Successful treatment with urgent revascularization and parent artery occlusion for a ruptured intratumoral aneurysm following prior meningioma surgery: illustrative case

BACKGROUND

An intratumoral aneurysm encased within the associated intracranial tumor is rare, and hemorrhage caused by its rupture is even more rare. While urgent and adequate surgical treatment is important, the treatment can be difficult given the limited understanding of this rare condition.

OBSERVATIONS

A 69-year-old man who had undergone meningioma surgery 30 years prior presented with a disturbance in consciousness. Magnetic resonance imaging revealed massive intracerebral and subarachnoid hemorrhage. A round, partially calcified mass, which was diagnosed as recurrent meningioma, was also observed. Subsequent cerebral angiography revealed that the source of the hemorrhage was an intratumoral aneurysm in the dorsal internal carotid artery (ICA) encased within the recurrent meningioma. Urgent surgical ICA trapping and high-flow graft bypass were conducted. The postoperative course was uneventful, and he was referred to another hospital for rehabilitation.

LESSONS

This is the first case report of a ruptured intratumoral aneurysm being treated with urgent combined revascularization and parent artery trapping surgery. This surgical approach may be a feasible treatment option for such a challenging condition. Additionally, this case highlights the importance of diligent long-term follow-up after skull-base surgery, as minor intraoperative vascular wall injury may trigger the development and rupture of an intracerebral aneurysm.

Vascular steal and associated intratumoral aneurysms in highly vascular brain tumors: illustrative case

BACKGROUND

Intratumoral aneurysms in highly vascular brain tumors can complicate resection depending on their location and feasibility of proximal control. Seemingly unrelated neurological symptoms may be from vascular steal that can help alert the need for additional vascular imaging and augmenting surgical strategies.

OBSERVATIONS

A 29-year-old female presented with headaches and unilateral blurred vision, secondary to a large right frontal dural-based lesion with hypointense signal thought to represent calcifications. Given these latter findings and clinical suspicion for a vascular steal phenomenon to explain the blurred vision, computed tomography angiography was obtained, revealing a 4 × 2-mm intratumoral aneurysm. Diagnostic cerebral angiography confirmed this along with vascular steal by the tumor from the right ophthalmic artery. The patient underwent endovascular embolization of the intratumoral aneurysm, followed by open tumor resection in the same setting without complication, minimal blood loss, and improvement in her vision.

LESSONS

Understanding the blood supply of any tumor, but highly vascular ones in particular, and the relationship with normal vasculature is undeniably important in avoiding potentially dangerous situations and optimizing maximal safe resection. Recognition of highly vascular tumors should prompt thorough understanding of the vascular supply and relationship of intracranial vasculature with consideration of endovascular adjuncts when appropriate.

Role of 64 slice multidetector computed tomography and angiography to establish relationship between tumor size, aneurysm formation and spontaneous rupture of renal angiomyolipomas: Single center experience

OBJECTIVE

To evaluate the role of computed tomography (CT) angiography using 64 slice multidetector CT scan to establish relationships among tumor size, aneurysm formation, and spontaneous rupture of renal angiomyolipomas (AML).

MATERIALS AND METHODS

Total 27 patients were diagnosed as having renal angiomyolipoma (AML) at institute of kidney disease and research center from June 2008 to June 2015. All patients with renal AML underwent contrast-enhanced CT (CECT) with CT angiography with 64 slice multidetector CT scan.

RESULTS

Total 34 kidneys were found to be affected by AML. Out of which 6 AML were ruptured and remaining 28 were unruptured. If tumor size of 4 cm or larger is used as predictor of rupture; sensitivity 20%, specificity 89%, positive predictive value 83.3%, and negative predictive value 28.5%; and If aneurysm size >5 mm is used as predictor of rupture; sensitivity 75%, specificity 90%, positive predictive value 50%, and negative predictive value 96.4% was found.

CONCLUSION

Tumor size, aneurysm size and tumor multiplicity cannot use as a predictor of spontaneous rupture of the tumor.