Unusual Presentation of Heart Failure Secondary to Ruptured Aneurysmal Sinus of Valsalva: A Case Report

Sinus of Valsalva Aneurysm (SOVA) arises from an abnormal dilation of the aortic root, leading to enlargement between the aortic annulus and the sinotubular junction. Although often presenting without symptoms, these aneurysms bear the potential for life-threatening complications, primarily from the looming risk of rupture. We present the case of a 42-year-old Malay gentleman with a history of bilateral pedal edema and dyspnea on exertion who was diagnosed with a ruptured sinus of Valsalva aneurysm. The patient underwent successful surgical repair of the aneurysm, leading to symptomatic improvement and favorable outcomes. This case highlights the importance of early diagnosis and prompt surgical intervention in managing this uncommon condition.

Endovascular treatment of direct carotid cavernous fistula resulting from rupture of intracavernous carotid aneurysm: A case report

BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,are rare.The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk.During physical examination,there was right eye exophthalmos and ocular motor palsy.The rest of the neurological examination was clear.Notably,the patient had no history of head injury.The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula.Coils and Onyx were placed through the femoral venous route,followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique.No intraoperative or perioperative complications occurred.Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.

Interobserver reliability of computed tomography angiography in the assessment of ruptured intracranial aneurysm and impact on patient management

BACKGROUND Aneurysmal subarachnoid hemorrhage is an emergency that can lead to a high mortality rate and many severe complications.It is critical to make a rapid radiological evaluation of ruptured intracranial aneurysms(RIAs)to determine the appropriate surgical treatment.AIM To assess the reliability of computed tomography angiography(CTA)in assessing different features of ruptured intracranial aneurysm and its impact on patient management.METHODS The final cohort of this study consisted of 146 patients with RIAs(75 male and 71 female)who underwent cerebral CTA.Their age ranged from 25 to 80,and the mean age±SD was 57±8.95 years.Two readers were asked to assess different features related to the aneurysm and perianeurysmal environment.Inter-observer agreement was measured using kappa statistics.Imaging data extracted from non-contrast computed tomography and CTA were considered to categorize the study population into two groups according to the recommended therapeutic approach.RESULTS The inter-observer agreement of both reviewers was excellent for the detection of aneurysms(K=0.95,P=0.001),aneurysm location(K=0.98,P=0.001),and(K=0.98,P=0.001),morphology(K=0.92,P=0.001)and margins(K=0.95,P=0.001).There was an excellent interobserver agreement for the measurement of aneurysm size(K=0.89,P=0.001),neck(K=0.85,P=0.001),and dome-to-neck ratio(K=0.98,P=0.001).There was an excellent inter-observer agreement for the detection of other aneurysm-related features such as thrombosis(K=0.82,P=0.001),calcification(K=1.0,P=0.001),bony landmark(K=0.89,P=0.001)and branch incorporation(K=0.91,P=0.001)as well as perianeurysmal findings including vasospasm(K=0.91,P=0.001),perianeurysmal cyst(K=1.0,P=0.001)and associated vascular lesions(K=0.83,P=0.001).Based on imaging features,87 patients were recommended to have endovascular treatment,while surgery was recommended in 59 patients.71.2%of the study population underwent the recommended therapy.CONCLUSION CTA is a reproducible promising diagnostic imaging modality for detecting and characterizing cerebral aneurysms.

Analysis of the Risk of Basilar Aneurysm Rupture Based on CTA Morphological Parameters

Objective:To investigate morphological risk factors of basilar aneurysm rupture based on computer tomography angiography(CTA)parameters.Materials and methods:The clinical and CTA data of 43 patients with basilar aneurysm admitted to Shaanxi Provincial People's Hospital from January 2015 to July 2023 were analyzed.The patients were divided into“ruptured group”and“unruptured group,”and the morphological parameters of aneurysms were measured.The general data and morphological parameters between the two groups were statistically analyzed.Logistic regression was used to analyzed statistically significant parameters,and the receiver operating characteristic curve was drawn to evaluate its diagnostic effectiveness.Results:Irregular aneurysms were more likely to rupture than regular aneurysms(χ^(2)=13.971,P<0.05).The maximum diameter(4.92[3.37-6.94]mm),length-width ratio(1.31[1.14-1.55]),height(4.08[2.71-5.34]mm),aspect ratio(0.99[0.84-1.45]),and inflow angle(133.63±11.21°)of aneurysms in the ruptured group were larger than the unruptured group,and the differences were statistically significant(P<0.05).Binary logistic regression showed that aneurysm shape(OR=39.347,P=0.021),length-width ratio(OR=313.062,P=0.033),and inflow angle(OR=1.156,P=0.004)were independent risk factors for rupture.The area under the curve were 0.809,0.842.and 0.894,respectively.Conclusion:Aneurysm shape,aspect ratio,and blood flow incidence angle are independent risk factors for basilar aneurysm rupture,which means that they can be used to predict the risk of rupture to a certain extent.

Fatal Cataclysmic Otorrhagia and Epistaxis Due to a Ruptured Aneurysm of the Petrous Internal Carotid Artery: A Case Report

Background: Aneurysms of the internal carotid artery within the petrous temporal bone are extremely rare;their true incidence is unknown. The exact cause is unclear: they may be congenital or result from trauma, infection, or radiation. Aim: We report a case of massive otorrhagia and epistaxis from a ruptured aneurysm of the petrous internal carotid artery. Case Presentation: A 34-year-old man presented to our department for the first time with repeated left otorrhagia ongoing for 5 years, left sided pulsatile tinnitus and left conductive hearing loss. In his history, we noted a right hemi-corporeal deficit of sudden onset one month ago and the head-CT showed a left frontoparietal subarachnoid hemorrhage without any visualised vascular malformation. Otomicroscopy showed a pulsatile mass visible at the posterior part of the hypotympanum. There was a right-sided hemiparesis estimated at 2/5 with no disorder of the sensitivity. After hemodynamic stabilization, the patient was discharged from the hospital and treatment was scheduled in interventional radiology and neurosurgery unit. Unfortunately the patient presented at home with a cataclysmic hemorrhage by massive otorrhagia and epistaxis and arrived dead at the emergency unit. Conclusion: The treatment of a petrous carotid aneurysm must be carried out quickly considering the risk of rupture leading to a cataclysmic hemorrhage that can be rapidly life threatening.

Mechanics of formation and rupture of human aneurysm

The mechanical response of the human arterial wall under the combined loading of inflation,axial extension,and torsion is examined within the framework of the large deformation hyper-elastic theory.The probability of the aneurysm formation is explained with the instability theory of structure,and the probability of its rupture is explained with the strength theory of material.Taking account of the residual stress and the smooth muscle activities,a two layer thick-walled circular cylindrical tube model with fiber-reinforced composite-based incompressible anisotropic hyper-elastic materials is employed to model the mechanical behavior of the arterial wall.The deformation curves and the stress distributions of the arterial wall are given under normal and abnormal conditions.The results of the deformation and the structure instability analysis show that the model can describe the uniform inflation deformation of the arterial wall under normal conditions,as well as formation and growth of an aneurysm under abnormal conditions such as the decreased stiffness of the elastic and collagen fibers.Prom the analysis of the stresses and the material strength,the rupture of an aneurysm may also be described by this model if the wall stress is larger than its strength.

Clinical Efficacy of Shenmai Injection in the Treatment of Cerebral Vasospasm after Ruptured Aneurysm Surgery

Objective: To investigate the therapeutic effect of Shenmai Injection on postoperative cerebral vasospasm in patients with ruptured aneurysms. Methods: Seventy patients undergoing craniotomy for ruptured aneurysms in our hospital were selected as study subjects and randomly divided into control (n = 33) and research (n = 37) groups, they were treated with nimodipine and nimodipine combined with Shenmai injection after operation. The blood flow velocity in the middle cerebral artery (MCA) before and at 1, 3, 7, 11 and 14 days after surgery and the incidence of cerebral vasospasm during these days were compared, and the GCS scores at 14 days postoperatively and GOS scores at 6 months postoperatively were compared between the two groups. Results: There were no statistically significant differences in the occurrence of cerebral vasospasm, GCS or GOS scores between the two groups (P > 0.05), but the period of postoperative cerebral vasospasm in the study group was significantly shorter than that in the control group. Conclusion: Shenmai injection has the effect of shortening the cycle of occurrence of cerebral vasospasm after the operation of ruptured aneurysms, promoting patients to recover as early as possible and reducing their physical and mental burden.

Diagnosis of ruptured superior mesenteric artery aneurysm mimicking a pancreatic mass

Aneurysms and pseudoaneurysms of the superior mesenteric artery are potentially lethal and should be treated as urgently as possible.In a 52-year-old man with occasional epigastric pain,we accidentally discovered a superior mesenteric artery aneurysm that was ruptured with spontaneous tamponade in the uncinate process and in the head of the pancreas.The ruptured aneurysm had a heterogeneous appearance due to its thrombotic and hemorrhagic content,and it simulated a voluminous mass in the head and uncinate process of the pancreas,associated with mild dilatation of the main pancreatic duct.Recent advances in multidetector computed tomography and magnetic resonance imaging have enabled radiologists to develop a correct diagnosis of mesenteric aneurysms and pseudoaneurysms of the visceral branches of the abdominal aorta,and to differentiate this diagnosis from that of pancreatic or peripancreatic masses;angiography is currently used to confirm a diagnosis and to develop therapeutic treatments.

Unusual upper gastrointestinal bleeding: Ruptured superior mesenteric artery aneurysm in rheumatoid arthritis

This case report describes an unusual case of upper gastrointestinal (UGI) bleeding caused by a ruptured superior mesenteric artery (SMA) aneurysm in the duodenum in a patient with rheumatoid arthritis. The patient presented with UGI bleeding and hemorrhagic shock. Emergency UGI endoscopy could not identify the source of the bleeding because of excessive blood clots under the second portion of the duodenum. An SMA aneurysm with active contrast extravasation was diagnosed by computed tomography. The aneurysm, together with the fourth portion of the duodenum and the proximal portion of the jejunum, was surgically resected, and the SMA was skeletonized. On postoperative day 15, the patient was discharged from hospital under satisfactory conditions. Rheumatoid arthritis has been known to cause a wide spectrum of manifestations, and an SMA aneurysm is an unusual extra-articular manifestation. An SMA aneurysm rupture presenting as upper gastrointestinal bleeding is a rare complication with a high mortality rate. The clinician must be alert to this potential issue to achieve rapid diagnostic confirmation, and immediate surgical or radiological intervention.

Intra-Operative Rupture of Remote Aneurysm during Transphenoidal Resection of Pituitary Macroadenoma

Rupture of intracranial aneurysm resulting in subarachnoid hemorrhage is well known to carry significant risk of poor outcome. Intra-operative rupture of an unknown intracranial aneurysm during a neurosurgical procedure is a rare occurrence that can lead to devastating consequences if not recognized and managed appropriately. Here we describe to our knowledge, the first reported case of previously unknown, remote from the surgical site, intra-operative posterior cerebral artery aneurysm rupture during transnasal endoscopic transphenoidal resection of a pituitary macroadenoma, review relevant literature, and discuss strategies to reduce surgical risk and improve patient outcomes.

Supraceliac Aortic Clamping for Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Short Aortic Neck Length

Objective: Prompt bleeding control with proximal aortic clamping and subsequent aortic repair are very important for ruptured abdominal aortic aneurysm. However, unsuitable anatomy, such as short aortic neck length, not only disturbs the means to an expeditious repair, but may also increase morbidity and mortality. In the present study, we aimed to evaluate the efficacy of supraceliac aortic clamping for improving surgical outcomes for patients with ruptured abdominal aortic aneurysm, who have a short aortic neck length. Method: Between April 2010 and September 2015, eighteen patients underwent emergent open surgical repair of ruptured abdominal aortic aneurysm. Eight patients with a short aortic neck length underwent supraceliac aortic clamping, and 10 underwent infrarenal aortic clamping. Results: The mean supraceliac aortic clamping time was 30 ± 7 minutes. There was 1 operative death in the infrarenal aortic clamping group due to respiratory failure, and the overall operative mortality was 6%. There were no significant differences between the 2 groups with respect to postoperative complication rates or mortality. Furthermore, there were no significant differences in variables of renal function between the 2 groups, through-out the study period. Conclusion: Supraceliac aortic clamping was associated with minimal mortality and morbidity, but not with harmful effects on postoperative renal function. Thus, supraceliac aortic clamping can be safely applied for ruptured abdominal aortic aneurysm with short aortic neck length.

Spontaneous Disappearance of a Ruptured Intracranial Aneurysm

The spontaneous disappearance of a ruptured intracranial aneurysm is unusual and its mechanism remains incompletely understood. However, several hypotheses are put forward and are mostly found in Virchow’s triad. We report the case of a man who suffered subarachnoid hemorrhage by rupture of a blister aneurysm of the P1 segment of the left posterior cerebral artery. A control arteriography performed one week after the rupture showed a disappearance of the aneurysm and a significant vasospasm of the carrier artery. Angiograms performed at 3 weeks and 3 months confirmed this disappearance of the aneurysm and a return to normal artery size. Clinically the patient was doing well. Therefore his aneurysm was spontaneously declared cured. Several studies are needed to clarify the natural history of spontaneously thrombosed aneurysms and elucidate their occurrence mechanism in order to improve the management of intracranial aneurysmal pathology.

Can We Predict Abdominal Aortic Aneurysm (AAA) Progression and Rupture by Non-Invasive Imaging?—A Systematic Review

Introduction: The most commonly used predictor of aneurysm behavior in clinical decision-making is size. There are however small aneurysms that rupture and certain large aneurysms remain asymptomatic. There is growing evidence to suggest that other variables may provide better information on metabolic and physiological properties of aortic wall and therefore better predict aneurysm behavior. Methods: The literature was systematically reviewed from 1975-May 2011 to examine the evidence to support the use of non-invasive imaging modalities that might predict aneurysm behavior. Results: Ultrasound can be used to measure multiple dynamic aortic properties (i.e. distensibility and compliance) in addition to diameter. These parameters better predict aneurysm behavior. Computer tomography can utilize assessment of aortic calcification, presence of intra-luminal thrombus and distensibility. Finite element analysis model has been validated in-vivo to calculate peak wall stress, assess effects of intra-luminal thrombus and calcification. It however relies on assumptions related to aneurysm properties and therefore remains relatively inaccurate in the clinical setting. Small numbers of observational human studies have evaluated the role of 18F-FDG PET/CT in aneurysms. Larger studies are needed, as 18F-FDG uptake is patchy and heterogeneous even in small number of patients. It varies in the same patient with time, as aneurysms grow in intermittently. We discuss functional magnetic resonance imaging with novel tracers such as 99 mTc-annexin-V and nanoparticles. Conclusion: Multimodality imaging with complementary methods such as CT, functional MRI (fMRI), ultrasound and physiological measurements improve the definition of aneurysm pathobiology. Larger-scale clinical validation is beginning to promise a new paradigm in cardiovascular diagnostics.

Biomechanical Considerations in the Unruptured Cerebral Aneurysm Study (UCAS Japan): Rupture Risk and True Stress of Wall

When an unruptured aneurysm is found, deciding whether to operate or follow up is one of the most important issues. There are guidelines for making the best final decision on treatment, taking into account the effectiveness of diagnostic and therapeutic devices and the risk-benefit ratio of patients, caregivers, and healthcare professionals. The guidelines evidence-based of large clinical data for this purpose are presented by national medical societies. As one of the rupture risk indicators, there is the hazard risk ratio derived by the UCAS Japan research group based on the statistical method of 6697 aneurysms in 5720 patients with cerebral aneurysms of 3 mm or more. Therefore, we investigated the biomechanical significance of this hazard risk ratio using a spherical aneurysm model. It was revealed that 1) the reason why the frequency of aneurysm rupture is relatively high up to about 10 mm, 2) the UCAS hazard risk ratio corresponds to stress of the aneurysm wall, and the true stress can be calculated by multiplying the patient’s blood pressure, and 3) the factors that cause the daughter’s sac (irregular protrusion of the aneurysm wall). In addition, our two methods for measuring the strength of the blood vessel wall of an individual patient were described.

Clipping versus Coiling in Ruptured Aneurysms of the Anterior Cerebral Circulation

Objective: To evaluate and compare the outcomes of microsurgical clipping and endovascular coiling of ruptured anterior cerebral circulation aneurysms. Methods: The current study retrospectively included 61 patients presented with subarachnoid hemorrhage (SAH), treated by clipping or coiling for ruptured aneurysms located in anterior circulation. Anatomic outcome and post-operative ischemic events were evaluated. The primary clinical outcomes were evaluated as operative complications while the secondary clinical outcome was evaluated by modified Rankin scale (mRS) at discharge. Results: Of 61 ruptured aneurysms, 47 and 14 were treated by surgery and coiling, respectively. The average follow-up duration was 19.1 ± 18.6 months for clipping and 21.7 ± 14.8 months for coiling. Complete occlusion was greater in surgery group (80.8%) than endovascular group (21.4%). Re-growth occurred in 2 cases of the coiling group only. Ischemic events were encountered in both groups;silent ones were higher in coiling group (21.4%) than in clipping group (6.3%), while symptomatic ones were higher in the clipping group (49%). Good outcome (mRS 0 - 2) was 51% and 71.4% after clipping and coiling respectively. Postoperative hospital period was longer after clipping (P = 0.04). Conclusions: For anterior circulation ruptured aneurysms, both treatments are feasible, coiling showed lower rate of morbidity while clipping results were better regarding durability and recurrence. Coil embolization may be preferred, which is the current point proved by the RCT like ISAT, but if you choose the patients carefully and find out the optimal candidate for the clipping, the clipping is still enough feasible as a mainstream.

What Should Be Done if There Is Coronary Artery Disorder in Ruptured Abdominal Aortic Aneurysm?

Abdominal aortic aneurysm (AAA) is the most common type of aneurismal diseases. Generally, it is asymptomatic and when it is ruptured, it develops with high morbidity and mortality. Case report: A 62-years-old male patient consulted our emergency with a pain at his dorsum and lumbar part. Cardiologist with a suspicion of coronary artery disorder or dissection, coronary angiography was executed. Consecutive lesions of LAD artery (left anterior descending) 40% - 50% and 90%, CX artery (circumflex) 40% and 80% - 90%, and a lesion of RCA (right coronary artery) 20% - 30% were detected. With a suspicion of rupture, abdominal aneurysm tomography (CT) was demanded. In the tomography, a 7-cm-diameter ruptured abdominal aortic aneurysm was diagnosed. Levosimendan support was started. Under the support of levosimendan a Y graft operation was performed. The operation was ended up with levosimendan support considering that coronary bypass would increase mortality and morbidity. Discussion: Approximately 50% of the ruptured aneurysms are died before they reach hospital while the 30% - 70% operated ones are died within 30 days after operation. Early diagnosis and follow-up is extremely important to decrease morbidity and mortality. The patients consulting with rupture must be taken to the operation without delay. What should be done if coronary artery disorder is detected in the patient whose AAA is ruptured and if the bypass is necessary? In our opinion, a decision must be made according to the patient’s clinical condition. As a result of our case, we thought repairing the abdominal aortic aneurysm necessitates the other comorbidites must be treated medically. We aimed to decrease the cardiac oxygen requirement by starting levosimendan and decline afterload. If the patient, whose coronary artery disorder is detected, is under risk and his overall condition is bad, we think that coronary bypass operation can be delayed.

Successful use of emergent endovascular aneurysm repair for a ruptured hypotensive abdominal aortic aneurysm

Ruptured aortic aneurysm has a surgical mortality ranging from 50%-70%, one of the highest rates of all vascular emergencies [1-5]. Less invasive approaches to repair have been developed that could potentially improve these statistics [1,5-7]. Endovascular aneurysm repair (EVAR) is a minimally invasive approach that may be an alternative to open surgical repair for select cases of ruptured aortic aneurysms [1,5]. Unfortunately, the role of EVAR in patients with acute rupture of an abdominal aneurysm is not clear, especially for patients that are hemodynamically unstable [1,8-10]. The literature is limited regarding use of EVAR in this population of patients. We present a case of the successful use of EVAR for an emergent repair in a hypotensive hemodynamically unstable patient with an acutely ruptured abdominal aortic aneurysm (AAA).

The hemodynamic study for growth factor evaluation of rupture cerebral aneurysm followed up for five years

Computer-based simulations are essential for clarifying the hemodynamics of brain aneurysms. Since cerebrovascular disease is often fatal, it is strongly desirable to predict its progression. While previous studies have clarified the initiation mechanism of aneurysms, their growth mechanism remains unclear. Consequently, it is difficult to develop a diagnostic system for predicting aneurysm rupture. This study seeks to clarify the mechanism of aneurysm growth by identifying significant hydrodynamic factors. We focus on a single ruptured aneurysm that was followed up for five years. Computer simulations and fluid dynamic experiments with silicone vessel models were performed. To confirm the reliability of data in the computer simulations, we conducted particle image velocimetry measurements in steady flow. We then performed computer simulations for pulsatile conditions to determine an effective index for aneurysm growth. We obtained good agreement between the trends in the obtained computer simulation and experimental data. Numerical simulations for pulsatile flow in three models revealed that aneurysms grew in regions having a low wall shear stress, a low aneurysm formation indicator, and a high oscillatory shear index.

Silent Contained Rupture of an Inflammatory IgG4-Related Abdominal Aortic Aneurysm

This report describes a case of a 66-year-old male patient with accidental diagnosis of chronic contained rupture of an aortic aneurysm. Surgery was performed through a median laparotomy. A thick periaortic tissue with fibrosis and lymphnodes covered the AAA. Immunohistochemical examination of the aneurismatic aortic wall revealed intense positivity for inflammatory markers and a large number of immunoglobulin G4 (IgG4) positive cells. The postoperative course was uneventful and patient was discharged in the fifth postoperative day. Patient was then followed periodically at the outpatient rheumatologic clinic. No adverse events occurred during 3 and 6 months follow up. Conclusion: Identification of IgG4-inflammatory aneurysms as an expression of the IgG4-related systemic disease is essential both for clinical follow up and surgical and pharmacological treatment considering the possibility of aneurysm rupture and the involvement of other organs.

Infracallosal Aneurysm Rupture Revealed by Chronic Subdural Hematoma: A Case Report

Chronic subdural hematoma (CSDH) is one of the most common entities seen in neurosurgery. We report a case of infracallosal aneurysm revealed by CSDH in a 52 years old woman. She presented 3 days alteration of consciousness in 2019 and repeated in September 2020 a severe headache and dizziness. There was no history of others symptoms, nor head trauma. Routine blood examination and coagulation profile were normal. Emergency computed tomography (TC) showed a left temporoparietal-occipital CSDH. Cerebral Angio CT found a bilobated of A2 aneurysm. The precallosal interhemispheric approach was made and clipping the aneurysm after evacuation of CSDH without complication. CSDH is one of the revealed features of intracerebral aneurysm rupture.