Dealing only with the ruptured paraclinoid aneurysm, without taking care of the underlying cerebral ischemia owing to concomitant extracranial ICA dissection, could be an insufficient approach for treatment. In the presented case of a giant ruptured paraclinoid aneurysm and coexistence of severe bilateral ICA dissecting stenosis, trapping with matching the bypass flow was the proper solution for managing simultaneously with the aneurysm and the cerebral ischemia from the left side. Anticoagulants and antiplatelets were applied safely to treat the right internal CAD.
Introduction: Spinal cord metastases represent a small proportion of intramedullary tumors. The occurrence of such lesion over the course of malignant disease is usually a predictor for shortened life expectancy and is often associated with severe neurological deficits. Treatment options include microsurgical excision, radio-, chemo- or palliative therapy. Despite these possibilities the optimal management of patients with intramedullary spinal cord metastases (ISCM) is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Materials: We are presenting a case of a 68-year-old male with gradually increasing spinal neurological deficit – axial low back pain, numbness and muscle weakness in both legs and gait disturbance. Arterial hypertension was pointed as the only comorbidity of the patient. The MRI showed an intramedullary solitary lesion in the lumbar intumescence at the level of Th12 and L1 vertebra. Results: The patient underwent surgery and the tumor was totally excised. The symptoms improved dramatically. The histology evidence a metastasis from a lung adenocarcinoma. Six months later he presented with severe back pain, progression of the paresis and urinary retention. Tumour recurrence was detected by MRI. After careful decision making and taking into consideration the risk of permanent neurological deficit a reoperation was performed. The lesion was gross-totally removed with improvement in functions and no neurological deterioration registered in the postoperative period. Conclusion: It is possibly the symptoms from an intramedullary metastatic lesion to precede the detection of the primary tumour. The low frequency of occurrence and the absence of a manifested and diagnosed primary malignant process should not stop us thinking in the direction of metastasis. Surgical resection with function preservation is highly aimed. Operation and even reoperation in some cases is acceptable.
OBJECTIVE: The purpose of the present research was to evaluate the morphometric characteristics of ruptured and unruptured aneurysms in series of surgically treated patients with multiple intracranial aneurysms. According to the findings the differences between ruptured and unruptured aneurysms were analyzed in patients with subarachnoid hemorrhage and multiple intracranial aneurysms. METHODS: Sixty eight patients with 174 multiple aneurysms and clinical presentation of aneurismal subarachnoid hemorrhage were treated in two hospitals in Sofia, Bulgaria between 1991 and 2010. The ruptured aneurysm was identified from preoperative studies (head computed tomography, digital subtraction angiography, computed tomography angiography) and it was proved during the surgical procedure. The preoperative angiograms were used to perform measurements of morphometric characteristics of ruptured and unruptured cerebral aneurysms. We used univariable logistic regression analysis to obtain odds ratios. Cochran-Mantel-Haenszel test for dependence was performed to obtain adjusted odds ratio and P value for dependence. RESULTS: In 16 (23.53%) patients, the ruptured aneurysm was not the largest one. The calculated odds ratios with 95% confidence intervals revealed strong association with rupture for the aneurysm size ≥ 7.5 mm, aneurysm location at anterior communicating-anterior cerebral artery complex, irregular aneurysm shape and angle of inclination. The average value of the angle of inclination was 153.06° ± 21.16 for the ruptured aneurysms and 106.78° ± 29.50. After performing a test for dependence and adjustment for aneurysm size and location, size ratio, irregular shape, terminal aneurysm type and aneurysm inclination angle were strongly associated with aneurysm rupture. CONCLUSION: The only independent significant determinant for aneurysm rupture besides aneurysm size and location was aneurysm inclination angle (P < 0.05).
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