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1.
World Neurosurg ; 138: e579-e590, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32165343

RESUMO

BACKGROUND: The interhemispheric approach (IHA) provides an excellent surgical corridor for clipping anterior communicating artery aneurysms (AcoAAs). However, an important disadvantage of the approach is obtaining proximal control at A1 in the last stage of dissection, especially in anterior or superior projecting AcoAAs and ruptured cases. We describe and evaluate the microsurgical clipping of AcoAAs using the IHA with early A1 exposure. METHODS: This was a retrospective descriptive study in patients with AcoAA who received microsurgical clipping through the IHA with early A1 exposure between April 2016 and May 2019. Aneurysm morphology, projection, completeness of clipping, surgical complications, and outcomes were collected from medical records. RESULTS: Twenty-five patients with AcoAA received microsurgical clipping via the IHA with early A1 exposure. Twenty-three patients (92%) presented with subarachnoid hemorrhage. Intraoperative rupture while dissecting the interhemispheric fissure occurred in 2 cases, for which proximal control via subfrontal route was effectively performed. Of the patients, 100% achieved complete obliteration of their aneurysms. Postoperative anosmia was detected in 22.7%. In ruptured cases, 16 (88.9%) of the good grade patients achieved a good outcome (Glasgow Outcome Scale scores of 4 and 5) at 3 months after the operation. CONCLUSIONS: The IHA with early A1 is safe and effective for clipping AcoAAs.


Assuntos
Artéria Cerebral Anterior/cirurgia , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/patologia , Aneurisma Roto/cirurgia , Artéria Cerebral Anterior/patologia , Craniotomia , Dura-Máter/cirurgia , Feminino , Escala de Resultado de Glasgow , Humanos , Aneurisma Intracraniano/patologia , Complicações Intraoperatórias/cirurgia , Masculino , Microcirurgia , Pessoa de Meia-Idade , Transtornos do Olfato/etiologia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Hemorragia Subaracnóidea/patologia , Hemorragia Subaracnóidea/cirurgia , Resultado do Tratamento
2.
BMC Neurol ; 20(1): 70, 2020 Feb 29.
Artigo em Inglês | MEDLINE | ID: mdl-32113481

RESUMO

BACKGROUND: In aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms (MIAs) identification of the bleeding source cannot always be assessed according to the hemorrhage pattern. Therefore, we developed a statistical model for the prediction of the ruptured aneurysm in patients with SAH and multiple potential bleeding sources at the time of ictus. METHODS: Between 2012 and 2015, 252 patients harboring 619 aneurysms were admitted to the authors' institution. Patients were followed prospectively. Aneurysm and patient characteristics, as well as radiological findings were entered into a computerized database. Gradient boosting techniques were used to derive the statistical model for the prediction of the ruptured aneurysm. Based on the statistical prediction model, a scoring system was produced for the use in the clinical setting. The aneurysm with the highest score poses the highest possibility of being the bleeding source. The prediction score was then prospectively applied to 34 patients suffering from SAH and harboring MIAs. RESULTS: According to the statistical prediction model the main factors affecting the rupture in patients harboring multiple aneurysms were: 1) aneurysm size, 2) aneurysm location and 3) aneurysm shape. The prediction score identified correctly the ruptured aneurysm in all the patients that were used in the prospective validation. Even in the five most debatable and challenging cases assessed in the period of prospective validation, for which the score was designed for, the ruptured aneurysm was predicted correctly. CONCLUSIONS: This new and simple prediction score might provide additional support for neurovascular teams for treatment decision in SAH patients harboring multiple aneurysms. In a small prospective sample, the prediction score performed with high accuracy but larger cohorts for external validation are warranted.


Assuntos
Aneurisma Roto/patologia , Aneurisma Intracraniano/patologia , Modelos Estatísticos , Hemorragia Subaracnóidea/patologia , Adulto , Idoso , Aneurisma Roto/complicações , Feminino , Humanos , Aneurisma Intracraniano/complicações , Masculino , Pessoa de Meia-Idade , Neuroimagem , Estudos Prospectivos , Hemorragia Subaracnóidea/etiologia
3.
World Neurosurg ; 137: e138-e143, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32004740

RESUMO

BACKGROUND: Mirror intracranial aneurysms with different rupture status is a useful model to investigate features associated with aneurysm rupture. Morphological and hemodynamic analyses of ruptured middle cerebral artery (MCA) mirror aneurysms are rarely reported. The purpose of this study was to determine the morphological or hemodynamic characteristics associated with ruptured MCA mirror aneurysms. METHODS: We performed a retrospective analysis of consecutive 317 patients with MCA aneurysms. Ruptured MCA mirror aneurysms (1 ruptured and mirror unruptured aneurysm) were included. In the matched pairs of ruptured and unruptured mirror aneurysms, 13 morphological parameters were measured using 3-dimensional computed tomography angiography and 6 hemodynamic parameters were evaluated using high-resolution computational fluid dynamic simulations. The association of morphological and hemodynamic characteristics with the rupture of MCA mirror aneurysms was determined. RESULTS: A total of 20 (6.31%) patients with 40 MCA mirror aneurysms were included in this study. There were significant differences in morphological and hemodynamic parameters between the ruptured and unruptured mirror aneurysms. Irregular aneurysms were 3 times more common in the ruptured aneurysms than in the unruptured aneurysms. A larger aneurysm (P = 0.025), a higher aneurysm (P = 0.020), a larger size ratio (P = 0.009), a higher bottleneck ratio (P = 0.033), an irregular aneurysm (P = 0.022), a higher maximum intra-aneurysmal wall shear stress (WSS; P = 0.020), and a lower normalized average WSS (P = 0.008) were associated with MCA mirror aneurysm rupture. CONCLUSIONS: Larger aneurysms, a larger size ratio, irregular aneurysms, a lower spatial average WSS, and a higher maximum WSS may contribute to evaluating the risk of rupture of MCA aneurysms independent of patient characteristics.


Assuntos
Aneurisma Roto/complicações , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/patologia , Artéria Cerebral Média/patologia , Aneurisma Roto/patologia , Angiografia Digital/métodos , Angiografia Cerebral/métodos , Feminino , Hemodinâmica/fisiologia , Humanos , Hidrodinâmica , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Estudos Retrospectivos , Estresse Mecânico
4.
J Neurol Surg A Cent Eur Neurosurg ; 81(2): 177-184, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31935782

RESUMO

BACKGROUND: Advances in the endovascular armamentarium, such as flow diversion and stenting devices, provide treatment options for posterior circulation intracranial aneurysms (IAs) with complex angioarchitecture. Delayed IA rupture following flow diversion is a rare but often fatal complication. Giant IAs likely pose a higher risk because of the extensive clot formation and its suspected detrimental effect on the aneurysmal wall. However, mechanisms that lead to delayed rupture are poorly understood, and few cases provide thorough documentation of macroscopic and histologic findings. CLINICAL PRESENTATION: After our 60-year-old patient with a giant basilar aneurysm underwent treatment with a LEO stent, the postoperative clinical course remained uneventful until day 4 when he suffered an unexpected fatal subarachnoid hemorrhage (SAH). Autopsy demonstrated extensive hemorrhage, large intraluminal thrombus, and ruptured IA wall. The aneurysm, which ruptured linearly, was completely filled with a clot that seemed to have outgrown the thin aneurysm wall. Histologic specimens revealed thinning and degenerative changes of the aneurysm's wall, and sparse neutrophilic and histiocytic inflammatory infiltrate adjacent to the rupture site, a finding consistent with recently published cases of IA rupture. CONCLUSIONS: Our case report highlighting the clinical course and autopsy findings of a fatal SAH shortly after stenting this giant basilar artery aneurysm adds to the few previously reported fatal cases of IA rupture after endovascular treatment. Our macroscopic and histologic findings suggested that multimodal changes of inflammation, wall sheer tress (mechanical), and recanalization were involved.


Assuntos
Aneurisma Intracraniano/etiologia , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Stents/efeitos adversos , Aneurisma Roto/etiologia , Aneurisma Roto/patologia , Autopsia , Evolução Fatal , Humanos , Aneurisma Intracraniano/patologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/patologia , Hemorragia Subaracnóidea/etiologia
5.
World Neurosurg ; 136: e300-e309, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31901493

RESUMO

OBJECTIVE: Although the risk of aneurysm remnants after microsurgical clipping is generally low, complete aneurysm occlusion is not always guaranteed. We performed a morphometric analysis of intracranial aneurysms to identify predictors for aneurysm remnants and to propose a novel risk score. METHODS: This is a retrospective, single-center analysis of consecutive patients with ruptured and unruptured aneurysms who underwent microsurgical clipping and postoperative digital subtraction angiography between 2010 and 2018. Based on preoperative rotational angiography, distinct morphologic aneurysm characteristics were determined and correlated with postoperative angiographic results. Factors predictive in the univariate and multivariate analyses were determined to establish a risk score for postoperative remnants after aneurysm clipping. RESULTS: Among 140 patients with 166 clipped aneurysms, aneurysm remnants were present in 19.9%. In the multivariate analysis, ruptured aneurysm status (odds ratio [OR], 7.8; 95% confidence interval [CI], 1.7-36; P < 0.01) and increased aspect ratio (OR, 1.9; 95% CI, 1.0-4.0; P = 0.07) were associated with postoperative aneurysm remnants. Anterior communicating artery location (P = 0.02), internal carotid artery location (P = 0.06), increased aneurysm inclination angle (P < 0.01), and irregular aneurysm shape (P = 0.07) were further predictors for aneurysm remnants in the univariate analysis. These factors were weighted and included into a risk sum score for postoperative aneurysm remnants (range, 0-8 points), which performed with good accuracy (area under the curve = 0.807). CONCLUSIONS: After external validation of the proposed risk score, it could help identify cases requiring angiographic control after aneurysm surgery.


Assuntos
Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adolescente , Adulto , Idoso , Aneurisma Roto/patologia , Aneurisma Roto/cirurgia , Feminino , Humanos , Masculino , Microcirurgia/instrumentação , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/instrumentação , Estudos Retrospectivos , Fatores de Risco , Instrumentos Cirúrgicos , Adulto Jovem
6.
World Neurosurg ; 136: e660-e670, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31996334

RESUMO

BACKGROUND: Since the International Subarachnoid Aneurysm Trial, coiling has been favored over clipping for intracranial aneurysms, resulting in selection of increasingly complex aneurysm configurations for clipping. We present the outcomes of clipping of aneurysms not suitable for coiling, with transit time flowmetry technology to aid monitoring of intraoperative flow. METHODS: All consecutive patients surgically treated for intracranial aneurysms were included. We assessed intraoperative arterial blood flow in relation to postoperative ischemia and unfavorable outcome (modified Rankin Scale score 3-6), along with radiological occlusion rate, at 6 months and 1 year after surgery. RESULTS: Mortality at 1 year was 7.9%, with a 21.6% rate of an unfavorable outcome. Almost all (96.1%) of patients with unruptured aneurysms had an favorable outcome at 1 year, compared with 71.9% of patients with aneurysmal subarachnoid hemorrhage. Postoperative computed tomography imaging showed an 86.7% occlusion rate and a 7.5% rate of clip-related ischemia. Flow <40% of baseline significantly predicted clip-related ischemia (odds ratio [OR], 5.14; 95% confidence interval [CI], 1.41-8.4; P = 0.012). Clip reposition aided by transit time flowmetry resulted in restored flow >50% above baseline flow in 85.7% of aneurysms. Less than 50% flow from baseline was an independent predictor of unfavorable outcome (OR, 3.85; 95% CI, 1.6-9.0; P = 0.001), along other risk factors. CONCLUSION: In this study of clinical and radiological outcomes of surgically treated cerebral aneurysms not suitable for unassisted coiling, we showed positive results for these challenging aneurysms, aided by transit time flowmetry as a valuable tool, providingquantitative measurements of arterial blood flow to help achieve optimal clip placement and minimizing aneurysm residuals that may be sites of rebleeding. Adequate flow, defined as ≥50% of baseline, greatly reduces the risk of unfavorable outcome.


Assuntos
Aneurisma Roto/cirurgia , Aneurisma Intracraniano/cirurgia , Adulto , Idoso , Aneurisma Roto/mortalidade , Aneurisma Roto/patologia , Angiografia Digital/métodos , Angiografia por Tomografia Computadorizada/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Aneurisma Intracraniano/mortalidade , Aneurisma Intracraniano/patologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Resultado do Tratamento
7.
World Neurosurg ; 134: 141-144, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31698118

RESUMO

BACKGROUND: Subarachnoid hemorrhage resulting from spontaneous perforation of a small intracranial vessel, with resultant pseudoaneurysm formation, has not been widely reported in the literature. CASE DESCRIPTION: We present the case of a 71-year-old patient with rupture of a small aneurysm of a duplicated left anterior choroidal artery causing an acute third nerve palsy. The aneurysm was not able to be treated endovascularly without sacrifice of the parent vessel. At surgery, a pseudoaneurysm was seen completely separate from the parent vessel, which was actively bleeding through a hole in the vessel. The pseudoaneurysm was indenting the oculomotor nerve. After confirmation of adequate collateral flow, the abnormal segment of vessel was trapped and the pseudoaneurysm removed with surrounding clot. The patient's cranial nerve palsy resolved. CONCLUSIONS: This case illustrates an unusual sequela of subarachnoid hemorrhage presenting a unique challenge in surgical management.


Assuntos
Falso Aneurisma/patologia , Aneurisma Intracraniano/patologia , Hemorragia Subaracnóidea/etiologia , Idoso , Falso Aneurisma/complicações , Falso Aneurisma/cirurgia , Aneurisma Roto/complicações , Aneurisma Roto/patologia , Aneurisma Roto/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Perfuração Espontânea/complicações , Perfuração Espontânea/patologia , Perfuração Espontânea/cirurgia
8.
J Forensic Sci ; 65(2): 649-654, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31553499

RESUMO

Fibromuscular dysplasia is an idiopathic, nonatheromatous, and noninflammatory arterial disease that most commonly affects the renal and carotid arteries. We report a child with subarachnoid and ocular hemorrhage associated with an aneurysm due to fibromuscular dysplasia. Computed tomography following a witnessed collapse revealed diffuse subarachnoid hemorrhage and severe cerebral edema. An autopsy confirmed the radiographic findings and detected bilateral retinal hemorrhages, optic nerve sheath hemorrhages, and a ruptured saccular aneurysm due to focal fibromuscular dysplasia involving the intracranial right vertebral artery. This case documents a fatal subarachnoid hemorrhage in a child with an intracranial saccular aneurysm caused by fibromuscular dysplasia. The associated retinal hemorrhages are easily detected by postmortem monocular indirect ophthalmoscopy.


Assuntos
Aneurisma Roto/patologia , Displasia Fibromuscular/diagnóstico , Aneurisma Intracraniano/patologia , Doenças do Nervo Óptico/patologia , Hemorragia Retiniana/patologia , Hemorragia Subaracnóidea/patologia , Morte Encefálica , Pré-Escolar , Patologia Legal , Hematoma Subdural/patologia , Hemorragia/patologia , Humanos , Masculino
9.
World Neurosurg ; 134: 79-85, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31669242

RESUMO

BACKGROUND: Segmental arterial mediolysis (SAM) is a rare non-atherosclerotic, noninflammatory vascular disease, characterized by mediolysis. We report an extremely rare case of subarachnoid hemorrhage (SAH) due to a ruptured blood blister-like aneurysm (BBA) of the internal carotid artery associated with SAM-related arteriopathy. CASE DESCRIPTION: We experienced a case of SAH followed by intraperitoneal hemorrhage that occurred 12 days after the SAH onset. SAH was caused by a ruptured BBA of the internal carotid artery, which was treated by trapping with high-flow bypass. Intraperitoneal hemorrhage was caused by a rupture of a posterior inferior pancreaticoduodenal artery (PIPDA) aneurysm, which induced hypovolemic shock resulting in death in spite of endovascular internal trapping. Postmortem pathologic examination revealed that the PIPDA pseudoaneurysm was due to SAM. CONCLUSIONS: We should pay attention to the association of SAM, which is a potentially life-threatening pathology when treating cerebral BBAs.


Assuntos
Aneurisma Roto/patologia , Artéria Carótida Interna/patologia , Artéria Mesentérica Superior/patologia , Túnica Média/patologia , Doenças Vasculares/patologia , Aneurisma Dissecante/etiologia , Aneurisma Dissecante/patologia , Aneurisma Roto/etiologia , Hemorragia/etiologia , Hemorragia/patologia , Humanos , Aneurisma Intracraniano/etiologia , Aneurisma Intracraniano/patologia , Masculino , Pessoa de Meia-Idade , Doenças Vasculares/complicações
10.
World Neurosurg ; 133: e320-e326, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31520758

RESUMO

BACKGROUND: Compared with intracranial aneurysms (IAs) at other locations, pericallosal artery aneurysms (PAAs) have demonstrated an extremely high risk of rupture. However, owing to their rarity, our understanding of their morphological characteristics has been limited, and whether the morphological characteristics of PAAs contribute to this high rupture risk has remained unexplored. In the present study, we aimed to provide a detailed description of the morphological characteristics of PAAs and investigate the association between its morphology and rupture risk compared with anterior circulation IAs at other locations. METHODS: A total of 40 patients with 45 PAAs and 348 patients with 392 anterior circulation IAs at other locations were recruited. The clinical and radiological data for these patients were retrospectively reviewed. The differences in the morphological parameters, including the aneurysm diameter, neck width, height, width, parent artery diameter, inflow angle, aspect ratio (AR), size ratio (SR), and aneurysm diameter/width ratio, between PAAs and other IA groups were compared. RESULTS: Of the 45 PAAs, 22 (48.9%) had ruptured. The proportion of ruptured aneurysms was greater for PAAs than for anterior circulation IAs at other locations. For both ruptured and unruptured anterior circulation IAs, PAAs had the highest AR and SR among all IA groups and had the largest inflow angle. CONCLUSION: The morphological characteristics of PAAs are unique. Compared with other anterior circulation IAs, PAAs have significantly increased ARs, SRs, and inflow angles, which, ultimately, promote their high propensity toward rupture.


Assuntos
Aneurisma Roto/diagnóstico por imagem , Artéria Cerebral Anterior/diagnóstico por imagem , Angiografia Cerebral/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Adolescente , Adulto , Idoso , Aneurisma Roto/epidemiologia , Aneurisma Roto/patologia , Artéria Cerebral Anterior/patologia , Corpo Caloso/irrigação sanguínea , Suscetibilidade a Doenças , Feminino , Humanos , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
11.
World Neurosurg ; 135: e710-e715, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31887464

RESUMO

BACKGROUND: Coil protrusion occasionally occurs during embolization and can lead to thromboembolic complications. We aimed to evaluate the efficacy of rescue stenting procedures with a low-profile stent system (LVIS Jr.) for treating ruptured intracranial aneurysms during complicated coil embolization. METHODS: We performed a retrospective review to identify patients who had subarachnoid hemorrhage and were treated with LVIS Jr. stent rescue therapy. We enrolled 15 patients with intracranial aneurysms and evaluated the technical success and immediate postprocedural clinical and angiographic outcomes. RESULTS: All 15 patients underwent successful rescue-stent treatment, and no thrombotic or hemorrhagic complications occurred. Immediate postprocedural angiography revealed complete aneurysm occlusion in 40% (6/15) of the patients, whereas 60% (9) of the patients had a residual neck. Among the 12 patients who underwent follow-up angiography, 10 (83.3%) patients had complete aneurysm occlusion, 1 (8.3%) had a residual neck, and 1 (8.3%) showed an increase in the filling status of the aneurysm. There were no thrombotic complications during the follow-up period. CONCLUSIONS: Our findings indicate that LVIS Jr. stent rescue therapy is clinically useful for handling coil protrusion during the embolization of ruptured intracranial aneurysms.


Assuntos
Aneurisma Roto/terapia , Embolização Terapêutica/instrumentação , Aneurisma Intracraniano/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/patologia , Prótese Vascular , Embolização Terapêutica/métodos , Feminino , Humanos , Aneurisma Intracraniano/patologia , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Terapia de Salvação/instrumentação , Terapia de Salvação/métodos
12.
J Neurointerv Surg ; 12(6): 621-625, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31871070

RESUMO

BACKGROUND AND PURPOSE: Despite significant technical advances, recanalization rates after endovascular therapy of ruptured intracranial aneurysms (IAs) remain a clinical challenge. A histopathological hallmark of ruptured human IA walls is mural cell loss. Mural smooth muscle cells (SMCs) are known to promote intraluminal healing in thrombosed experimental aneurysms. In this rat model we assess the natural history and healing process after coil embolization in SMC-rich and decellularized aneurysms. METHODS: Saccular aneurysms were created by end-to-side anastomosis of an arterial graft from the descending thoracic aorta of a syngeneic donor rat to the infrarenal abdominal aorta of recipient male Wistar rats. Untreated arterial grafts were immediately transplanted, whereas aneurysms with loss of mural cells were chemically decellularized before implantation. Aneurysms underwent coil implantation during aneurysm anastomosis. Animals were randomly assigned either to the non-decellularized or decellularized group and underwent macroscopic and histological analyses on days 3, 7, 21, or 90 post-coil implantation. RESULTS: A total of 55 rats underwent macroscopic and histologic analysis. After coil embolization, aneurysms with SMC-rich walls showed a linear course of thrombosis and neointima formation whereas decellularized aneurysms showed marked inflammatory wall degeneration with increased recanalization rates 21 days (p=0.002) and 90 days (p=0.037) later. The SMCs showed the ability to actively migrate into the intra-aneurysmal thrombus and participate in thrombus organization. CONCLUSIONS: Coil embolization of aneurysms with highly degenerated walls is prone to further wall degeneration, increased inflammation, and recanalization compared with aneurysms with vital SMC-rich walls.


Assuntos
Aneurisma Roto/patologia , Modelos Animais de Doenças , Embolização Terapêutica/tendências , Endotélio Vascular/patologia , Aneurisma Intracraniano/patologia , Aneurisma Roto/terapia , Animais , Prótese Vascular , Embolização Terapêutica/métodos , Humanos , Aneurisma Intracraniano/terapia , Masculino , Ratos , Ratos Wistar
13.
Neurol India ; 67(5): 1257-1263, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31744954

RESUMO

Background: Aneurysms arising from the proximal segment (A1) of the anterior cerebral artery (ACA) are relatively rare. Because of their small size, abnormal location in relation to the parent artery and the risk of damage to the surrounding perforators, their surgical management is a big challenge. We present our experience with 7 patients of A1 segment aneurysms. Settings and Design: Tertiary care referral center. Materials and Methods: Seven patients who were diagnosed with A1 aneurysms between 2009 and 2017 were included. Preoperative evaluation included Non-Contrast Computed Tomography (NCCT) head and angiography (Digital Subtraction Angiography with/without CT-Angiography). The clinicoradiological condition of the patients was graded as per World Federation of Neurological Surgeons (WFNS), Fisher and Hunt and Hess (H and H) Grading systems. A retrospective review of clinical features, radiological descriptions, surgical treatment, and outcomes was done. Results: All patients underwent microneurosurgical clipping. All aneurysms were saccular, ranging in size from 4 to 14 mm and neck size varied from 2 to10 mm. Most aneurysms 5 (71.4%) had a posterior direction. Anatomical variations were noticed in 3 (42.8%) patients. Posteroinferiorly directed aneurysms were difficult to clip. As per Glasgow Outcome scale (GOS), 6 (85.7%) patients had a good outcome, whereas 1 (14.2%) had poor outcome. As per the modified Rankin Scale (mRS) too, 6 (85.7%) had a favorable outcome. There were no deaths. Conclusion: A1 aneurysms are frequently associated with vascular anomalies and generally rupture when small. A1 aneurysms with a superior and anterior direction are relatively easy to clip whereas those directed postero-inferiorly are difficult. Close association with critical perforators also compounds the situation. Due to the rarity of A1 aneurysms, large series are few in literature.


Assuntos
Aneurisma Roto/cirurgia , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Aneurisma Roto/patologia , Artéria Cerebral Anterior/patologia , Artéria Cerebral Anterior/cirurgia , Feminino , Humanos , Masculino , Microcirurgia/instrumentação , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/instrumentação , Instrumentos Cirúrgicos , Resultado do Tratamento
14.
PLoS One ; 14(11): e0224013, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31697715

RESUMO

BACKGROUND: The prognostic factors and outcome of aneurysms appear to be dependent on its locations. Therefore, we compared left- and right- sided aneurysms in patients with aneurysmal subarachnoid hemorrhage (SAH) in terms of differences in outcome and prognostic factors. METHODS: Patients with SAH were entered into a prospectively collected database. A total of 509 patients with aneurysmal subarachnoid hemorrhage were retrospectively selected and stratified in two groups depending on side of ruptured aneurysm (right n = 284 vs. left n = 225). Midline aneurysms of the basilar and anterior communicating arteries were excluded from the analysis. Outcomes were assessed using the modified Rankin Scale (mRS; favorable (mRS 0-2) vs. unfavorable (mRS 3-6)) six months after SAH. RESULTS: We did not identify any differences in outcome depending on left- and right-sided ruptured aneurysms. In both groups, the significant negative predictive factors included clinical admission status (WFNS IV+V), Fisher 3- bleeding pattern in CT, the occurrence of delayed cerebral ischemia (DCI), early hydrocephalus and later shunt-dependence. The side of the ruptured aneurysm does not seem to influence patients´ outcome. Interestingly, the aneurysm side predicts the side of infarction, with a significant influence on patients´ outcome in case of left-sided infarctions. In addition, the in multivariate analysis side of aneurysm was an independent predictor for the side of cerebral infarctions. CONCLUSION: The side of the ruptured aneurysms (right or left) did not influence patients' outcome. However, the aneurysm-side predicts the side of delayed infarctions and outcome appear to be worse in patients with left-sided infarctions.


Assuntos
Aneurisma Roto/patologia , Infarto/patologia , Hemorragia Subaracnóidea/patologia , Isquemia Encefálica/patologia , Feminino , Humanos , Hidrocefalia/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Resultado do Tratamento
15.
Arterioscler Thromb Vasc Biol ; 39(10): 2157-2167, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31462093

RESUMO

OBJECTIVE: Although the clinical and biological importance of calcification is well recognized for the extracerebral vasculature, its role in cerebral vascular disease, particularly, intracranial aneurysms (IAs), remains poorly understood. Extracerebrally, 2 distinct mechanisms drive calcification, a nonatherosclerotic, rapid mineralization in the media and a slower, inflammation driven, atherosclerotic mechanism in the intima. This study aims to determine the prevalence, distribution, and type (atherosclerotic, nonatherosclerotic) of calcification in IAs and assess differences in occurrence between ruptured and unruptured IAs. Approach and Results: Sixty-five 65 IA specimens (48 unruptured, 17 ruptured) were resected perioperatively. Calcification and lipid pools were analyzed nondestructively in intact samples using high resolution (0.35 µm) microcomputed tomography. Calcification is highly prevalent (78%) appearing as micro (<500 µm), meso (500 µm-1 mm), and macro (>1 mm) calcifications. Calcification manifests in IAs as both nonatherosclerotic (calcification distinct from lipid pools) and atherosclerotic (calcification in the presence of lipid pools) with 3 wall types: Type I-only calcification, no lipid pools (20/51, 39%), Type II-calcification and lipid pools, not colocalized (19/51, 37%), Type III-calcification colocalized with lipid pools (12/51, 24%). Ruptured IAs either had no calcifications or had nonatherosclerotic micro- or meso-calcifications (Type I or II), without macro-calcifications. CONCLUSIONS: Calcification in IAs is substantially more prevalent than previously reported and presents as both nonatherosclerotic and atherosclerotic types. Notably, ruptured aneurysms had only nonatherosclerotic calcification, had significantly lower calcification fraction, and did not contain macrocalcifications. Improved understanding of the role of calcification in IA pathology should lead to new therapeutic targets.


Assuntos
Aneurisma Roto/patologia , Aterosclerose/patologia , Calcinose/patologia , Processamento de Imagem Assistida por Computador/métodos , Aneurisma Intracraniano/patologia , Microtomografia por Raio-X/métodos , Idoso , Análise de Variância , Aterosclerose/diagnóstico por imagem , Calcinose/diagnóstico por imagem , Calcinose/epidemiologia , Humanos , Aneurisma Intracraniano/cirurgia , Pessoa de Meia-Idade , Prevalência , Medição de Risco , Amostragem , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Coleta de Tecidos e Órgãos
16.
Am J Forensic Med Pathol ; 40(4): 386-390, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31305278

RESUMO

The injection of drugs of abuse causes many millions of deaths each year; deaths are mostly due to fatal overdose and the trauma and infection caused by repeated injections. The scientific literature widely reports cases of infected pseudoaneurysm in injecting drug abusers; however, most of these autopsy cases deal with the rupture of pseudoaneurysm of the femoral artery. We present fatal hemorrhagic shock in a heroin-cocaine abuser subsequent to rupture of pseudoaneurysm of the brachial artery; the man collapsed just before injecting himself with a dose of heroin-cocaine (speedball).


Assuntos
Falso Aneurisma/patologia , Aneurisma Roto/patologia , Artéria Braquial/patologia , Choque Hemorrágico/etiologia , Abuso de Substâncias por Via Intravenosa/complicações , Adulto , Usuários de Drogas , Evolução Fatal , Humanos , Masculino
17.
PLoS One ; 14(7): e0220121, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31329646

RESUMO

BACKGROUND: It is well known that ruptured intracranial aneurysms are associated with substantial morbidity and mortality, yet our understanding of the genetic mechanisms of rupture remains poor. We hypothesize that applying novel techniques to the genetic analysis of aneurysmal tissue will yield key rupture-associated mechanisms and novel drug candidates for the prevention of rupture. METHODS: We applied weighted gene co-expression networks (WGCNA) and population-specific gene expression analysis (PSEA) to transcriptomic data from 33 ruptured and unruptured aneurysm domes. Mechanisms were annotated using Gene Ontology, and gene network/population-specific expression levels correlated with rupture state. We then used computational drug repurposing to identify plausible drug candidates for the prevention of aneurysm rupture. RESULTS: Network analysis of bulk tissue identified multiple immune mechanisms to be associated with aneurysm rupture. Targeting these processes with computational drug repurposing revealed multiple candidates for preventing rupture including Btk inhibitors and modulators of hypoxia inducible factor. In the macrophage-specific analysis, we identify rupture-associated mechanisms MHCII antigen processing, cholesterol efflux, and keratan sulfate catabolism. These processes map well onto several of highly ranked drug candidates, providing further validation. CONCLUSIONS: Our results are the first to demonstrate population-specific expression levels and intracranial aneurysm rupture, and propose novel drug candidates based on network-based transcriptomics.


Assuntos
Aneurisma Roto/genética , Redes Reguladoras de Genes , Aneurisma Intracraniano/genética , Transcriptoma , Aneurisma Roto/patologia , Encéfalo/metabolismo , Encéfalo/patologia , Colesterol/genética , Colesterol/metabolismo , Antígenos HLA/genética , Antígenos HLA/metabolismo , Humanos , Fator 1 Induzível por Hipóxia/genética , Fator 1 Induzível por Hipóxia/metabolismo , Aneurisma Intracraniano/patologia , Sulfato de Ceratano/genética , Sulfato de Ceratano/metabolismo , Macrófagos/metabolismo
18.
World Neurosurg ; 130: 277-284, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31323409

RESUMO

Cerebral aneurysms (CAs) are characterized by a pathological wall structure with internal elastic lamina and media disruption, which leads to focal weakened pouches of the arterial wall. The prevalence of unruptured CAs has been estimated to be 2%-5% in the general population. During the past few decades, the pathophysiological mechanisms behind the formation, growth, and rupture of CAs have been the focus of numerous research studies. In the present review, we have summarized the inflammatory pathways, genetics, and risk factors for the formation, growth, and rupture of CAs. In addition, we have discussed the concepts of geometric indexes, flow patterns, and fluid dynamics that govern CA development.


Assuntos
Aneurisma Roto/patologia , Hemodinâmica/fisiologia , Inflamação/patologia , Aneurisma Intracraniano/patologia , Aneurisma Roto/diagnóstico , Aneurisma Roto/cirurgia , Angiografia Cerebral/métodos , Humanos , Imageamento Tridimensional/métodos , Inflamação/complicações , Aneurisma Intracraniano/diagnóstico , Aneurisma Intracraniano/cirurgia
19.
J Clin Neurosci ; 67: 185-190, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31253387

RESUMO

Aneurysm wall thickness is an important determinant of aneurysm progression and intra-procedural rupture. Several previous studies have evaluated the association between hemodynamic stress and aneurysm wall thickness, but conflicting results were obtained and no consensus has been achieved. According to the intraoperative findings, twenty-eight unruptured middle cerebral artery (MCA) aneurysms presented with thin-walled regions were enrolled in our study. Patient-specific 3D aneurysm models were constructed from preoperative computed tomography angiography (CTA) data and computational fluid dynamics (CFD) analyses were performed under pulsatile-flow conditions. Thin-walled regions of aneurysm dome were recognized by two experienced reviewers based on the intraoperative microscopy findings. Hemodynamic parameters derived from CFD analysis, including normalized wall shear stress (NWSS), normalized pressure (NP), the oscillatory shear index (OSI) and relative residence time (RRT), were compared between thin-walled regions and surrounding normal-thickness areas. Of the included aneurysms, twenty-eight pairs of thin-walled and normal surrounding regions were determined. Compared with surrounding tissues, thin-walled regions of aneurysm wall tended to present with higher pressure (1.232 vs 1.043, p < 0.05) and lower wall shear stress (0.693 vs 0.868, p < 0.05). Multivariate analysis revealed that elevated NP was significantly associated with thinning of the local aneurysm wall. Higher pressure and lower WSS were characteristic hemodynamic features associated with thinner regions of the aneurysm wall, elevated NP was an independent risk factor for local aneurysm wall thinning. CFD seems to be a useful method to estimate the location of thin-walled region, which will be helpful in reducing the risk of intraoperative rupture.


Assuntos
Simulação por Computador , Hemodinâmica/fisiologia , Hidrodinâmica , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/fisiopatologia , Adulto , Aneurisma Roto/patologia , Aneurisma Roto/fisiopatologia , Angiografia por Tomografia Computadorizada , Humanos , Pessoa de Meia-Idade , Modelos Biológicos , Análise Multivariada , Estresse Mecânico
20.
World Neurosurg ; 129: e831-e837, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31207378

RESUMO

BACKGROUND: Treatment of unruptured intracranial aneurysms (IAs) in elderly patients is associated with a high risk of morbidity and mortality, necessitating a thorough understanding of the potential rupture risk. The aim of this study was to identify morphologic parameters and anatomic locations that could discriminate ruptured IAs in patients ≥70 years old. METHODS: Retrospective analysis was performed of three-dimensional angiograms and medical records of 344 patients with 411 saccular IAs. Patients ≥70 years old were defined as elderly. IAs were subdivided into ruptured and unruptured. Morphologic parameters and anatomic locations were compared in elderly and younger (<70 years old) patients with ruptured and unruptured IAs. RESULTS: The study included 266 patients <70 years old and 78 patients ≥70 years old with 411 aneurysms (102 ruptured and 309 unruptured). In the elderly group, 22 of 95 aneurysms were ruptured (23.15%) compared with 80 of 316 (25.3%) in the younger group. Size ratio and aspect ratio were higher in ruptured IAs, but only in the younger group. Undulation index, indicating IA shape irregularity, was significantly different between ruptured and unruptured IAs in younger and elderly groups. The only variables associated with rupture in the elderly group were undulation index (0.11 ± 0.07 vs. 0.07 ± 0.06, P = 0.02) and location (P = 0.001). CONCLUSIONS: Aneurysm size, size ratio, and aspect ratio may not be reliable discriminants of rupture in elderly patients. Unruptured IAs in elderly patients should be evaluated on the basis of shape irregularity and anatomic location.


Assuntos
Aneurisma Roto/patologia , Aneurisma Intracraniano/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
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