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Additional cases of IAs in identical twins 339, 349 as well as familial aggregations

of IAs without a recognized inherited disorder have also been reported but are felt

to be rare ( It has been estimated that < 2 of IAs are familial! "ost reported

casus consist of onl# 2 famil# members with IAs, and the are most commonl#

siblings! Anal#sis of case reports reveals that when IAs occur in siblings the# tend to

occur at identical or mirror images site, and in comparison to sporadic IAs, familiasIAs tend to rupture at a smaller size and #ounger age, and that the incidence of

anterior communicating arter# aneur#sm is lower! It has been postulated that IAs

occuring in sibling ma# represent a distinct population of IAs!

$he Indications and best method for investigation of as#mptomatic relatives of a

patient found to harbor an intracranial aneur#sm are controversial! %egatives

studies (angeograph#, &'A, "A!!) do not guarantee that a later date an aneur#sm

will not be discovered that either subse*uentl# developed or e+panded, or was

simpl# not detected on the initial stud#! erebral angiograph# is the most sensitive

stud#, how ever the ris- and e+pense ma# not .ustif# its use as screening test in

man# cases! /urthermore there is some evidence that aneur#sms that rupture tend

to do shortl# after their formation which would reduce the value of screening!

'creening recommendations 0 1rst degree relatives (especiall# siblings) are at

higher ris- of harboring IAs, and should undergo "I and "A screening! /inding

suspicious for IA(s) re*uire followup with four vessel arteriograph# to con1rm

suspected lesions ( "A has a high falsepositive rate of 5 ) and to ruleout

additional IAs!

30.15. Traumatic aneurysms

$raumatic Aneur#sms ($as) comprise < of intracranial aneur#sms! A6Apseudoaneur#sms ( a rupture of all the vessel wall la#ers with the 7wall8 of the

aneur#sm being formed b# sorrounding cerebral structures! $he# man# occur rarel#

in childhood! $he mechanism of in.ur# usuall# falls into one of the following groups!

! $hose arising from penetrating trauma usuall# from gunshot wounds,

although penetration with a sharp ob.ect ( which is less common) ma# be

more prone to cause traumatic aneur#sms!

2! $hoe arising from close head in.ur#0 more common! $heories of pathogenesis

include traction in.ur# to the reveal wall or entrapment within a fracture! $end

to occur either 0

A! :eripherall#

! &istal anterior cerebral arter# aneur#sms secondar# to impact against

the falcine edge


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2! &istal cortical arter# aneur#sms 0 ;ften associated with an overl#ing

s-ull fracture, some times growing s-ull fracture!

! At the s-ull base, usuall# involving the IA in one of the following sites 0

! :etrous portion

2! avernous carotid arter# 0

a! Aneur#sm enlargement ma# cause a progressive zinus s#ndrome

b! upture ma# lead to a posttraumatic carotidcavernous 1stula (see

page 3) or to massive epista+is in the presence of a sphenoid

sinus fracture!

3! 'upraclinoid carotid arter#

4! Istrogenic 0 following surger# in or around the s-ull base, the sinoses or orbita

(icluding following transaphenoidal surger#)

Presentation

1. Delayed intracranial hemorrhage (subdural, subarachnoid,

intreventricular, or intraparenchymal; The most common

presentation. Ts tend to have a high rate o! rupture.

". #ecurrent epista$is

3. Progressive cranial nerve palay

%. &n!arging s'ull !racture

5. ay be incidental )nding on *T +can

Treatment

Although there are case reports of spontaneous resolution, treatment is usuall#

recommended! IA aneur#sms at the s-ull base undergo trapping or endovascular

embolization! :eripheral lesions should be treated surgicall# with clipping of

aneur#sm nec-, e+cision of the aneur#sm, coiling or wrapping if no other method isfesible!

30.1. ycotic aneurysms

$he name 7m#cotic8 originated with ;uler in whose time the term referred to an#

infections process rather then the current usage which infers a fungal etiolog#!

urrentl# accepted terminolog# favors infectious aneur#sm ( or bacterial


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aneur#sm)! Infectious aneur#sms can, however, also occur with fungal infections!

$end to form indistal (often unnamed) vessels!

&P-D&/ 2 PTP+-/

• omprise 4 of intracranial aneur#sms

• ;ccurs in 3= of patiens with subacute bacterial endocarditio ('>)

• "ost common location distal "A branches (?= @)

• At least 2 have or develop multiple aneur#sms

• Increased fre*uenc# in immunocompromised patiens (e!g AI&') and drug

users

• "ost probabl# start in the adventitia (outer la#er) and upread inward

&4/T-6

lood cultures and B: ma# identit# the infectious organism! $able 3= shows

t#pical pathogens recovered! :atients with suspected infectious aneur#sms should

undergo echocardiograph# to loo- for signs of endocarditis!

;rganism omment

'treptococcus'taph#lococcus"iscellaneous"ultiple%o growth%o infototal

44 @ 5= 2 4 99

T#&T&6T

$hese aneur#sms usuall# have fusiform morpholog# and are usuall# ver# friable,

therefore surgical treatment in diCcult andDor ris-#! "ost cases are treated acutel#

with antibiotics which are continued 45 wee-s! 'erial angiograph# ( at ? da#s

and !=,3,5 and 2 months, even if aneur#sms seem to be getting smaller, the#

ma# subse*uentl# increases and new ones ma# form) helps document eEectiveness

of medical therap# ('erial "A ma# be a viable alternative in some cases )!

Aneur#sms ma# continue to shrin- following completion of antibiotic therap#!

&ela#ed clipping ma# be more feasible,indication include 0

• :atients with 'AF

• Increasing size of aneur#sms while on antibiotics ( controversial, some sa#

not mandator#)!

• /ailure of aneur#sms to reduce in size after 45 wee-s of antibiotics!:atients with '> re*uiring valve replacement should have bioprothetic (i!e

tissue valves instead of mechanical valves to eliminate the need for ris-#

anticoagulation!


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30.17. iant aneurysms

is- of rebleeding

;verall rebleed rate is ,=D#r, which is lower then with aneur#smal 'AF or

rebleeding from AG"s! $here also a small ris- of dela#ed cerebral ischemia(vasospasm)! %eurological outcome is li-ewise better!

"A%AH>">%$

Heneral measures

$hese patients are still at ris- for the same complications of 'AF as with

aneur#smal 'AF0 Gasospasm, h#drocephalus, h#ponatremia, rebleeding, etc!(see

page 4) and should be managed as an# 'AF (see page 4)! 'ome subgroups

ma# be at lower ris- for complications and ma# be managed accordingl# (e!g! see

:retruncal nonaneur#sm 'AF (:%'AF) below!

#epeat angiography

ield of positive second angiogram after technicall# ade*uate negative stud#0 !@

9!@ )3? in earl# (pre$) studies, 224 *uoted more recentl# 359,3?,3?2 ! $

scan 1ndings are helpful in the decision to repeat angiograph#3?3! ? of cases

with diEuse 'AF and thic- la#ering of blood in the anterior interhemispheric 1ssure

were associated with an AcoA aneur#sm that show up on repeat angiograph# 35?!

$he absence of blood on $ (performed within 4 da#s of 'AF), or thic- blood in the

perimesencephalic cisterns alone (see below) were unli-el# to be associated with a

missed aneur#sm!

ecomendations regarding repeat angio 0

! repeat angio after J 4 da#s ( allow pasospasm K some clot to resolve) AA! $echnicall# ade*uate 4 vessel angiogram is negative, and evidence for

'AF is strong! ;riginal angio was incomplete or if there are suspicious 1ndings


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2! If $ localizes blood clot to particular area, place special attention to this area

on repeat angio3! &o not repeat angio for classic pretruncal 'AF (see below) or if no blood on

$4! :atients are usuall# -ept in the hospital 4 da#s while waiting for repeat

angio (to watch for and manage complication of 'AF or bleeding)

ther studies1. imaging studies of the brain0 "I (with "A if avaliable) or $ (with angio

$ if avaliable)! $his ma# visualize an aneur#sm that fails to show up on

angiograph#, and ma# identif# other sources of 'AF such as

angiographicall# occult vascular information ( see page =), tumor!!!!!!". tests to ruleout spinal AG"0 a rare cause of intracebral 'AF (see page

=?)A! spinal "I0 cervical, thoracic and lumbar! spinal angiograph# 0 too diCcult and ris-# to be .usti1ed in most cases

of angio negative 'AF! onsider in cases with high suspicion of spinal

source!

+urgical e$plorationAdvocated b# some for cases of 'AF with $ 1ndings compatible with an

aneur#smal source in which a suspicious area is demonstrated angiographicall# 359

with carefull e+planation to the patient and famil# of the possibilit# of negative

operative 1ndings!

30.18. 6onaneurysmal +

/or etiologies of 'AF other aneur#sm, see page 34

P#&T#6*/ 666&#+/ + (P6+9

%ee perimesencephalic nonaneur#smal 'AF 3?4! $he suggestion to change the name

to pretruncal non aneur#smal 'AF was proposed because improved neuroimaging

techni*ues have shown the true anatomic localization of the blood to be in front of

the brain stem (truncus cerebri) centered in front of the pons rather than

perimesencephalic 3?=!

A distinct entit# considered to be a benign condition with good outcome and less ris- of

bleeding and vasospasm than other patients with 'AF of un-nown etiolog#3?5

(norebleeding occured in 3? patients with :%'AF and 4= months mean followup3?? , nor in 59

patients with @= months followup3?2, vasospasm has been reported in onl# 3 patients and

ma# have been related to cerebral angiograph# rather than the :%'AF, and although it is

slow, the incidence of angiographic vasospasm ma# be higher than oroginall# though3?@)!

$he actual etiolog# has #et to be determined, but i# ma# be secondar# to rupture of a small

perimesencephalic vein or capillar#3?@!


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Presentation

:atients ma# present with severe paro+#smal FA, meningismus, photophobia, and nausea!

Boss of consciousness is rare! $hese patients are usuall# not criticall# ill ( all were grade or

2), however, complications such as h#ponatremia or cardiac abnormalities ma# occur!

:reretinal Femorrhages and sentinel FDA have not occured!

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