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Intraventricular hemorrhage (IVH) in adults usually occurs in the setting of aneurysmal subarachnoid hemorrhage or hypertension-related intracerebral hemorrhage. Thus, the underlying cause of IVH is apparent from history and radiographic findings. If the underlying cause of IVH is not apparent, additional studies, including cerebral angiography, magnetic resonance imaging, and toxicology screening, should be performed to identify etiologic agents that may alter management of IVH. Management of IVH is thus done amidst (and must be tempered by) the multiple pharmacologic, surgical, and critical care interventions directed toward the diagnosis and treatment of the underlying cause of IVH. The most immediate threat to life posed by IVH is the development of acute obstructive hydrocephalus. If the hydrocephalus is contributing to a neurologic decline, it must be treated emergently with external ventricular drainage (EVD) through an intraventricular catheter (IVC). The patient with IVH should be evaluated and treated for deficient clotting function before an IVC is inserted. For this purpose, clotting function can be adequately assessed by prothrombin and partial thromboplastin times. Insertion of an IVC may significantly lower intracranial pressure, increasing the transmural pressure difference across the wall of a ruptured cerebral aneurysm and precipitating rerupture of the aneurysm. Therefore, with IVH secondary to a ruptured cerebral aneurysm, it is advisable to delay treatment of hydrocephalus that is not contributing to a neurologic decline until the aneurysm is repaired. Hydrocephalus contributing to significant neurologic decline in the setting of a ruptured aneurysm must be treated immediately despite the unprotected status of the aneurysm. Extreme diligence must be used to allow for the slow, controlled release of cerebrospinal fluid after IVC insertion. This will mitigate the effects of increasing the transmural pressure gradient across the wall of the ruptured aneurysm. In the patient with a neurologic deficit who has IVH-related hydrocephalus and an associated intracerebral hemorrhage, it is best to assume that the hydrocephalus is a significant contributor to the deficit and that it should be treated with EVD. An IVH that is not causing hydrocephalus but is apparently occluding one or both foramina of Monro or the third ventricle should be treated with EVD because obstructive hydrocephalus may develop precipitously and, if unrecognized, may cause irreversible brain damage or death. An IVH that is not likely to cause hydrocephalus because of small volume relative to its location can be followed expectantly. Intraventricular injections of thrombolytic agents through an IVC is a treatment option that may be considered in all patients with IVH that is causing or threatening to cause obstructive hydrocephalus. Unrepaired cerebral aneurysms, untreated cerebral arteriovenous malformations, and clotting disorders are contraindications for this intervention. The surgical evacuation of IVH has a role only in very rare cases in which the IVH is causing a significant mass effect independent of hydrocephalus and associated intraparenchymal brain hemorrhage.
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PMID:Intraventricular Hemorrhage in Adults. 1109 7

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.
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PMID:Subarachnoid haemorrhage: diagnosis, causes and management. 1115 54

An aneurysm is an abnormal dilatation of an artery, often as a result of atherosclerotic disease. Hypertension, connective-tissue disease and a family history of aneurysms are predisposing risk factors. They may occur at any point in the vasculature from the aortic root to distal peripheral vessels, but they are most common in the abdominal aorta. Many times they are asymptomatic and undiagnosed, but as they progressively enlarge, they may compress on surrounding structures, release atherosclerotic debris or thrombi and possibly rupture. Aneurysms occur in approximately 3% of people older than 50; some of these do not rupture. An aneurysm is not typically painful until it dissects or ruptures. [table: see text] The abdominal aorta splits at the level of the umbilicus, so the abdomen must be palpated above the level of the umbilicus to feel for aortic enlargement. Obese patients make detection more difficult, as the presence of a pulsatile mass may be covered. An aneurysm will still conduct blood flow into the lower extremities, so pulses will not be compromised, and capillary refill and temperature will be normal. An acute rupture is a catastrophic event characterized by poor perfusion or frank shock and pain in the abdomen, back or groin. Accompanying symptoms may include a pulsatile abdominal mass, absence of distal pulses, and radiating pain into the lower back that is often described as "tearing" or "ripping." The risk of rupture has a direct correlation with an aneurysm's size. Generally, elective surgery is considered with an abdominal aneurysm larger than 4.5 centimeters, but there are many factors which may preclude repair. Non-surgical treatment of an aneurysm has been performed by percutaneously placing a prosthetic graft at the site, anchoring the graft above and below the aneurysm, thereby isolating the aneurysm from the circulation. Surgical treatment for elective repair of an aneurysm that is not ruptured is still very difficult and has a significant risk of complications. A ruptured abdominal aortic aneurysm has a very high incidence of mortality. Early identification and rapid transport to a facility with vascular surgery services are the keys to survival. This case demonstrates early recognition by the EMS crew and successful resuscitation from a cardiac arrest due to profound shock. In other cases, EMS providers may have the first and only opportunity to recognize a ruptured aneurysm and direct the ED and surgical teams to the cause of sudden shock or cardiac arrest.
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PMID:Gut feeling. 1465 9

Cerebral saccular aneurysms are relatively common, and are most commonly located at the branching points of large arteries of the circle of Willis. Many are asymptomatic and only discovered incidentally. Available evidence suggests that these aneurysms develop as a result of a combination of congenital or inherited defects weakening the arterial wall, and acquired degenerative vascular disease. It appears that most untreated cerebral aneurysms will get larger, and that all aneurysms have the potential to rupture. The only consistent significant predictor of aneurysmal rupture in most studies is the size of an aneurysm. Aneurysms less than 5mm have a very low rupture rate while those greater than 10mm have a significant risk of subsequent rupture. There is no consensus on the influence of the other reported risk factors such as hypertension, cigarette smoking and aneurysm location, on aneurysmal rupture. Those who have suffered a ruptured aneurysm are at a high risk for a recurrent haemorrhage shortly after the initial one.
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PMID:Natural history of cerebral saccular aneurysms. 1590 16

Seasonal and circadian variation in the incidence of ruptured abdominal aortic aneurysm (RAAA) has been reported. We explored the role of atmospheric pressure changes on rupture incidence and its relationship to cardiovascular risk factors. During a three year-period, 1st April 1998 and 31st March 2001, data was prospectively acquired on 144 Ruptured Abdominal Aortic Aneurysm (RAAA) presenting to the Regional Vascular Surgery Unit at the Royal Victoria Hospital, Belfast, Northern Ireland. For each patient the chronology of acute onset of symptoms and presentation to the regional vascular unit was recorded, along with details of standard cardiovascular risk factors. During the same period meteorological data including atmospheric pressure and air temperature were recorded daily at the regional meteorological research unit, Armagh. We then analyzed the monthly mean values for daily rupture incidence in relation to the monthly values for atmospheric pressure, pressure change and temperature. Furthermore atmospheric pressure on the day of rupture, and day preceding rupture, were also analyzed in relation to days without rupture presentation and between individual ruptures for various cardiovascular risk factors. Data demonstrated a significant monthly variation in aneurysm rupture frequency, (p<0.03, ANOVA). There was also a significant monthly variation in mean barometric atmospheric pressure, (p<0.0001, ANOVA), months with high rupture frequency also exhibiting low average pressures in the months of April (0.24 +/- 0.04 ruptures per day and 1007.78 +/- 1.23 mB) and September (0.16 +/- 0.04 ruptures per day and 1007.12 +/- 1.14 mB), respectively. The average barometric pressures were found to be significantly lower on those days when ruptures occurred (n=1127) compared to days when ruptures did not occur (n=969 days), (1009.98 +/- 1.11 versus 1012.09 +/- 0.41, p<0.05). Full data on risk factors was available on 103 of the 144 rupture patients and was further analyzed. Interestingly, RAAA with a known history of hypertension, (n=43), presented on days with significantly lower atmospheric pressure than those without, (n=60), (1008.61 +/- 2.16 versus 1012.14 +/- 1.70, p<0.05). Further analysis of ruptures grouped into those occurring on days above or below mean annual atmospheric pressure 1013.25 (approximately 1 atmosphere), by Chi-square test, revealed three cardiovascular risk factors significantly associated with low-pressure rupture, (p<0.05). Data represents mean +/- SEM, statistical comparisons with Student t-test and ANOVA. These data demonstrate a significant association between periods of low barometric pressure and high incidence of ruptured aneurysm, especially in those patients with known hypertension. The association between rupture incidence and barometric pressure warrants further study as it may influence the timing of elective AAA repair.
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PMID:Periods of low atmospheric pressure are associated with high abdominal aortic aneurysm rupture rates in Northern Ireland. 1623 64

The present review focuses on the process by which selected pharmacologic agents can be employed in the management of specific problems that arise during surgical procedures, including tumor or trauma with elevated intracranial pressure, previously ruptured aneurysm, and procedures that may require some degree of controlled hypertension, such as carotid endarterectomy or temporary clipping. A balanced view between older established data, newer information, and long-term clinical practice in caring for such patients is presented. The emphasis is on intravenous rather than inhaled agents; issues that involve neuromuscular blockers are not addressed here.
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PMID:Process-based pharmacology in neuroanesthesia. 1701 49

Aneurysmal disease of the hypogastric branches is rare; it may be life-threatening, and the treatment is often challenging. Herein, we report the case of an 81-year-old man with arterial hypertension, obesity, renal insufficiency, and psychiatric disorders who was emergently admitted for a symptomatic ruptured aneurysm of a hypogastric arterial branch, as seen on magnetic resonance angiography. Endovascular treatment was performed by means of a dual approach: distal embolization with microspheres and Gianturco coils, followed by proximal complete exclusion via deployment of a stent-graft in the common iliac artery. The outcome was favorable, with complete exclusion of the aneurysm and normalization of renal function. Endovascular treatment with distal embolization and proximal stent-graft release can be safe and effective, and the technique can be used in emergency circumstances with good morphologic and clinical results.
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PMID:Distal embolization and proximal stent-graft deployment: a dual approach to endovascular treatment of ruptured superior gluteal artery aneurysm. 1842 53

We report a patient with a persistent primitive trigeminal artery (PPTA) detected incidentally during cerebral angiography for the ruptured aneurysm. Cerebral angiography revealed a PPTA and eight anterior circulation cerebral aneurysms. Although cerebrovascular fragility, hemodynamic stress and hypertension are well known as etiologic factors for development of cerebral aneurysms, there is a known association of aneurysms with a PPTA, fetal carotid-basilar anastomosis. Furthermore, this case is rare from the viewpoint of aneurysm multiplicity.
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PMID:Multiple cerebral aneurysms with persistent primitive trigeminal artery. 1863 25

Distal posterior inferior cerebellar artery (dPICA) aneurysms are rare with an incidence of approximately 1% of all intracranial aneurysms. The frequent reports of the non-branching aneurysms or tandem aneurysms in an identical artery may be related to the embryology of dPICA and the anterior inferior cerebellar artery which is distinct from other cerebral arteries, as characterized by a thin vessel wall and tortuous course. In this paper, the authors present a case of a 67-year-old man with a ruptured de novo dPICA aneurysm in the tonsillomedullary segment, which occurred 3 years after clipping of a ruptured aneurysm in the identical segment of the dPICA. The patient had a history of smoking and uncontrolled hypertension. He presented with a sudden onset of severe headache and vomiting. On admission computed tomography demonstrated subarachnoid hemorrhage in the left cerebello-medullary cistern with intra-forth ventricular clots. Vertebral angiography demonstrated a saccular dPICA aneurysm just distal from the previous clip. Based on the angiographic characteristics of the aneurysm and the potential difficulty of a second clipping operation, coil embolization of the parent artery was performed. The postoperative course was uneventful except for the presence of hoarseness. The unusual development and location of ruptured de novo dPICA aneurysm may be explainable by uncontrollable risk factors, as well as by the embryological features of dPICA. Careful follow-up neuroimaging studies and management of risk factors should be continued even after complete neck clipping or coil embolization in cases of dPICA aneurysm.
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PMID:[A de novo distal PICA aneurysm occurring 3 years after clipping of another distal PICA aneurysm: a case report]. 1976 26

The evidence-based guideline 'Diagnosis and treatment of abdominal aortic aneurysm' is applicable to all patients with an atherosclerotic fusiform or ruptured aneurysm of the abdominal aorta (AAA) and can be found on www.vaat-chirurgie.nl, click on Richtlijnen. An AAA with a diameter < 5.5 cm is treated conservatively and monitored by sonographic surveillance. All patients are advised secondary prevention with antiplatelet therapy, a statin, treatment of hypertension and smoking cessation. Depending on comorbidity, the indication for an operation is an AAA diameter of 5.5 cm. The anatomical characteristics of the AAA guides the choice for an open operation or endovascular aneurysm repair (EVAR). In view of the lower perioperative mortality, EVAR is the treatment of choice. Due to the high prevalence of AAA in siblings of patients with an AAA the screening of these family members should be considered. The minimum number of elective operations per hospital per year has been set at 15.
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PMID:[Guideline 'Diagnosis and treatment of abdominal aortic aneurysm']. 2005 Nov 51


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