Hydroxyurea for treatment of unresectable and recurrent meningiomas. I. Inhibition of primary human meningioma cells in culture and in meningioma transplants by induction of the apoptotic pathway

PURPOSE: Venous aneurysms have been reported to occur in most major veins. These aneurysms may be misdiagnosed as soft tissue masses or as inguinal or femoral hernias. Venous aneurysms of the deep system have been associated with deep venous thrombosis (DVT) and pulmonary embolism (PE). To more precisely characterize these lesions, we reviewed our experience with the disease. METHODS: A retrospective analysis of our experience over 22 years was performed. The presentation and management of these lesions were reviewed and compared with the literature. RESULTS: Thirty-nine venous aneurysms were reported in 30 patients. There were 14 men and 16 women. The patients' ages ranged from 3 to 75 years. Thirty aneurysms were located in the lower extremities, four in the upper extremity, and five in the internal jugular vein. Fifty-seven percent of lower extremity aneurysms occurred in the deep system. Patients' symptoms were a mass (75%) associated with pain (67%) and swelling (42%). Thromboembolism occurred in six patients, DVT in three, and PE in three. Eight of nine patients (89%) who had aneurysms of the superficial venous system had their condition misdiagnosed. Diagnosis was made by phlebography (60%), color flow duplex scanning (27%), continuous-wave Doppler scanning (10%), or magnetic resonance imaging (10%). The aneurysm size ranged from 1.7 to 6.0 cm. Management consisted of tangential excision in five (17%), total excision in 23 (77%), and observation in seven (6%). CONCLUSIONS: Venous aneurysms are unusual vascular malformations that occur equally between the sexes and are seen at any age. Most patients have a painful mass of the extremity, and diagnosis is achieved by radiologic examination. Superficial venous aneurysms of the inguinal region are often misdiagnosed. Thromboembolism is more common in aneurysms involving the deep venous system. Because of their potential morbidity, management should be surgical in the majority of cases.     

Thrombosis of the cranial vena cava in a cow

Thrombosis of the cranial vena cava in a cow was followed by the formation of aneurysms in the pulmonary arteries. Embolism, pulmonary hypertension and the development of a collateral venous and lymphatic circulation are the suggested causes of these uncommon arterial lesions.     

Vietnam: appropriate management of a pediatric hospital in the context of limited resources

The presence of any pulsatile mass suggests an underlying aneurysm. When such masses occur in the buttock, the differential diagnosis includes aneurysms arising from branches of gluteal vessels or aneurysms developing in a persistent sciatic artery (PSA). The investigation and management of two patients with pulsatile masses are described. Review of the embryologic aspects of these masses and the important literature on the subject led to the conclusions that when a pulsatile buttock mass is encountered, an anomalous PSA should be suspected. A gluteal artery aneurysm can be treated by ligation or occlusion, but for a sciatic artery aneurysm surgical ablation is necessary and distal perfusion must be achieved postoperatively.     

Response to treatment of chronic daily headache with analgesic abuse

The incidence of right aneurysms of the innominate or subclavian arteries is not very high. The majority of these aneurysms is placed in the distal segment of subclavian arteries. These aneurysms are involved in the complex of the thoracic outlet compressive neurovascular syndrome, especially in occurrence of the cervical rib. All aneurysms in this region can rupture and embolize. This is the main purpose of surgical management of this clinical entity. The aim of this study is to refer an interesting case history of a relatively young patient with a right aneurysm of the middle portion of left subclavian artery. The patient had no known vascular risks and the aneurysm was asymptomatic, the only sign was the visible and palpable pulsating mass over the left clavicle. The aneurysms of the middle and central portion of the left subclavian artery are usually explored through the left high posterolateral thoracotomy. The authors refer their experience with the use of a modified technique of exposure--supraclavicular (or transclavicular) incision with the subperiostal resection of the medial portion of the clavicle. This approach affords excellent exposure and a safe surgical procedure. This approach has been described in 1988 by H. Machleder. The advantage of this approach is a diminished risk of surgery in comparison with the transthoracic approach. The authors suppose, however, that it can be useful in traumatic or occlusive lesions, as well.     

Multiple idiopathic arterial aneurysms in children: a case report and review of the literature

A 6-year-old boy from China presented initially at 2 years of age with a pulsatile mass in his right antecubital fossa. He was not fully evaluated until the age of six years, when pan-angiography and computed axial tomography scan revealed multiple aneurysms of his right brachial artery, right radial artery aneurysms, an infrarenal aortic aneurysm, and a right internal carotid artery aneurysm in the region of the cavernous sinus. The patient underwent uneventful repairs of both the abdominal aortic aneurysm and the multiple aneurysms of the right arm. Pathologic evaluation was significant for medial fibrosis of the arterial wall with decreased and disordered elastin fibers. Review of the previously reported cases in children indicate the upper extremity arteries are involved in 92% of patients, the aortoiliac region in 92% of patients, and the renal/mesenteric vessels in 77% of cases. Lower extremity and cerebrovascular arteries are involved to a lesser extent. Children with peripheral aneurysms should have pan-angiography performed before treatment is begun. Surgical repair in these cases has been excellent.     

Historic and future health promotion contexts for nursing

Lumbar artery aneurysms are uncommon lesions that usually present as pseudoaneurysms secondary to vessel injury. Despite their small size and retroperitoneal location, these lesions are potentially lethal once they rupture. This report describes a ruptured lumbar artery aneurysm which was successfully treated in a minimally invasive fashion. The diagnosis was suggested by computed tomography scan and confirmed with angiography. Successful treatment consisted of placing intravascular metallic coils into the lumbar artery. The literature contains only seven previous reports of ruptured lumbar artery aneurysms and these were managed either operatively or via an endovascular approach. Based upon the outcome of all reported cases, we believe that coil embolization of lumbar artery aneurysms following diagnostic angiography is an appropriate and effective mean of treating these lesions.     

Rupture of a previously documented small asymptomatic intracranial aneurysm in a patient with autosomal dominant polycystic kidney disease. Case report

Intracranial aneurysms are common extrarenal manifestations of autosomal dominant polycystic kidney disease (ADPKD). Although their natural history is not completely understood, small asymptomatic intracranial aneurysms in patients with ADPKD often are not treated but are followed with serial magnetic resonance (MR) angiography. The authors report the unique case of a patient with ADPKD who bled from a previously documented asymptomatic 3-mm intracranial aneurysm. This 42-year-old man with ADPKD suffered a subarachnoid hemorrhage (SAH) from a 7-mm left pericallosal artery aneurysm. This aneurysm was clipped and the patient made an excellent recovery. An irregular asymptomatic 3-mm right middle cerebral artery (MCA) aneurysm had also been demonstrated on angiography. While the patient was considering elective surgery for the MCA aneurysm, he suffered a hemorrhage from this lesion 10 weeks after the initial SAH. The aneurysm was clipped and the patient made a satisfactory recovery (he was moderately disabled). In this report the authors indicate that small asymptomatic intracranial aneurysms are not always innocuous in patients with ADPKD, and they suggest that treatment should be strongly considered for these lesions in this group of patients when there is a history of SAH or the aneurysm is irregular in appearance. Because MR angiography studies may not adequately define the configuration of small aneurysms and irregularity may easily be missed, conventional angiography is recommended for patients with ADPKD who are found to have an intracranial aneurysm on screening with MR angiography.     

Giant aneurysms of the proximal anterior cerebral artery: report of three cases

Aneurysms of any size involving the A1 segment of the anterior cerebral artery are unusual, but giant aneurysms in this location are exceedingly rare, with only five cases previously reported in the literature. We report three cases of A1 segment giant aneurysms presenting with mass effect that were successfully treated. A discussion of the salient features of diagnosis and treatment are presented, along with a brief review of the literature describing these aneurysms. The role of newer imaging modalities, including magnetic resonance imaging, magnetic resonance angiography, and intraoperative angiography, is discussed. The three patients were treated by direct exploration, trapping, and endaneurysmal decompression. Giant A1 segment aneurysms present a unique opportunity to safely trap and decompress the aneurysm with definitive cure.     

Application of a new covered endoprosthesis in the treatment of occlusive and aneurysmal peripheral arterial diseases

The aim of this study was to report the authors' experience of a new auto-expandable nitinol stent covered by a thin layer of polyester, the Cragg Endopro System 1, for percutaneous internal revascularisation. One hundred and forty-two patients (120 men, 22 women; average age: 63.5 +/- 10 (38-88) received a total of 204 stents (58 iliac, 75 femoral, 9 politeal). The lesions were stenosis in 61 cases, occlusions in 61 cases and aneurysms in 20 cases. The mean length at the femoro-popliteal level was 14.2 +/- 2.4 cm (4-30), at iliac level 9.4 +/- 0.9 (3-15). Implantation was successful in 140/142 cases, a technical success in 136/142 cases (96%). There were 4 acute thromboses requiring surgery and 4 others treated successfully by thrombolysis. There were 18 secondary thromboses. Twenty-nine patients had pyrexia and pain in the treated limb for several days. Over a 27 months follow-up all the iliac stents remained patent; there were 8 restenoses unrelated to the stent, 7 of which were treated by a repeat angioplasty. The primary (PI) and secondary (PII) patency rates at 27 months were: iliac, PI = 97%, PII = 100%; global femoral, PI = 64%, PII = 76% (stenosis PI = 59%, PII = 81%; occlusions, PI = 65%, PII = 74%); lesions of less than 15 cm, PI = 68%, PII = 93%; lesions over 15 cm, PI = 54%, PII: 76%; aneurysms, PI and PII = 88%). The authors conclude that the Cragg Endopro System 1 stent is safe and effective in the treatment of long lesions and aneurysms with encouraging medium term results suggesting that it may be a real alternative to surgery.     

Surgical approaches to basilar bifurcation aneurysms

Basilar bifurcation aneurysms are technically challenging and their treatment is often associated with greater morbidity than aneurysms located in the anterior circulation. These lesions can be treated using surgical, endovascular, or a combination of techniques. Several surgical approaches have evolved to treat basilar bifurcation aneurysms; none, however, is suitable for all aneurysms in this location. This article reviews the natural history, clinical presentation, evaluation, and selection of treatment approach and details various surgical techniques. The use of endovascular techniques is reviewed briefly.     

Hypothermic cardiac standstill for cerebral aneurysm surgery

Surgical management of giant cerebral aneurysms remains a major technical challenge for modern neurosurgeons. Endovascular approaches for giant aneurysms does not provide an acceptable alternative to direct surgical approaches. The use of deep hypothermic circulatory arrest as an adjunct during clipping of complex giant aneurysms shows promise as a treatment for otherwise incurable lesions. Patient selection and techniques of circulatory arrest surgery are discussed.     

Aneurysm of the internal auditory artery: our experience and review of the literature

The aneurysms of the internal auditory artery (IAA) situated distal from anterior inferior cerebellar artery (AICA)-IAA junction, are extremely rare lesions. A case of distal aneurysm if IAA is presented causing subarachnoid haemorrhage (SAH) and complete ipsilateral deafness. After the neurosurgical treatment the hearing of the patient definitely improved. The literature of distal aneurysms of AICA is reviewed focusing on the clinical features of these malformations, causing cerebello-pontine angel (CPA) symptoms with or without SAH.     

Partial thrombosis of canine carotid bifurcation aneurysms with cellulose acetate polymer

OBJECTIVE: To investigate the usefulness of a cellulose acetate polymer (CAP) solution for partial thrombosis of aneurysms. METHODS: We created 14 canine cervical carotid bifurcation aneurysms, 11 of which were subsequently thrombosed partially with CAP solution. We then conducted angiographic and histological investigations. RESULTS: Nine aneurysms were thrombosed 50 to 70% by volume, although a significant crescent crevice between the aneurysmal sac and the CAP mass was left in four of the aneurysms. In the remaining two aneurysms in which a crescent crevice had been seen in the initial stage of CAP injection, 80% and more than 95% thrombosis were needed to occlude the crevice, respectively. Follow-up angiograms of the seven aneurysms with no crescent crevice revealed no shifts of position of the CAP mass toward the bottom of the aneurysm sac, but slight ballooning of the remnants was observed in two of them. The angiograms of the other four aneurysms with significant crescent crevices demonstrated rupture with a massive hematoma in one and shifts of the CAP mass with marked enlargement of remnants in three. Histologically, the seven aneurysms with no enlarged remnants had newly developed membranes consisting of endothelium, infiltrated spindle-shaped cells, collagen, and elastic fibers. In contrast, in the three markedly enlarged aneurysms, there were only recent clots between the CAP mass and the aneurysm lumen and no development of endothelium. CONCLUSION: Partial thrombosis with CAP solution is useful to keep aneurysms in a stable configuration, unless a crescent crevice has been left.     

Evaluation of coronary flow velocity dynamics and flow reserve in patients with Kawasaki disease by means of a Doppler guide wire

OBJECTIVES: To assess the pathophysiologic effects of the coronary sequelae of Kawasaki disease on coronary hemodynamic variables, we regionally evaluated the flow velocity dynamics and flow reserve in coronary vessels with lesions using an intracoronary Doppler flow guide wire. BACKGROUND: The pathophysiologic effects of the coronary sequelae of Kawasaki disease on coronary hemodynamic variables have not been completely clarified, and we previously reported some discrepancies between coronary angiographic findings and exercise stress tests in Kawasaki disease. METHODS: Doppler phasic coronary flow velocity was determined using an 0.018-in. (0.046-cm) intracoronary Doppler flow guide wire at rest and during the adenosine triphosphate-induced hyperemic response in 95 patients (75 male, 20 female, mean age 9.8+/-6.2 years) with Kawasaki disease. RESULTS: In 25 patients with coronary aneurysms in 29 vessels, the average peak velocity and diastolic to systolic velocity ratio were significantly (p < 0.05) decreased in the moderate-sized and large-sized aneurysms. Significantly lower values in coronary flow reserve (CFR) were noted in 3 of 10 vessels with moderate aneurysms and in 4 of 7 vessels with large aneurysms. A significant positive correlation (y = 0.53x + 14.6, r2 = 0.91) was observed between the percent diameter stenosis evaluated by angiography and that calculated from the flow velocity measurement. However, the percent diameter stenosis calculated from the flow velocity measurement was underestimated compared with that determined by angiography in the stenotic lesions of intermediate severity. A reduced CFR was noted in five of seven vessels with intermediate stenosis ranging from 50% to 75%, and also in three vessels with mild stenosis ranging from 30% to 40%. A reduced CFR was also observed in six of the eight angiographically normal vessels associated with the area of reduced perfusion on exercise thallium-201 myocardial scintigraphy. CONCLUSIONS: Abnormalities in flow dynamics and a reduction in flow reserve were revealed in coronary aneurysms of intermediate to large size and in stenotic lesions, even of mild to intermediate severity, in patients with Kawasaki disease. Abnormalities in the coronary microcirculation, as well as epicardial lesions, contribute to the pathophysiologic responses in Kawasaki disease.     

Myocardial infarction in an adult resulting from coronary aneurysms previously documented in childhood after an acute episode of Kawasaki's disease

Coronary aneurysms resulting from a previous episode of Kawasaki's disease are considered an important cause of myocardial infarction in children. A case of a 19-year-old man presenting with an acute myocardial infarction associated with coronary aneurysms is described. These coronary lesions were previously evaluated angiographically and echocardiographically at the age of 13 years, 5 months after the acute episode of a Kawasaki's disease.     

Using polymerase chain reaction for rapid sex-determination of a case of sirenomelia

Developing endoluminal technology has permitted the management of selected aneurysms using stent-grafts, but the applicability and durability of these new devices has not yet been proven. Standard treatment of mycotic aneurysms generally requires arterial ligation, excision and debridement, and autologous or extraanatomic synthetic bypass. A saphenous vein-covered stent was used to exclude an expanding, mycotic, superficial femoral artery aneurysm in a critically ill patient. Although stent-graft exclusion was intended as a bridge to standard therapy, the mass resolved, the superficial femoral artery remains patent, and the patient is symptom-free at 1 year without further intervention. Additional experience is required to determine whether stent-grafts have a role in the management of mycotic aneurysms.     

Aneurysm of the popliteal artery. A case contribution of a 15-year surgical experience

This retrospective study involves 45 patients operated in the years 1980-1994 for popliteal artery aneurysms with a posterior approach. The number of aneurysms is 60 because 15 were bilateral; 18 patients presented a polianeurysmatic involvement of the arterial tree. In 14 cases the intervention were performed on asymptomatic patients, in 46 cases the patients were symptomatic for ischemic disease. The reconstructive interventions were performed on 58 cases and only in 2 cases the medial approach to popliteal vessel were preferred on the basis of the great dimension of the aneurysms which involved also the superficial femoral artery. PTFE grafts were adopted in 33 cases, saphenous vein in 19 cases and Dacron grafts in 5 cases. We had no perioperative mortality and 4 patients died for causes not correlated to the intervention. We had perioperative complication in the group of asymptomatic patients. In the group of symptomatic patients 5 underwent a major amputation. The global patency of these grafts is 86% after 10 years. The posterior approach to the popliteal vessels has the advantage of a better view of the aneurysmatic mass and the anatomic structures and it permits a direct end graft. This graft is usually shorter than in the case of the medial approach and cannot be compressed by the aneurysmatic mass.     

Development of a dissecting aneurysm on the vertebral artery immediately after occlusion of the contralateral vertebral artery: a case report

A 49 year old female presented with subarachnoid hemorrhage due to a ruptured dissecting aneurysm on the left vertebral artery (VA). Following an occlusion test, we performed proximal occlusion of the left VA with detachable balloons. However, a dissecting aneurysm on the right VA developed three weeks later. After an occlusion test had showed no change in cerebral blood flow, auditory brain stem response, or neurological status, proximal occlusion of the right VA was performed. The patient has returned to normal life without neurological deficits. Bilateral dissecting aneurysms of the VA are quite common, but de novo VA dissecting aneurysms or enlargement of such aneurysms after occlusion of contralateral VA are rare. This case suggests that hemodynamics stress may be a causal factor in the development of VA dissecting aneurysms. Careful pre- and post-operative neuroradiological examination of the contralateral VA are required in patients undergoing VA occlusion for dissecting aneurysms.     

Clinical results of endovascular stent graft repair for fifty cases of thoracic aortic aneurysms

Between February 1995 and December 1997, 50 cases (55 lesions) of thoracic aortic aneurysms including 20 cases of aortic dissections were treated with an endovascular technique using the stent grafts. All patients were treated in the operating room under general anesthesia and the stent grafts were implanted through 18 Fr. or 20 Fr. sheaths via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in 53 of 55 lesions (delivery success rate: 96.4%). Exclusion of the aneurysms and entry closing without endoleak were achieved within two weeks after the operation in 43 of 53 lesions (initial success rate: 81.1%). Endoleak was found in 10 lesions (minor endoleak: 8 and major endoleak: 2 lesions). Two patients died in the periopertive period of delivery failures as injury to external iliac artery and damage to the delivery sheath caused by tortuous and narrow access routes. Endovascular stent graft repair of thoracic aortic aneurysms is minimally invasive operation in comparison with conventional surgical graft replacement with extracorporeal circulation. These early results suggest that the stent graft repair is possibly safe and useful treatment for the patients of thoracic aortic aneurysms especially in high risk patients. However, careful long-term follow-up is necessary to prove the value and the effects of this endovascular treatment and improvement of the stent graft system and technical training of endovascular surgery for operators are required to reduce the delivery failure and to determine the stent graft repair is reliable treatment.     

Neuroimaging

Nonenhanced CT scan remains the most valuable and available neuroimaging study available in the ED. Nonenhanced CT scans are excellent for identifying acute hemorrhage, mass lesions, hydrocephalus, and cerebral edema. It is of limited value in identifying old blood, small abscesses and tumors, arteriovenous malformations, and aneurysms; in these cases, either enhancement of the CT or MR imaging may be preferable. The role of MR imaging is evolving and is becoming a neuroimaging modality more easily available to the emergency physician. When available, it is the preferred neuroimaging study for ischemic infarcts, lacunar infarcts, and encephalitis.