nesses casos é uma emergência médica. O tratamento endovascular desses aneurismas tem se estabelecido como uma alternativa minimamente invasiva à cirurgia aberta clássica, tornando-se a opção de primeira escolha. Contudo, 20 a 50% dos pacientes portadores de aneurisma de aorta abdominal não apresentam anatomia favorável para o tratamento endovascular devido à presença de colo curto ou pelo acometimento de ramos viscerais pelo aneurisma. Relatamos um caso de uma paciente de 70 anos submetida à correção endovascular de aneurisma roto justarrenal com implante de stents paralelos para as renais (técnica de chaminé). São apresentados dados clínicos e detalhes do procedimento. O sucesso técnico foi obtido e não houve relato de complicações pós-operatórias.

Abstract Rupture of an abdominal aortic aneurysm is an event with a high mortality rate and treatment is a medical emergency. Endovascular treatment of these aneurysms has become established as a minimally invasive alternative to classical open surgery and is now the first-choice option. However, 20 to 50% of patients with abdominal aortic aneurysms do not have anatomy favorable for endovascular treatment because of a short aneurysm neck or because visceral branches are involved by the aneurysm. We report the case of a 70-year-old patient who underwent endovascular repair of a ruptured juxtarenal aneurysm with deployment of parallel stents in the renal arteries (in a chimney technique). Clinical data and details of the procedure are reported. Technical success was achieved and there were no postoperative complications.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times / Tratamento endovascular das emergências dos aneurismas aortoilíacos em tempos de COVID-19

Abstract In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Resumo Relatamos uma série de casos de quatro pacientes consecutivos, admitidos com emergências relacionadas a aneurismas aortoilíacos em um período de 3 dias e submetidos a tratamento endovascular. A primeira paciente, do sexo feminino, com 81 anos e com histórico de aneurisma da aorta, apresentou dor abdominal iniciada nos últimos 12 dias. O segundo paciente era do sexo masculino, com 63 anos e foi admitido com hematêmese 3 dias antes da admissão, com angiotomografia demonstrando fistula aortoentérica. A terceira paciente, do sexo feminino e com 77 anos, foi admitida com quadro de ruptura de aneurisma da artéria ilíaca comum direita. O quarto paciente consecutivo apresentou dor abdominal iniciada 2 semanas antes da internação e aneurisma roto da aorta. Todos os quatro pacientes apresentaram emergências aortoilíacas e receberam alta sem complicações maiores ou mortalidade cirúrgica. O relato desta série de casos demonstra que, apesar da situação pandêmica da COVID-19, uma vez que as cirurgias eletivas diminuíram, as urgências vasculares aumentaram.

Pulmonary artery aneurysm rupture

Pulmonary artery aneurysm is a disorder of varying etiology and should be diagnosed early for appropriate interventions. A 45-year-old man was hospitalized for chest pain, dyspnea, cough, chills, diarrhea, and vomiting, which had started 3 weeks before admission. Physical examination indicated a reduced vesicular murmur in the right hemithorax. A chest x-ray performed indicated a pneumothorax and pulmonary abscess in the right hemithorax. Thoracostomy released abundant purulent and fetid fluid. Direct examination of the pleural fluid using saline revealed structures similar to Trichomonas. Non-contrast chest computed tomography revealed right pneumothorax along with an irregular cavitation located at the pleuropulmonary interface of the posterior margin of the right lower lobe. A pleurostomy was performed. On the second postoperative day, the patient suffered a sudden major hemorrhage through the surgical wound and died on the way to the operating room. The autopsy revealed an abscess and ruptured aneurysm of the lower lobar artery in the lower right lung. Microscopic examination revealed extensive liquefactive necrosis associated with purulent inflammation and the presence of filamentous fungi and spores. This case can be characterized as a severe disorder that requires early diagnosis to achieve a good therapeutic response and to avoid fatal outcomes.

Anterior Communicating Artery Aneurysm Uncommon Hemorrhagic Presentation: Case Report

Intracranial aneurysm rupture causes subarachnoid hemorrhage in 80% of the cases, and it may be associated with intracerebral hemorrhage and/or intraventricular hemorrhage (IVH) in 34% and 17% of the patients, respectively. However, on rare occasions, aneurysm rupturemay be present causing isolate intracerebral hemorrhage or IVH without subarachnoid hemorrhage. We describe an unusual case of an anterior communicating aneurysm rupture presented with IVH, without subarachnoid hemorrhage. Although isolated IVH is rare, aneurysm rupture is a possible condition. Patients presenting with head computed tomography revealing IVH without subarachnoid hemorrhage should be promptly investigated with contrasted image exam to identify and treat possible causes, even in the absence of subarachnoid hemorrhage.

Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.

Rotura de aneurisma de artéria poplítea em paciente clinicamente diagnosticado com síndrome de Marfan / Ruptured popliteal artery aneurysm in a patient with a clinical diagnosis of Marfan syndrome

Resumo A artéria poplítea é o principal local para a ocorrência de aneurismas periféricos. Suas formas de apresentação agudas são potencialmente ameaçadoras à viabilidade do membro e à vida, dentre as quais destacamos a sua rotura. Apesar de ser um evento raro, sua rotura demanda rápida proposta de intervenção para satisfatório desfecho terapêutico. O tratamento padrão-ouro é o cirúrgico convencional e se dá pela interposição de veia safena magna. Trabalhos feitos nas últimas décadas vêm encontrando associações entre a síndrome de Marfan e aneurismas periféricos. Este relato apresenta um caso de um aneurisma de artéria poplítea esquerda roto tratado com sucesso em um paciente de 82 anos diagnosticado clinicamente como portador de síndrome de Marfan previamente desconhecida.

Abstract The popliteal artery is the main site of occurrence of peripheral aneurysms. Acute presentations constitute a potential threat to limb viability and to life, especially in the event of rupture. Rupture is a rare event, but one that demands an immediate intervention decision to achieve a satisfactory treatment outcome. The gold standard treatment is conventional surgery, effecting repair by interposition of a great saphenous vein graft. Studies conducted in recent decades have found associations between Marfan Syndrome and peripheral aneurysms. This report presents a case of a ruptured left popliteal artery aneurysm successfully treated in an 82-year-old patient clinically diagnosed with previously unknown Marfan syndrome.

Pseudoaneurisma micótico por embolismo séptico en paciente pediátrico con leucemia linfoblástica aguda / Mycotic aneurism for septic embolism in a pediatric patient with acute linfoblastic leukemia

Resumen Los aneurismas pediátricos son raros y pueden se causados por infección al dañar la pared arterial formando una saculación ciega contigua a su lumen denominada pseudoaneurisma micótico. La mayoría de los casos reportados son de pacientes ancianos con comorbilidades y los agentes causantes más frecuentes son Staphylococcus spp, Salmonella spp, Streptococcus spp y raramente hongos. Se presenta el caso de un niño de 3 años con: diagnóstico reciente de leucemia linfoblástica aguda de precursores B en remisión; alto riesgo de recaída por tratamiento incompleto y antecedente de bacteremia por Staphylococcus epidermidis y fungemia por Cándida tropicalis; vegetaciones cardiacas que hacen embolismo a hígado, bazo, pulmón y cerebro, y pseudoaneurisma micótico parcialmente trombosado de la arteria ilíaca común y externa. El diagnóstico temprano de esta entidad es de vital importancia por el riesgo de ruptura y el manejo quirúrgico dependerá de la localización, el tamaño y las complicaciones asociadas.

Abstract Pediatric aneurysms are rare and can be caused for damaging of the arterial wall secondary to an infection, forming a blind sacculation contiguous to its lumen called mycotic pseudoaneurysm. The majority of reported cases are from elderly patients with comorbidities. The most frequent involucre microorganisms are Staphylococcus spp, Salmonella spp, Streptococcus spp and rarely fungi. We present the case of a 3-year-old boy, with a recent diagnosis of acute lymphoblastic leukemia of B precursors in remission, with a high risk of relapse due to incomplete treatment and a history of bacteremia due to Staphylococcus epidermidis and fungemia due to Candida tropicalis; with cardiac vegetations that produce liver, spleen, lung and brain embolism, in whom a partially thrombosed mycotic pseudoaneurysm of the common and external iliac artery is found. The early diagnosis of this entity is of vital importance because of the risk of rupture. Surgical management will depend on the location, size and associated complications.

Hemoperitoneo en el post parto secundario a la rotura aneurismática de la arteria ovárica: Caso Clínico / Post partum hemoperitoneum secondary to ovarian aneurysm rupture: Case Report

Resumen El hallazgo de hemoperitoneo en el post parto secundario a la rotura aneurismática de la arteria ovárica es una situación clínica extremadamente rara que presenta un cuadro clínico inespecífico y puede poner en riesgo la vida del paciente. El ultrasonido es una modalidad segura y rápida para la detección de líquido libre intraperitoneal. (1) . La tomografía computada es la herramienta de elección para un diagnóstico rápido y seguro (2) ; y la angiografía con embolización durante el mismo procedimiento es una alternativa útil y altamente efectiva para la resolución del cuadro. (3). Presentamos el caso de una multípara puérpera de 34 años que consulta en el servicio de urgencia por intenso dolor abdominal. La paciente se encontraba hemodinámicamente estable y afebril. La tomografía computada demostró un hematoma retroperitoneal y hemoperitoneo asociado a un aneurisma de la arteria ovárica derecha. Fue evaluada por el servicio de radiología intervencional y se trasladó de emergencia al pabellón angiográfico donde se realizó la embolización de la lesión mediante la cateterización vascular supra selectiva. La paciente evolucionó de manera favorable y fue dada de alta una semana después. Es necesario tener un alto índice de sospecha en pacientes de riesgo para lograr un diagnóstico y tratamiento oportuno.

SUMMARY Spontaneous ovarian artery aneurysm rupture is a rare postpartum life-threatening event with non-specific clinical manifestations. The present article reports the case of a 34 year old multiparous post partum women who came to the emergency department with acute onset of intense abdominal right flank pain. Patient was afebrile and hemodynamically stable. A computed tomography revealed a retroperitoneal haematoma and hemoperitoneum related to an aneurysm of the right ovarian artery. The patient was taken to the interventional radiology suite and selective embolization was performed. Following the procedure, the patient symptoms subsided and 7 days later she was discharged. A high index of suspicion in patients with risk factors can lead to a prompt diagnosis and treatment. Computed tomography is the image modality for a fast and safe evaluation, although diagnostic angiography and subsequent transcatheter embolization are thought to be effective for treatment.

Bleeding risk of small intracranial aneurysms in a population treated in a reference center / Risco de sangramento de aneurismas intracranianos pequenos em uma população tratada em um centro de referência

ABSTRACT Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. Methods: We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. Results: The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. Conclusion: In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.

RESUMO Grandes estudos multicêntricos demostram que aneurismas intracranianos pequenos são associados a risco de sangramento mínimo. Outras grandes séries têm evidenciado que aneurismas rotos são em sua maioria os pequenos. Neste estudo questionamos até que ponto os aneurismas pequenos não são perigosos. Métodos: Avaliamos 290 novos casos de aneurismas tratados em nossa instituição durante 6 anos (43,7% rotos). Realizamos análises multivariadas com aspectos epidemiológicos dos pacientes, doenças cardiovasculares e três parâmetros angiográficos: maior diâmetro, diâmetro do colo e diâmetro do vaso nutridor do aneurisma. Estimativas de risco foram calculadas utilizando-se modelo de regressão logística. Parâmetros do tamanho aneurismático foram estratificados de acordo com curvas ROC. Também calculamos a razão de chances (odds ratios) de ruptura baseadas nas análises das curvas ROC. Resultados: O maior diâmetro médio para os grupos de aneurismas rotos e não-rotos foi 13.3 ± 1.7mm e 22.2 ± 2.2 (p < 0.001). Análises multivariadas revelaram uma correlação positiva entre ruptura aneurismática e hipertensão arterial (p < 0.001) e uma correlação inversa entre ruptura e as três medidas angiográficas (p < 0.01). Aneurismas da artéria cerebral anterior foram os que mais sangraram (p < 0.05). Análises das curvas ROC demonstram que no maior diâmetro de 15mm, a sensibilidade e especificidade para se predizer ruptura são de 83% e 36%. Baseando-se nessas estratificações, calculamos uma chance de ruptura para aneurismas menores de 15mm de 46% e de 25% para aneurismas maiores. Conclusão: Na população estudada, aneurismas pequenos são mais propensos a romper. Desta forma, a necessidade de intervenção para aneurismas pequenos não deve ser relevada.

Massive hemoptysis following Rasmussen's aneurysm: a case report

Rasmussen's aneurysm (RA) is a pseudoaneurysm of a pulmonary artery (AP), adjacent to or within a tuberculous cavity, appearing in 5% of these lesions. Its rupture might provoke massive hemoptysis (MH) with a near 50% mortality. The aim of this article is to report a case of massive hemoptysis following Rasmussen's aneurysm. 52-year-old man with recent history of hospita-lization due to pneumonia associated to influenza A and decompensated hyperthyroidism, pre-sents outpatient chest radiograph with signs of hyperinflation and scarring apical opacities, the patient returned to the hospital due to sharp pain of left hemi thorax during inspiration accom-panied with bloody sputum, asthenia and non-quantified weight loss. He evolves to frank MH, requiring endotracheal intubation managed in the intensive care unit (ICU). Chest computed tomography (CT) reported ground-glass opacity, nodules with a tendency to cavitation, tree-in-bud pattern in agreement with inflammation and infection, active TB is considered, and truncus of PA with vascular lesion suggestive of aneurysm dependent on pulmonary circulation, possibly RA. Fibrobronchoscopy reported signs of old and recent bleeding of left bronchial tree, probably of the lingula, blood clots in right bronchial tree. Molecular study and TB cultures was negative. Endovascular procedure with arteriography was carried out, revealing amputation of left distal segmental PA carrying the pseudoaneurysm with complete regression, discarding embolization RA It must be considered among the differential diagnoses of MH, especially on patients with pulmonary TB complications, such as the reported case. Due to its associated increased morta-lity, once RA is identified, it must be either endovascularly or surgically eradicated.

Ruptured renal artery aneurysm in a pregnant woman: case report and literature review / Ruptura de aneurisma de artéria renal em gestante: relato de caso e revisão da literatura

Abstract Renal artery aneurysms (RAAs) are rare and usually asymptomatic; ~ 90% of them are unilateral. Once diagnosed during pregnancy, they may rupture, presenting a high maternal-fetal risk. The present study reports the case of a 32-year-old pregnant woman with a 30-week gestational age and a ruptured unilateral RAA.

Resumo Os aneurismas de artéria renal (AAR) são raros, normalmente assintomáticos, e ~ 90% dos casos são unilaterais. Uma vez diagnosticados durante a gestação, estes podem se tornar predisponentes a rotura e apresentar elevado risco materno-fetal. O presente artigo relata o caso de uma gestante de 32 anos, com idade gestacional de 30 semanas e quadro de AAR unilateral roto.

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report

ABSTRACT CONTEXT: Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease. Case Report: A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination. CONCLUSION: Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Abdominal Apoplexy after Pulmonary Lobectomy for Lung Cancer / Apoplejía abdominal tras una lobectomía pulmonar por cáncer de pulmón

ABSTRACT Abdominal apoplexy is a rare clinical entity, and its clinical manifestations are diverse. This case report is of a 52-year-old man who developed right upper abdominal pain with unstable haemodynamics 32 hours after right upper pulmonary lobectomy for lung carcinoma. Abdominal computed tomography showed a ruptured right gastric artery aneurysm.

RESUMEN La apoplejía abdominal es una entidad clínica rara, y sus manifestaciones clínicas son diversas. Este es un reporte de caso de un hombre de 52 años que presentó dolor abdominal superior derecho con hemodinámica inestable, 32 horas después de una lobectomía pulmonar superior derecha por carcinoma del pulmón. La tomografía computarizada abdominal mostró una ruptura de aneurisma de la arteria gástrica derecha.