Internal carotid artery aneurysm mimicking normal-tension glaucoma.

Differentiating glaucomatous from nonglaucomatous optic disc cupping remains challenging. We present a case of a 48-year-old woman with an internal carotid aneurysm of approximately 3.5 mm × 6.5 mm that mimicked normal-tension glaucoma. The patient had a 2-year history of low vision acuity in her left eye and frontal oppressive headache. Owing to the carotid aneurysm, she developed an asymmetric vertical cup-to-disc ratio above 0.2, and marked inferotemporal neuronal rim loss and pallor of the residual rim were noted in the left disc. She also developed a visual field defect with an arcuate scotoma in the left eye. The patient was referred to a neurosurgeon and underwent endovascular aneurysm occlusion. This case highlights the diagnostic importance of recognizing that many neurological defects remain underdiagnosed.

Multiple Enlarged Aneurysms in Primary Racemose Hemangioma of the Bronchial Artery: Successful Prophylactic Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate and Coils.

An asymptomatic 48-year-old man presented with multiple aneurysms in a primary racemose hemangioma of the right bronchial artery. Bronchial arteriography revealed a tortuous artery with four fusiform aneurysms of varying sizes and aneurysmal dilatation with marked thrombus formation in the long segment of the distal portion. Because the tip of catheter could not pass beyond the aneurysmal dilatation, we performed balloon-occluded embolization using a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized oil. For four other aneurysms, we performed embolization using a coil alone or with NBCA. After 6 months, right bronchial arteriography revealed no enhancement of the aneurysms. Despite the rarity of this procedure, embolization with NBCA is a good option for bronchial artery aneurysm embolization.

[TREATMENT DILEMMAS IN BEHÇET'S SYNDROME].

Behçet's disease is an inflammatory systemic disorder, characterized by a relapsing and remitting course, it manifests with oral and genital ulcerations, skin lesions, uveitis, vasculitis, central nervous system and gastrointestinal involvement. The main histopathological finding is widespread vasculitis of the arteries and veins. Therapy is variable and depends largely on the severity of the disease and organ involvement. There is common practice to treat with anticoagulation in patients suffering from vessel thrombosis, but there are no control trials to support this tendency. Anticoagulation treatment can cause major bleeding events in patients suffering from aneurysms. In this case report we describe a treatment dilemma in a patient suffering from deep vein thrombosis and pulmonary aneurysms.

Successful treatment of central retinal artery thromboembolism with ocular massage and intravenous acetazolamide.

A 67-year-old woman presented with left-sided headache and blurred vision, worse during hypertensive episodes. CT angiography showed a 4 mm left internal carotid artery (ICA) aneurysm incorporating the ophthalmic artery. She passed a test balloon occlusion, so the aneurysm was coil occluded, without immediate complication. Four days postprocedure she experienced sudden loss of vision in the left eye and funduscopy showed central retinal artery occlusion secondary to emboli from the coiled aneurysm. She was treated promptly with intravenous acetazolamide and ocular massage and regained full visual acuity. Thromboembolism to the eye during or after neurointerventional treatment is a relatively rare but devastating complication. This report demonstrates the effectiveness of combined intravenous acetazolamide and ocular massage in dealing with this complication when delivered promptly.

Basic study of a mixture of N-butyl cyanoacrylate, ethanol, and lipiodol as a new embolic material.

PURPOSE: To clarify the configuration change of N-butyl cyanoacrylate (NBCA) polymerization with increasing proportion of ethanol, the properties of a mixture of NBCA with lipiodol plus ethanol (NLE), and the feasibility of use of NLE for aneurysm packing in a swine model. MATERIALS AND METHODS: The polymerization configuration of NLE was explored using ratios of 1-4 parts NBCA and 1-3 parts ethanol per 1 part of lipiodol; a 1:1 ratio of NBCA to lipiodol (NLE110) was used as a control. The distance that NLE migrated into saline flowing in a tube was measured. A carotid artery aneurysm was created in each of 18 swine. Aneurysmal packing with three configurations--NLE110, NLE at a ratio of 1:1:2 (NLE112), and NLE at a ratio of 1:1:3 (NLE113)--was attempted in six swine for each configuration. RESULTS: Regardless of NBCA composition, medium-sized droplets, a single large droplet, and a noodle-shaped extrusion were observed in NLE with lipiodol versus ethanol ratios of 1:1, 1:2, and 1:3. NLE110 migrated as viscous fluid to 190 cm from the injection site, whereas NLE112 migrated for 81 cm ± 11 and NLE113 migrated for 74 cm ± 9. Instant outflow of NLE110 from the six aneurysms caused occlusion of the parent artery, with adhesion to the microcatheter. Packing was achieved with minimal adhesion for all six of the aneurysms packed with NLE112 or with NLE113. CONCLUSIONS: With high ratios of ethanol, the NLE polymerization configuration acquired solid-like properties with potent occlusive ability and negligible adhesion to the microcatheter, suggesting its feasibility for packing of aneurysms.

Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms.

The objective of this study was to investigate the effect of transcatheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA)-Lipiodol mixture in patients with bronchial artery aneurysm (BAA). From January 2005 to January 2010, five patients presenting hemoptysis with six BAAs were treated with NBCA-Lipiodol mixture, including intra-aneurysm embolization (IAE) in one patient. Adjuvant embolization with spherical polyvinyl alcohol (PVA) embolic microparticles or NBCA was first performed to embolize the distal engorged bronchiectatic arteries. Bronchial arterial angiography showed six BAAs (four in the right lobe and two in the left lobe) and some engorged, tortuous bronchial arteries. TAE through microcatheter was successful in all cases. Postembolization angiogram demonstrated the NBCA cast and total occlusion of BAAs and bronchiectatic engorged vessels. After these procedures, hemoptysis completely disappeared in all patients. Follow-up computed tomography (CT) scan was performed at an average of 3 months (range 2 to 6), which showed no enhancement of BAAs and accumulation of NBCA. TAE is a minimally invasive, effective, and reliable approach for treatment for patients with BAA. NBCA-Lipiodol mixture provides a good choice for treatment of BAA, especially when catheterization of the efferent branches is impossible.

Assessment of EmboGel--a selectively dissolvable radiopaque hydrogel for embolic applications.

PURPOSE: To evaluate the embolic properties of an alginate-based embolic biomaterial (EmboGel) and its solvent (EmboClear) in treatment of aneurysms. MATERIALS AND METHODS: EmboGel is a mixture of iohexol and alginate that polymerizes into a hydrocoil when delivered through a coaxial catheter with a distal mixing tip, exposing alginate to a calcium chloride solution. In contrast to previously reported embolic agents, EmboGel can be selectively dissolved by EmboClear, a mixture of the enzyme alginate lyase and ethylenediaminetetraacetic acid (EDTA). The embolic and contrast properties of EmboGel were assessed in in vitro models of saccular aneurysm and an aortic aneurysm endoleak. The dissolvability of EmboGel with EmboClear was assessed further after endovascular delivery in the New Zealand white rabbit in the native aortoiliofemoral territory, a created saccular aneurysm, and the native carotid arteries. RESULTS: EmboGel effectively filled aneurysm cavities in the case of stent excluded saccular and fusiform aneurysms. EmboGel was readily dissolved by EmboClear in vitro and after in vivo embolization. When the distal abdominal aorta and pelvic arteries were occluded with EmboGel, within 1 minute of EmboClear infusion, patency of the aorta and most of the pelvic circulation was regained as noted by angiography. Embolization in the subclavian artery and numerous distal branches was rapidly dissolved by EmboClear. Finally, the carotid artery occluded with EmboGel regained patency after administration of EmboClear. CONCLUSIONS: EmboGel is a dissolvable alginate-based biomaterial that can be used for numerous embolic applications. EmboGel can be selectively dissolved with EmboClear, a solution of alginate lyase and EDTA.

Pancreatitis after transcatheter embolization of a splenic aneurysm.

A 52-year-old woman was treated for a splenic aneurysm that was found on abdominal computed tomography (CT) during a preoperative assessment for rectal cancer. The aneurysm was embolized using the "double coil-delivered microcatheter technique," and 4 ml of a mixture of N-butyl 2-cyanoacrylate (NBCA) and iodized oil (Lipiodol) (NBCA/Lipiodol = 1.0: 2.5) were injected into the aneurysm. The patient complained of left upper quadrant abdominal pain immediately after the procedure. A blood test 2 days after the procedure showed an increased white blood cell count (13,100/microl), C-reactive protein (13.36 mg/dl), and pancreatic amylase (428 U/l). Abdominal CT scan showed a huge cystic lesion at the pancreatic tail, in the center of which was a highly enhanced area due to accumulated NBCA-Lipiodol. Postembolization pancreatitis was diagnosed, and treatment with fasting and a drip infusion of nafamostat mesilate was started. The patient's abdominal pain became less severe within 3 days, and the pancreatic enzyme level had normalized 14 days after treatment. On CT, the cystic lesion at the pancreatic tail was smaller 20 days after the procedure, and it had disappeared completely 75 days after the procedure.

Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications.

PURPOSE: To describe a 10-year experience of endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis, and to analyze this experience and propose a classification based on computed tomography (CT) and angiographic findings that has therapeutic implications. This may reduce the rate of recurrent bleeding after surgery or endovascular treatment. MATERIALS AND METHODS: Twenty-three patients with aneurysms or pseudoaneurysms associated with acute pancreatitis were treated by endovascular or percutaneous methods. All underwent CT and angiography. The early development of a simple classification based on the CT and angiographic findings was used to guide treatment decisions. In accordance with this classification, 19 patients were treated by primary coil embolization and four were treated by primary percutaneous thrombin injection. RESULTS: Among the 19 patients treated by primary coil embolization, there were two early recurrences of the pseudoaneurysm. All four patients treated by percutaneous thrombin injection exhibited late recurrences and were successfully treated by percutaneous thrombin injections. Twenty-one patients (91.3%) were alive at 6 months. CONCLUSIONS: Endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis is safe and effective and is associated with good outcomes, but careful follow-up is necessary. The decision of which treatment option is most appropriate can be made in accordance with a classification based on CT and angiographic appearance.

Bronchial artery aneurysm embolization with NBCA.

We present a case of asymptomatic bronchial artery aneurysm that formed a fistula with part of the pulmonary artery (there was no definite fistula with the pulmonary vein). We were able to catheterize the feeding vessel but could not reach the aneurysm. We therefore injected a mixture of N-butyl-2-cyanoacrylate (NBCA; Histoacryl, B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) from the feeding vessel. The fistula, aneurysm, and feeding vessel were almost totally occluded. After embolization, the patient coughed a little; there were no other definite side effects or complications. One and 3 months later, on chest CT, the aneurysm was almost completely occupied with hyperattenuating NBCA-Lipiodol embolization. NBCA is a liquid embolization material whose time to coagulation after injection can be controlled by diluting it with Lipiodol. It is therefore possible to embolize an aneurysm, feeding vessels, and efferent vessels (in our case, it was a fistula) by using an NBCA-Lipiodol mixture of an appropriate concentration, regardless of whether the catheter can reach the aneurysm or not.

Popliteal aneurysm as a cause of leg pain in a geriatric patient.

OBJECTIVE: To discuss the management of a patient with unilateral lower extremity pain as a consequence of a popliteal aneurysm. CLINICAL FEATURES: An 85-year-old male had difficulty in ambulating due to low back and lower extremity pain. Standard tests demonstrated and reproduced pain at the lower back while inspection, palpation, and auscultation revealed a pulsatile mass in the popliteal fossa of the right knee. INTERVENTION AND OUTCOME: Specific joint manipulation for relief of low back pain was performed. Comanagement of the patient with a vascular surgeon and subsequent surgical intervention resulted in relief of lower extremity pain. CONCLUSION: Resolution of pain and guarded gait was accomplished by a multidisciplinary approach combining conservative care and invasive techniques.

Venous aneurysm of the cephalic vein: report of a case.

We herein report the rare case of a 41-year-old Japanese woman in whom a venous aneurysm in the left cephalic vein was excised under local anesthesia. Histological examination revealed significant diminution in the number and size of muscle and elastic fibers in the aneurysm wall. Conceivably, a combination of endophlebohypertrophy and a congenital focal defect of the elastic and muscle fibers might have contributed to the development of this venous aneurysm.

[Experiences with the endovascular embolization therapy of aneurysms of the splanchnic arteries--a report on 13 cases]. / Erfahrungen mit der endovaskulären Embolisationstherapie von Aneurysmata der Splanchnikusarterien--Bericht über 13 Fälle.

PURPOSE: The authors report on their experience in endovascular embolization therapy in 13 cases with splanchnic artery aneurysms or pseudoaneurysms. PATIENTS AND METHODS: Three patients suffered from true aneurysms, ten patients presented pseudoaneurysms of different origin. Eight patients were transferred to our department for life-threatening intestinal bleeding. Five patients showed transpapillary bleeding, four of whom presented with haemobilia and one patient had intermittent bleeding into the pancreatic duct due to a true aneurysm of the splenic artery. Embolization was performed using a coaxial microcatheter coil delivery system. In 4 patients the aneurysm-bearing vessel was temporarily blocked during the intervention. RESULTS: In 11 patients definite occlusion of the aneurysm was obtained without surgical intervention. In one patient, suffering from a splenic aneurysm, we observed a partial inadvertent embolisation of the spleen which did not require further treatment. In one case, rupture of an hepatic aneurysm during embolization occurred. One patient with pseudoaneurysm due to displacement of a port catheter showed severe rebleeding one day after embolisation. CONCLUSION: Transcatheter embolization is an effective method for treatment of aneurysms of the splanchnic arteries. To avoid life-threatening bleeding due to rupture of the aneurysm, the feeding vessel should be temporarily blocked during embolization therapy.

Multiple intrahepatic aneurysms following transcatheter arterial embolization. Work in progress.

PURPOSE: To discuss the mechanism of multiple intrahepatic aneurysm formation after transcatheter arterial embolization (TAE) performed in five patients with hepatocellular carcinoma. MATERIALS AND METHODS: TAE was performed with gelatin sponge particles and iodized oil as embolic materials. Mitomycin C was also used in four cases. RESULTS: Three to 14 aneurysms 1-6 mm in diameter were found in third-to sixth-order branches of the hepatic arteries at repeat angiography performed 25-45 days after TAE. Follow-up angiograms in three cases revealed that most aneurysms were no longer apparent except in one patient in whom two aneurysms remained and were larger than before. In none of the five cases were any signs of aneurysm rupture noted. CONCLUSION: Radiologists should be aware of this complication of TAE. It is speculated that the main cause of aneurysm formation in these patients was the embolic agents used.

Pseudoaneurysm of common iliac artery mimicking colonic metastasis on double-contrast barium enema.

We describe a patient with a pseudoaneurysm of the right common iliac artery that on a double-contrast barium enema mimicked the appearance of metastatic tumor involving the sigmoid colon, including a mass effect and spiculated, tethered mucosal folds. In the appropriate clinical setting, computed tomography, magnetic resonance imaging, and aortography help to distinguish a pseudoaneurysm from metastatic tumor involving the bowel.

Lumbar artery aneurysm with acute aortic occlusion resulting from chiropractic manipulation: a case report.

A 44-year-old man with an acute aortic occlusion after chiropractic manipulation was found to have a lumbar artery aneurysm. This article presents a previously undescribed entity, a lumbar artery aneurysm, which manifested as a unique cause of distal aortic occlusion in a patient with chronic back pain.

Surgery of vertebrobasilar aneurysms and nimodipine.

Five patients among 60 consecutive patients suffering from recent subarachnoid hemorrhage were operated for ruptured vertebrobasilar aneurysm. Topical nimodipine treatment was given during the operation after clipping and continued systemically for three weeks. One out of the five patients developed symptoms which could be ascribed to delayed arterial vasospasm. Nimodipine may be advantageous in preventing ischemic complications when used prophylactically. Further investigation is needed to elucidate its efficacy in cases of vertebrobasilar aneurysms and conventional timing of surgery.