Anatomy of the Middle Meningeal Artery

Introduction The middle meningeal artery (MMA) is an important artery in neurosurgery. As the largest branch of the maxillary artery, it provides nutrition to the meninges and to the frontal and parietal regions. Diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (TAVF), Moya-Moya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine, and meningioma,may be related to the MMA. The aim of the present study is to describe the anatomy of the MMA and to correlate it with brain diseases. Methods A literature review was performed using the PubMed, Scielo, Scientific Direct, Ebsco, LILACS, TripDataBase and Cochrane databases, with the following descriptors: neurosurgery, neuroanatomy, meninges and blood supply. Discussion The MMA is embedded in a cranial groove, and traumatic or iatrogenic factors can result in MMA-associated pseudoaneurysms or arteriovenous fistulas (AVFs). In hemodynamic stress, true aneurysms can develop. Arteriovenous fistulas, pseudoaneurysms, and true aneurysms can be effectively treated by endovascular or surgical removal. In MMD, the MMA plays a role in the development and in the improvement of collateral circulation. Finally, in cases of CSDH, when standard surgery and drainage fail, MMA embolization can constitute a great alternative. Conclusion The MMA is a relevant structure for the understanding of neurosurgical diseases. In conclusion, every neurosurgeon must know the anatomy of the MMA sufficiently to correlate it with the diagnosed pathology, thus obtaining treatment effectiveness and preventing brain lesion.

Surgical treatment of pseudoaneurysm of the ascending aorta in a patient with sepsis

Abstract Pseudoaneurysm of the ascending aorta (PAA) is a hazardous and potentially fatal cardiovascular disease. This condition is caused by the rupture of at least one layer of the vessel and contained by the remaining vascular layers or the surrounding mediastinal structures. We presented the surgical treatment of a patient with sepsis and large PAA and brachiocephalic trunk, which was compressing the brachiocephalic trunk leading to syncope.

Pseudoaneurisma de la arteria femoral profunda secundario a trauma penetrante: reporte de caso / Deep femoral artery pseudoaneurysm secondary to penetrating trauma: case report

Resumen Objetivo: El objetivo del trabajo es presentar una opción terapéutica adecuada para los pseudoaneurismas de la femoral profunda secundarios a trauma penetrante, así como realizar una revisión de la literatura sobre el manejo en estas patologías. Caso clínico: Paciente masculino de 21 años quien 5 meses previos a su valoración sufre una herida por arma punzocortante en el muslo izquierdo, desarrollando aumento de volumen el sitio de la lesión, dolor y limitación al movimiento. Se diagnostica un pseudoaneurisma de la arteria femoral profunda de 2,3 cm x 2,1 cm x 2,7 cm y un hematoma adyacente de 13,5 cm x 12,6 cm x 23 cm. Se realiza exclusión del pseudoaneurisma mediante cirugía endovascular con coils, posteriormente se evacúa el hematoma adyacente. Resultados: El paciente egresa al tercer día posoperatorio con mejoría de la sintomatología, antibioticoterapia y analgesia. Discusión y Conclusión: En el caso presentado la exclusión del pseudoaneurisma mediante coils facilitó el control de éste y la evacuación del hematoma adyacente, disminuyendo el riesgo de sangrado. Por lo que consideramos adecuada esta conducta terapéutica en pseudoaneurismas de la femoral profunda.

Aim: The aim of this paper is to present a case of a deep femoral artery pseudoaneurysm secondary to a penetrating trauma in the left thigh, its management and a literature review. Clinical Case: 21-year-old male referred to the emergency department of our institution 5 months after he was injured with a knife on his left thigh, with severe local swelling, local pain, and difficulty to the mobilization of the left leg. A 2.3 cm x 2.1 cm x 2.7 cm deep femoral artery pseudoaneurysm was diagnosed with a 13.5 cm x 12.6 cm x 23 cm adjacent hematoma. Endovascular exclusion was made with coils and evacuation of the hematoma with open surgery. Results: The patient was discharged on the third day postop without pain and walking with antibiotics and follow-up to a month did not reveal any complications. Discusion and Conclusion: Exclusion with coils is an adequate management in deep femoral pseudoaneurysms that facilitates the evacuation of the hematoma lowering the risk of bleeding.

Hemoptisis como signo de alarma de pseudoaneurisma de la aorta torácica: reporte de caso / Hemoptysis as a warning sign of thoracic aorta pseudoaneurysm: a case report

El pseudoaneurisma se define como un hematoma pulsátil repermeabilizado, encapsulado y en comunicación con la luz de un vaso dañado. Se origina cuando hay una disrupción de la pared arterial. La hemoptisis es un signo/síntoma de presentación muy rara de aneurisma aórtico torácico y de pseudoaneurisma aórtico torácico. Hay poca información sobre la hemoptisis asociada con la ruptura del aneurisma aórtico cuyo mecanismo no se explica por la presencia de una fístula aortopulmonar. Entre las hipótesis para explicar este fenómeno, se encuentra la capacidad de las arterias bronquiales de volverse hiperplásicas y tortuosas en presencia de una lesión que modifica la arquitectura pulmonar, siendo más susceptibles a la ruptura. También hay descripciones de lesiones directas del parénquima pulmonar por aneurisma roto. El presente caso nos ilustra que debemos considerar a la hemoptisis como signo de alarma en el diagnóstico diferencial de los aneurismas y pseudoaneurismas aórticos entre otras causas que puede ser fatal en breve tiempo por una hemorragia masiva.

Pseudoaneurysm is defined as a reperfused pulsatile hematoma, encapsulated and communicated with the damaged vessel's lumen. It originates when there is a disruption of the arterial wall. Hemoptysis is a very rare sign/symptom of a thoracic aortic aneurysm or pseudoaneurysm. There is little information on hemoptysis associated with aortic aneurysm rupture, whose mechanisms are not explained by the presence of an aortopulmonary fistula. Among the hypotheses to explain this phenomenon, is the ability of the bronchial arteries to become hyperplasic and tortuous in the presence of a lesion that modifies the pulmonary architecture, being more susceptible to rupture. There are also descriptions of direct lung parenchymal injury from ruptured aneurysm. The present case illustrates that we must consider the hemoptysis as a warning sign in differential diagnosis of aortic aneurysms and pseudo aneurysms, among other causes, that it can be fatal in a short time due to massive hemorrhage.

Pseudoaneurisma roto de artéria ileocólica: relato de caso / Ruptured ileocolic artery pseudoaneurysm: case report

Resumo Os aneurismas de artérias viscerais (AAVs) e pseudoaneurismas de artérias viscerais (PAAVs) são condições raras e potencialmente letais quando rotos. Em geral, são encontrados incidentalmente na tomografia computadorizada de pacientes assintomáticos. Embora a cirurgia aberta convencional seja considerada atualmente o tratamento padrão ouro, a abordagem endovascular vem ganhando relevo por ser considerada um procedimento minimamente invasivo e com riscos cirúrgicos menores. Destaca-se, nessa abordagem, o uso de embolização por molas (coils) em AAVs e PAAVs saculares e implante de stent modulador de fluxo como alternativa de tratamento para aneurismas fusiformes. Apresentamos o caso de uma paciente de 51 anos com queixa de dor abdominal aguda, taquicardia e hipotensão, com evidência de sangramento abdominal em angiotomografia e diagnóstico de pseudoaneurisma de artéria ileocólica (AIC) roto. Ela foi submetida a tratamento endovascular precoce de embolização da AIC com sucesso, e houve melhora do quadro clínico.

Abstract Visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) are rare conditions and are potentially lethal when they rupture. They are usually found as incidental findings on computed tomography (CT) scans of asymptomatic patients. Although conventional open surgery is currently considered the gold standard treatment, the endovascular approach has gained prominence as a minimally invasive procedure with lower surgical risk. In this approach, use of coil embolization in saccular VAAs and VAPAs and implantation of flow-modulating stents constitute alternative treatments for fusiform aneurysms. We present the case of a 51-year-old female patient complaining of acute abdominal pain, tachycardia, and hypotension, with evidence of abdominal bleeding on CT angiography, who was diagnosed with a ruptured ileocolic artery (ICA) pseudoaneurysm. She underwent early endovascular treatment for ICA embolization, which was successful and achieved clinical improvement.

Inferolateral post-myocardial infarction pseudoaneurysm. A rare case report / Pseudoaneurisma pós-infarto inferolateral. Um raro relato de caso

ABSTRACT: We report the case of a 76-year-old male patient with a history of ST-segment elevation myocardial infarction (STEMI) for 3 years. He was admitted to the Emergency Room with a new chest pain episode that began 40 days before and was diagnosed with left ventricular (LV) pseudoaneurysm through 3D transthoracic echocardiography and cardiac magnetic resonance imaging scans. The patient underwent angiography of the coronary arteries, identifying lesions with a multiarterial pattern. Surgical treatment and LV aneurysmectomy were performed with good clinical evolution.

RESUMO: Relatamos um caso de paciente do sexo masculino, de 76 anos, com antecedente de infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) há 3 anos. Foi admitido na unidade de pronto-socorro com nova dor torácica de início há 40 dias, sendo diagnosticado com pseudoaneurisma do ventrículo esquerdo por meio de exames de imagem (ecocardiograma transtorácico tridimensional e ressonância magnética cardíaca), tendo sido submetido a estudo angiográfico das coronárias, com identificação de lesões com padrão multiarterial. Foi realizado tratamento cirúrgico, aneurismectomia do ventrículo esquerdo, com boa evolução clínica.

Pseudoaneurisma postraumático de arteria femoral en una niña de dos años / Post-traumatic pseudoaneurysm of the femoral artery in a two-years- old girl

Introducción: Los aneurismas arteriales son poco frecuentes en edad pediátrica, sin embargo; se observa un incremento en la incidencia de pseudoaneurismas a partir de traumatismos vasculares, sobre todo, por la aplicación de procederes invasivos. También se observan en procesos infecciosos y tumorales adyacentes, que acaban por lesionar la pared arterial. La mayoría suelen ser asintomáticos, o se presentan como una masa pulsátil que se asientan sobre la zona de la arteria afectada. Objetivo: Demostrar la importancia del diagnóstico temprano de los pseudoaneurismas para el tratamiento quirúrgico oportuno y evitar complicaciones posteriores. Presentación del caso: se discute un caso de una paciente de dos años de edad con un trauma vascular iatrogénico en la extremidad inferior derecha, que se manifestó como una tumoración pulsátil. Se realizó eco-doppler y angiografía, con lo que se diagnosticó un aneurisma de la arteria femoral derecha. Se realizó una exéresis y reconstrucción vascular con buena evolución. Conclusiones: El diagnóstico rápido de estas entidades vasculares evita que se presenten complicaciones posteriores y aseguran una evolución rápida y satisfactoria de los pacientes que las padecen(AU)

Introduction: Arterial aneurysms are rare in the pediatric ages. However, it is observed an increasement of the incidence of pseudoaneurysms caused by vascular traumas, mainly due to the use of invasive procedures. It is also present in infectious and tumour processes that end up injuring the arterial wall. Most of them are asymptomatic or are presented as a pulsatile mass that sets up over the affected artery's zone. Objective: To show the importance of early diagnosis of pseudo-aneurysms. Case presentation: It is presented the case of a two years old patient with a iatrogenic vascular trauma in the right lower limb that manifested in the way of a pulsatile tumor. Through an eco-Doppler and an angiography, an aneurysm of the right femoral artery was diagnosed, which led to an excision and a vascular reconstruction with good evolution. Conclusions: Early diagnosis of these vascular entities allows its timely surgical treatment, avoids the appearance of further complications and assures a prompt and satisfactorily evolution of the patients(AU)

Correção cirúrgica de pseudoaneurismas e fístula arteriovenosa complexa entre vasos poplíteos / Surgical repair of pseudoaneurysms and complex arteriovenous fistula between popliteal vessels

A fístula arteriovenosa (FAV) é uma comunicação anormal e permanente entre uma artéria e uma veia devido a traumas penetrantes e lesões iatrogênicas. O trauma penetrante na parede arterial pode levar à formação de pseudoaneurismas (PSA) e, se houver lesão venosa concomitante, à formação de uma FAV. Os autores apresentam o caso de um paciente portador de FAV complexa de vasos poplíteos associada a pseudoaneurisma de artéria poplítea, sugeridos a partir de exames clínicos e exames de imagem, e tratados por cirurgia convencional devido à indisponibilidade de um stent graft com diâmetro apropriado, além de a cirurgia endovascular não estar disponível no serviço em que o paciente foi operado

An arteriovenous fistula (AVF) is an abnormal and permanent communication between an artery and a vein caused by penetrating traumas or iatrogenic injuries. A penetrating trauma to the endothelial wall can lead to formation of pseudoaneurysms (PSA) and to formation of an AVF. Here, the authors present the case of a patient with a complex AVF of popliteal vessels, associated with popliteal artery pseudoaneurysm, suggested by clinical features and imaging exams, and treated with conventional surgery due to unavailability of a stent graft with appropriate diameter and because endovascular surgery isn't provided at the service where this patient was operated

Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: case report and literature review / Tratamento endovascular da hemorragia digestiva aguda por volumoso pseudoaneurisma esplênico: relato de caso e revisão da literatura

O pseudoaneurisma da artéria esplênica é uma entidade rara, com pouco mais de 150 casos descritos na literatura. A pancreatite é a etiologia mais comum, seguida do trauma. Em contraposição ao aneurisma verdadeiro, esse pseudoaneurisma é frequentemente sintomático, com risco de ruptura de 47% e mortalidade de 90%, quando não tratado. Descrevemos o caso de uma paciente de 48 anos que apresentou hemorragia gastrointestinal associada a pancreatite crônica agudizada. Durante investigação, a endoscopia evidenciou sinais de sangramento recente, e a angiorressonância de abdome observou volumoso pseudoaneurisma da artéria esplênica. Foi submetida a tratamento endovascular com embolização com micromolas, não apresentando novos episódios de sangramento. Atualmente, o tratamento endovascular é efetivo com baixa morbimortalidade e taxas de sucesso de 79-100%, sendo uma técnica viável para pacientes com processo inflamatório abdominal em franca atividade. Realizamos uma revisão das técnicas endovasculares e agentes embolizantes usados para o tratamento dessa patologia

Pseudoaneurysm of the splenic artery is a rare entity, with little more than 150 cases described in the literature. Pancreatitis is the most common etiology, followed by trauma. In contrast with true aneurysms, pseudoaneurysms are frequently symptomatic, with a 47% risk of rupture and 90% mortality if left untreated. We describe the case of a 48-year-old female patient who suffered a gastrointestinal hemorrhage associated with acute-on-chronic pancreatitis. During workup, endoscopy revealed signs of recent bleeding and magnetic resonance angiography of the abdomen showed a large pseudoaneurysm of the splenic artery. The patient underwent endovascular treatment with microcoil embolization and no further bleeding episodes occurred. Endovascular treatment is now an effective option with low morbidity and mortality and success rates in the range of 79-100%, making it a viable technique for patients with active abdominal inflammation. We conducted a review of endovascular techniques and embolization agents used to treat this pathology

Comparison of perioperative outcomes with or without renorrhaphy during open partial nephrectomy: A propensity score-matched analysis

ABSTRACT Purpose: Renorrhaphy in partial nephrectomy may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to the formation of renal artery pseudoaneurysms or vascularized parenchymal volume reduction. Using propensity score matching, we compared surgical outcomes following non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy (OPN) for T1a renal tumors. Materials and Methods: We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent OPN for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables were adjusted using 1:1 propensity score matching between the two Groups: renorrhaphy (inner and outer layer sutures) and non-renorrhaphy (inner layer sutures only). Postoperative complications and renal function were compared between the two groups. Results: We matched 43 patients per Group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the two Groups. Urine leakage (Clavien-Dindo grade ≥3) occurred in 0 renorrhaphy cases and 2 non-renorrhaphy cases (0% versus 4.6%, P=0.49). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases and in 0 non-renorrhaphy cases (13% versus 0%, P=0.02). Conclusions: The non-renorrhaphy technique may result in a lower risk of RAP but a greater risk of urine leakage. This technique needs further refinement to become a standard procedure for OPN.

Pseudoaneurisma traumático de la arteria temporal superficial, reporte de un caso / Traumatic pseudoaneurysm of the superficial temporal artery, report of a case

Los pseudoaneurismas son una causa infrecuente de masa palpable en cabeza y cuello, habitualmente secundarios a procedimientos intervencionales; trauma e infeccioso son casos aislados. Caso Clínico. Se presenta el caso de un niño de 14 años que luego de haber sufrido un trauma contuso cortante en la región preauricular izquierda intervenido quirúrgicamente, desarrolla al mes un aumento de volumen pulsátil tras un trauma menor en la zona. En la ecografía se aprecia el signo del yin yang, indicador de pseudoaneurisma. Se realiza en pabellón el vaciamiento del pseudoaneurisma y posterior sutura vascular sin incidentes. Discusión. Pese a la baja frecuencia de pseudoaneurisma como causa de masa en cabeza y cuello, se debe considerar como diagnóstico diferencial en el contexto de masas pulsátiles post traumáticas, de horas a días de evolución. El estudio de elección es la ecografía doppler y el Gold Standard del manejo es quirúrgico con sutura vascular.

Pseudoaneurysms are an infrequent cause of palpable mass in the head and neck; usually secondary to invasive procedures; trauma and infectious causes are rare. Clinical Case. We present the case of a 14-year-old boy who, after suffering a blunt contusive trauma in the left preauricular region surgically treated, develops a month later a pulsatile volume increase after a minor trauma in the area. Ultrasound shows the yin yang sign, indicator of pseudoaneurysm. The emptying of the pseudoaneurysm and subsequent vascular suture was performed without incident. Discussion. Despite the low frequency of pseudoaneurysm as a cause of mass in the head and neck, it should be considered as a differential diagnosis in the context of post-traumatic pulsatile masses, from hours to days of evolution. The study of choice is Doppler ultrasound and the Gold Standard treatment is surgery with vascular suture.

Pseudoaneurisma de aorta abdominal como complicação de pancreatite crônica: relato de caso / Abdominal aortic pseudoaneurysm as a complication of chronic pancreatitis: case report

A pancreatite crônica é uma enfermidade associada a diversas complicações vasculares, como pseudocisto hemorrágico, trombose do sistema venoso portal e formações varicosas e pseudoaneurismáticas. O pseudoaneurisma de aorta abdominal secundário à pancreatite crônica é uma complicação rara, de difícil suspeição clínica, que requer tratamento complexo. A fisiopatologia dessa condição envolve a corrosão enzimática tecidual após a liberação e ativação de enzimas exócrinas proteolíticas das células acinares do pâncreas. O presente estudo relata o caso de um paciente de 52 anos, etilista crônico, internado com dor abdominal difusa, cuja propedêutica revelou se tratar de um pseudoaneurisma em aorta infrarrenal. Optou-se pelo tratamento cirúrgico convencional, levando-se em consideração a idade, as condições clínicas do paciente e a disponibilidade de endopróteses compatíveis com o diâmetro da aorta

Chronic pancreatitis can be complicated by several vascular disorders, such as bleeding pseudocysts, thrombosis of the venous portal system, varicosities, and pseudoaneurysms. Pseudoaneurysm of the abdominal aorta secondary to chronic pancreatitis is a rare complication. It is a challenging clinical situation, demanding a high degree of clinical suspicion, and requires complex therapeutic procedures. The pathophysiology of this condition involves interstitial liberation and activation of enzymes from the exocrine pancreatic glands and subsequent digestion of the surrounding tissues. In the present case report, we describe a 52-year-old patient complaining of diffuse abdominal pains. Clinical investigation revealed chronic alcoholism and imaging examinations showed a pseudoaneurysm of the infrarenal aorta. We decided to perform conventional surgical treatment after considering the patient's age and clinical status and the endoprostheses available at our hospital with diameters compatible with the patient's aorta