Aneurysm

Aneurysm



Definition of Aneurysm :

An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain (the circle of Willis) and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart. When the size of an aneurysm increases, there is a significant risk of rupture, resulting in severe hemorrhage, other complications or death. Aneurysms can be hereditary or caused by disease, both of which cause the wall of the blood vessel to weaken.

Aneurysms may be classified by type, location, and the affected vessel. Other factors may also influence the pathology and diagnosis of aneurysms.

Classification

True and false aneurysms

A true aneurysm is one that involves all three layers of the wall of an artery (intima, media and adventitia). True aneurysms include atherosclerotic, syphilitic, and congenital aneurysms, as well as ventricular aneurysms that follow transmural myocardial infarctions (aneurysms that involve all layers of the attenuated wall of the heart are also considered true aneurysms).

A false aneurysm or pseudo-aneurysm 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 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, arterial grafting, or use of an artery for injection. Like true aneurysms, they may be felt as an abnormal pulsatile mass on palpation.

Morphology

Aneurysms are classified by their macroscopic shape and size and are described as either saccular or fusiform. Saccular aneurysms are spherical in shape and involve only a portion of the vessel wall; they vary in size from 5 to 20 cm (8 in) in diameter, and are often filled, either partially or fully, by thrombus. Fusiform (“spindle-shaped”) aneurysms are variable in both their diameter and length; their diameters can extend up to 20 cm (8 in). They often involve large portions of the ascending and transverse aortic arch, the abdominal aorta, or less frequently the iliac arteries. The shape of an aneurysm is not pathognomonic for a specific disease.

Location

Cerebral aneurysms, also known as intracranial or brain aneurysms, occur most commonly in the anterior cerebral artery, which is part of the circle of Willis.This can cause severe strokes leading to death. The next most common sites of cerebral aneurysm occurrence are in the internal carotid artery.

Many non-intracranial aneurysms arise distal to the origin of the renal arteries at the infrarenal abdominal aorta, a condition some have postulated to be related to atherosclerosis. However, increasing evidence suggests abdominal aortic aneurysms are a wholly separate pathology.

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 can also occur in the legs, particularly in the deep vessels (e.g., the popliteal vessels in the knee).

Arterial and venous

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

Cause of Aneurysm :

High blood pressure, high cholesterol, and tobacco use, alcoholism may raise your risk of certain types of aneurysms. High blood pressure is thought to play a role in abdominal aortic aneurysms. Atherosclerotic disease (cholesterol buildup in arteries) may also lead to the formation of some aneurysms.

Pregnancy is often linked to the formation and rupture of splenic artery aneurysms.

Signs and Symptoms of Aneurysm :

Cerebral aneurysm Symptoms for a cerebral aneurysm occur when the aneurysm pushes on a structure in the brain. In the case of a cerebral aneurysm, the symptoms for an aneurysm that has ruptured and one that has not ruptured are different. Symptoms for an aneurysm that has not ruptured:

  • Fatigue
  • Loss of perception
  • Loss of balance
  • Speech problems
  • Double vision

Symptoms for a ruptured aneurysm:

  • Severe headaches
  • Loss of vision
  • Double vision
  • Neck pain and/or stiffness
  • Pain above and/or behind the eyes

Risk factors for Aneurysm :

Risk factors for an aneurysm include:

  • diabetes
  • obesity
  • hypertension
  • tobacco use
  • alcoholism
  • high cholesterol
  • copper deficiency
  • increasing age
  • congenital, or inherited, weakness in artery walls

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 tissue strength [Harris]. The lysyl oxidase that cross links connective tissue is secreted normally, but its activity is reduced, due to some of the initial enzyme molecules’ (apo-enzyme or enzyme without the copper) lack of copper. Aneurysms of the aorta are the chief cause of death of copper deficient chickens; depleting copper produces aneurysms in turkeys. Men who die of aneurysms have a liver content (of copper) that can be as little as 26% of normal. In such men the median layer of the blood vessel (where the elastin is) is thinner but its elastin copper content is the same as in the elastin of normal men. The body must therefore have some way of preventing elastin tissue from growing if there is not enough activated lysyl oxidase for it. A baby’s liver has up to ten times as much copper as an adult liver. Excess intake of zinc can lead to deficiency of copper (hypocupremia). This deficiency happens because excess zinc in the body triggers reduced absorption of copper in the GI tract, resulting in increased fecal loss of copper.

Diagnosis of Aneurysm:

Diagnosis of a ruptured cerebral aneurysm is commonly made by finding signs of subarachnoid hemorrhage on a computed tomography (CT) scan. If the CT scan is negative but a ruptured aneurysm is still suspected based on clinical findings, a lumbar puncture can be performed to detect blood in the cerebrospinal fluid. Computed tomography angiography (CTA) is an alternative to traditional angiography 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 cerebral arteries, and images are created using a CT scan. These images show exactly how blood flows into the brain arteries.

Prevention from Aneurysm:

Steps you can take to avoid other risk factors include: 

  • Quit smoking
  • Follow a healthy diet. Eat a low-fat, low-cholesterol diet to reduce plaque (fatty deposits) in the arteries
  • Control high blood pressure
  • Keep cholesterol at healthy level
  • Exercise regularly

Treatment of Aneurysm:

Historically, the treatment of arterial aneurysms has been limited to either surgical intervention, or watchful waiting in combination with control of blood pressure. In recent years, endovascular or minimally invasive techniques have been developed for many types of aneurysms.

Intracranial aneurysms

There are currently two treatment options for brain aneurysms: surgical clipping or endovascular coiling. There is currently debate in the medical literature about which treatment is most appropriate given particular situations.

Surgical clipping was introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. It consists of a craniotomy to expose the aneurysm and closing the base of the aneurysm with a clip. The surgical technique has been modified and improved over the years.

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. Platinum coils initiate a clotting reaction within the aneurysm that, if successful, will eliminate the aneurysm.

Aortic and peripheral aneurysms

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 easily inserted in its reduced diameter into the vascular stumps and then expanded up to the most appropriate diameter and permanently fixed there by external ligature. New devices were recently developed to substitute the external ligature by expandable ring allowing use in acute ascending aorta dissection, providing airtight (i.e. not dependent on the coagulation integrity), easy and quick anastomosis extended to the arch concavity. Less invasive endovascular techniques allow covered metallic stent grafts to be inserted through the arteries of the leg and deployed across the aneurysm.