Aneurysm

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Not to be confused with embolism.
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For other uses, see Aneurysm (disambiguation).
Aneurysm
Classification and external resources

Angiography of an aneurism in a cerebral artery

ICD-10 I72.
ICD-9 442
DiseasesDB 15088
MedlinePlus 001122
MeSH D000783

An aneurysm or aneurism (from Ancient Greek ἀνεύρυσμα - aneurusma "dilation", from

ἀνευρύνειν - aneurunein "to dilate"), is a localized, blood-filled dilation (balloon-like bulge) of a
blood vessel[1] caused by disease or weakening of the vessel wall.

Aneurysms most commonly occur in arteries at the base of the brain (the circle of Willis) and in
the aorta (the main artery coming out of the heart, a so-called aortic aneurysm). As the size of an
aneurysm increases, there is an increased risk of rupture, which can result in severe hemorrhage,
other complications or even death.

Look up aneurysm in Wiktionary, the free dictionary.

Contents
[hide]

 1 Diagnosis
 2 Classification
o 2.1 True and false
o 2.2 Morphology
o 2.3 Location
o 2.4 Arterial vs. venous
o 2.5 Underlying condition
 3 Risks
 4 Risk factors
o 4.1 Copper deficiency
 5 Formation
 6 Treatment
o 6.1 Treatment of cranial aneurysms
o 6.2 Treatment of aortic and peripheral aneurysms
 7 See also
 8 References
 9 External links

[edit] Diagnosis
Diagnosis of a ruptured cerebral aneurysm is commonly made by finding signs of subarachnoid
hemorrhage on a CT scan (Computed Tomography, sometimes called a CAT scan, a
computerized test that rapidly X-rays the body in cross-sections, or slices, as the body is moved
through a large, circular machine). If the CT scan is negative but a ruptured aneurysm is still
suspected, a lumbar puncture is performed to detect blood in the cerebrospinal fluid (CSF).
Computed Tomography Angiography (CTA) is an alternative to the traditional method and can
be performed without the need for arterial catheterization. This test combines a regular CT scan
with a contrast dye injected into a vein. Once the dye is injected into a vein, it travels to the brain
arteries, and images are created using a CT scan. These images show exactly how blood flows
into the brain arteries.

[edit] Classification
Aneurysms can be classified in several different ways:

 True or false
 Morphology
 Location
  Arterial vs. venous
 Underlying condition

[edit] True and false

In a true aneurysm the inner layers of a vessel have bulged outside the outer layer that normally
confines them. The aneurysm is surrounded by these inner layers.

A false- or pseudoaneurysm does not primarily involve such distortion of the vessel. It is a
collection of blood leaking completely out of an artery or vein, but confined next to the vessel by
the surrounding tissue. This blood-filled cavity will eventually either thrombose (clot) enough to
seal the leak or it will rupture out of the tougher tissue enclosing it and flow freely between
layers of other tissues or into looser tissues. Pseudoaneurysms can be caused by trauma that
punctures the artery and are a known complication of percutaneous arterial procedures such as
arteriography or of arterial grafting or of use of an artery for injection, such as by drug abusers
unable to find a usable vein. Like true aneurysms they may be felt as an abnormal pulsatile mass
on palpation.

[edit] Morphology

Aneurysms can be described by their shape. Traditionally, they are described as either "fusiform"
(resembling a narrow cylinder) or "saccular" (berry) (resembling a small sac), though alternatives
have been proposed.[2]

[edit] Location

Most frequent site of occurrence is in the anterior cerebral artery from the circle of Willis.

Most (94%) non-intracranial aneurysms arise distal to the origin of the renal arteries at the
infrarenal abdominal aorta, a condition mostly caused by atherosclerosis.

The thoracic aorta can also be involved. One common form of thoracic aortic aneurysm involves
widening of the proximal aorta and the aortic root, which leads to aortic insufficiency.
Aneurysms occur in the legs also, particularly in the deep vessels (e.g., the popliteal vessels in
the knee).

[edit] Arterial vs. venous

Arterial aneurysms are much more common, but venous aneurysms do happen (for example, the
popliteal venous aneurysm).

[edit] Underlying condition

Aneurysms can be classified by the underlying condition.

Many aneurysms are atherosclerotic in nature.

Another term used is "mycotic aneurysm". Some sources reserve this term for fungal infections
only,[3] while other sources use the term to describe bacterial infections as well.[4][5]

While most aneurysms occur in an isolated form, the occurrence of berry aneurysms of the
anterior communicating artery of the circle of Willis is associated with autosomal dominant
polycystic kidney disease (ADPKD).

The third stage of syphilis also manifests as aneurysm of the aorta, which is due to loss of the
vasa vasorum in the tunica adventitia.

[edit] Risks
Rupture and blood clotting are the risks involved with aneurysms. Rupture leads to drop in blood
pressure, rapid heart rate, high cholesterol, and lightheadedness. The risk of death is high except
for rupture in the extremities.

Blood clots from popliteal arterial aneurysms can travel downstream and suffocate tissue. Only if
the resulting pain and/or numbness are ignored over a significant[clarification needed] period of time will
such extreme results as amputation be needed. As long as treatment is sought quickly, a doctor
should be able to provide non-invasive treatment. Blood clots should be treated with care as
overpressure when trying to get rid of them can cause them to shift. Clotting in popliteal venous
aneurysms is much more serious as the clot can embolise and travel to the heart, or through the
heart to the lungs (a pulmonary embolism).

[edit] Risk factors

Risk factors for an aneurysm are diabetes, obesity, hypertension, tobacco use, alcoholism, and
copper deficiency.

[edit] Copper deficiency

A minority of aneurysms are caused by a copper deficiency. Numerous animal experiments have
shown that a copper deficiency can cause diseases affected by elastin[6] tissue strength [Harris].
The lysyl oxidase that cross links connective tissue is secreted normally, but its activity is
reduced,[7] due, no doubt, to some of the initial enzyme molecules (apo-enzyme or enzyme
without the copper) failing to contain copper.[8][9]

Aneurysms of the aorta are the chief cause of death of copper deficient chickens, and also
depleting copper produces aneurysms in turkeys.[10]

Men who die of aneurysms have a liver content (of copper) which can be as little as 26% of
normal.[11] The median layer of the blood vessel (where the elastin is) is thinner but its elastin
copper content is the same as normal men. The overall thickness is not different.[12] The body
must therefore have some way of preventing elastin tissue from growing if there is not enough
activated lysyl oxidase for it. Men are more susceptible to aneurysms than young women,
probably because estrogen increases the efficiency of absorption of copper. However, women
can be affected by some of these problems after pregnancy, probably because women must give
the liver of their babies large copper stores in order for them to survive the low levels of copper
in milk. A baby’s liver has up to ten times as much copper as adult livers.[13] Elastin is about as
flexible as a rubber band and can stretch to two times its length.[14] Collagen is about 1000 times
stiffer.

[edit] Formation
The occurrence and expansion of an aneurysm in a given segment of the arterial tree involves
local hemodynamic factors and factors intrinsic to the arterial segment itself.

The human aorta is a relatively low-resistance circuit for circulating blood. The lower extremities
have higher arterial resistance, and the repeated trauma of a reflected arterial wave on the distal
aorta may injure a weakened aortic wall and contribute to aneurysmal degeneration. Systemic
hypertension compounds the injury, accelerates the expansion of known aneurysms, and may
contribute to their formation.

Aneurysm formation is probably the result of multiple factors affecting that arterial segment and
its local environment.

Hemodynamically, the coupling of aneurysmal dilation and increased wall stress is approximated
by the law of Laplace. Specifically, the Laplace law applied to a cylinder states that the (arterial)
wall tension is equal to the pressure times the radius of the arterial conduit (T = P x R). As
diameter increases, wall tension increases, which contributes to more increase in diameter and
risk of rupture. Increased pressure (systemic hypertension) and increased aneurysm size
aggravate wall tension and therefore increase the risk of rupture. In addition, the vessel wall is
supplied by the blood within its lumen in humans (? although aorta has Vasa vasorum).
Therefore[citation needed] in a developing aneurysm, the most ischemic portion of the aneurysm is at
the farthest end, resulting in weakening of the vessel wall there and aiding further expansion of
the aneurysm. Thus eventually all aneurysms will, if left to complete their evolution, rupture
without intervention.

In dogs, collateral vessels supply the vessel[clarification needed] and aneurysms are rare.

[edit] Treatment
Historically, the treatment of arterial aneurysms has been surgical intervention, or watchful
waiting in combination with control of blood pressure. Recently, endovascular or minimally
invasive techniques have been developed for many types of aneurysms.

[edit] Treatment of cranial aneurysms

Currently there are two treatment options for brain aneurysms: surgical clipping or endovascular
coiling.

Surgical clipping was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. It
consists of performing a craniotomy, exposing the aneurysm, and closing the base of the
aneurysm with a clip. The surgical technique has been modified and improved over the years.
Surgical clipping remains the best method to permanently eliminate aneurysms.

Endovascular coiling was introduced by Guido Guglielmi at UCLA in 1991. It consists of

passing a catheter into the femoral artery in the groin, through the aorta, into the brain arteries,
and finally into the aneurysm itself. Once the catheter is in the aneurysm, platinum coils are
pushed into the aneurysm and released. These coils initiate a clotting or thrombotic reaction
within the aneurysm that, if successful, will eliminate the aneurysm. In the case of broad-based
aneurysms, a stent is passed first into the parent artery to serve as a scaffold for the coils ("stent-
assisted coiling").

At this point it appears that the risks associated with surgical clipping and endovascular coiling,
in terms of stroke or death from the procedure, are the same. The major problem associated with
endovascular coiling, however, is the high recurrence rate and subsequent bleeding of the
aneurysms. For instance, the most recent study by Jacques Moret and colleagues from Paris,
France, (a group with one of the largest experiences in endovascular coiling) indicates that
28.6% of aneurysms recurred within one year of coiling, and that the recurrence rate increased
with time. (Piotin M et al., Radiology 243(2):500-508, May 2007) These results are similar to
those previously reported by other endovascular groups. For instance Jean Raymond and
colleagues from Montreal, Canada, (another group with a large experience in endovascular
coiling) reported that 33.6% of aneurysms recurred within one year of coiling. (Raymond J et al.,
Stroke 34(6):1398-1403, June 2003) The long-term coiling results of one of the two prospective,
randomized studies comparing surgical clipping versus endovascular coiling, namely the
International Subarachnoid Aneurysm Trial (ISAT) are turning out to be similarly worrisome. In
ISAT, the need for late retreatment of aneurysms was 6.9 times more likely for endovascular
coiling as compared to surgical clipping. (Campi A et al., Stroke 38(5):1538-1544, May 2007)

Therefore it appears that although endovascular coiling is associated with a shorter recovery
period as compared to surgical clipping, it is also associated with a significantly higher
recurrence and bleeding rate after treatment. Patients who undergo endovascular coiling need to
have annual studies (such as MRI/MRA, CTA, or angiography) indefinitely to detect early
recurrences. If a recurrence is identified, the aneurysm needs to be retreated with either surgery
or further coiling. The risks associated with surgical clipping of previously-coiled aneurysms are
very high. Ultimately, the decision to treat with surgical clipping versus endovascular coiling
should be made by a cerebrovascular team with extensive experience in both modalities. At
present it appears that only older patients with aneurysms that are difficult to reach surgically are
more likely to benefit from endovascular coiling. These generalizations, however, are difficult to
apply to every case, which is reflected in the wide variability internationally in the use of
surgical clipping versus endovascular coiling.

[edit] Treatment of aortic and peripheral aneurysms

Aneurysms are treated by either endovascular techniques (angioplasty with stent) or open
surgery techniques. Open techniques include exclusion and excision. Exclusion of an aneurysm
means tightly tying suture thread around the artery both proximally and distally to the aneurysm,
to cut off blood flow through the aneurysm. If the aneurysm is infected or mycotic, it may then
be excised (cut out and removed from the body). If uninfected, the aneurysm is often left in
place. After exclusion or excision, a bypass graft can be placed, to ensure blood supply to the
affected area. For some aneurysm repairs in the abdomen, where there is adequate collateral
blood supply, bypass grafts are not needed.

For aneurysms in the aorta, arms, legs, or head, the weakened section of the vessel may be
replaced by a bypass graft that is sutured at the vascular stumps. Instead of sewing, the graft tube
ends, made rigid and expandable by nitinol wireframe, can be inserted into the vascular stumps
and permanently fixed there by external ligature.[1] [15] New devices were recently developed to
substitute the external ligature by expandable ring allowing use in acute ascending aorta
dissection, providing airtight, easy and quick anastomosis extended to the arch concavity [16][2]
[3]Less invasive endovascular techniques allow covered metallic stent grafts to be inserted
through the arteries of the leg and deployed across the aneurysm.

In medicine, an arterial aneurysm is an outpouching, or bulge, that develops in the wall of an artery.
Arterial aneurysms occur in the arteries, which are the blood vessels that carry blood away from the
heart. These are much more common than venous aneurysms, similar bulges that occur in the veins,
which carry blood towards the heart. The fact that arterial aneurysms are more common than venous
aneurysms may be attributed to the significantly higher blood pressure that occurs in arteries than in
veins.

The main threat posed by an arterial aneurysm is that the blood vessel may eventually rupture. If
this occurs, then tissues that are supplied with blood by the affected artery will be starved of the
nutrients and, critically, the oxygen that they need. Rupture usually only occurs when an
aneurysm has become very large. Therefore, it is important that patients who possess an arterial
aneurysm carefully manage their blood pressure, as high blood pressure increases the risk of an
arterial aneurysm growing, and may ultimately lead to rupture.

Abdominal aortic aneurysms are common aneurisms that often occur in older patients. Aortic
aneurysms may also occur in the chest region, and these are called thoracic aortic aneurysms.
Any kind of aortic aneurysm has the potential to be very serious, as a rupture can lead to
massive, sometimes fatal, bleeding.

A popliteal artery aneurysm is another common type of aneurysm. This type of aneurysm is
located at the back of the knee. Such aneurysms rarely rupture and are not usually considered life
threatening, although in some rare cases loss of blood flow to parts of the leg may result in the
development of gangrene, which may occasionally necessitate amputation of the limb.
Aneurysms may also develop at other locations in the leg. A femoral artery aneurysm occurs in
the groin region. As is the case with most aneurysms that occur in the limbs, these rarely rupture.

If an arterial aneurysm occurs in the brain, rupture can result in very serious damage. This is not
a common condition, and is normally detected in older patients, more commonly in women than
in men. A brain aneurysm, such as a cerebral artery aneurysm or an intracranial aneurysm, may
cause severe pain, loss of nervous sensation, blurred vision, vomiting, and strokes.