Ennis Jesus Duffis

The Natural History and Treatment Options for Unruptured Intracranial Aneurysms

Recent advances in angiographic technique have raised our awareness of the presence of unruptured intracranial aneurysms (UIAs). However, the appropriate management for these lesions remains controversial. To optimize patient outcomes, the physician must weigh aneurysmal rupture risk associated with observation against the complication risks associated with intervention. In the case that treatment is chosen, the two available options are surgical clipping and endovascular coiling. Our paper summarizes the current body of literature in regards to the natural history of UIAs, the evolution of the lesion if it progresses uninterrupted, as well as the safety and efficacy of both treatment options. The risks and benefits of treatment and conservative management need to be evaluated on an individual basis and are greatly effected by both patient-specific and aneurysm-specific factors, which are presented in this paper. Ultimately, this body of data has led to multiple sets of treatment guidelines, which we have summated and presented in this paper.

Genome-Wide Association Studies of Intracranial Aneurysms: An Update

Intracranial aneurysms (IAs) affect 2% to 5% of the population and can have catastrophic results on rupture, accounting for 80% all of subarachnoid hemorrhages (SAHs).1–4 This medical and surgical emergency carries a 40% to 50% mortality rate, with 12% of individuals expiring before receiving any medical attention.5 Survivorship is fraught with socioeconomic challenges because two thirds of patients are left with some form of permanent neurological deficit.4 Although most IAs do not cause clinical symptoms during life,6,7 the substantial mortality rate with initial presentation underscores the importance of early diagnosis and intervention in high-risk groups. Advances in neuroimaging, microsurgical clipping, and minimally invasive endovascular modalities have helped reduce the burden of these morbid events; however, patient selection remains controversial given the unpredictable nature of aneurysm progression. Likewise, appropriate management is confounded by complex influences from environmental and genetic factors. Individuals aged 40 to 60 years are at highest risk for IAs, with women affected more than men by a 3:2 ratio.7,8 Other modifiable risk factors are hypertension, atherosclerosis, smoking, and alcohol consumption.9,10 In addition to aneurysm size and location within the cerebrovasculature, these factors are used clinically to assess rupture risk.7 Certain inherited syndromes predispose individuals to the formation of IAs, including Autosomal Dominant Polycystic Kidney Disease and Ehlers–Danlos syndrome.11–13 Although individuals with these syndromes should be screened with computed tomography or magnetic resonance angiography when there is family history of stroke or SAH, they account for only 10% of all cases.14 In the absence of known predisposing genetic mutations, individuals with first-degree relatives with IAs are 4× more likely to develop IAs themselves.15 Moreover, evidence shows that these aneurysms present earlier in life and rupture at smaller sizes compared …

Current differential diagnoses and treatment options of vascular occlusions presenting as bilateral thalamic infarcts: a review of the literature

bilateral thalamic infarctions are rare and usually caused by vascular occlusions. When symptomatic, it is important to make a distinction between different vascular etiologies in order to provide an effective and timely therapeutic response. Clinical presentations may not adequately differentiate between the vascular etiologies alone. It is therefore important to use imaging technologies to distinguish appropriately the origin of the infarct so that proper treatment can be administered. Advanced imaging techniques, such as CT angiography and MR angiography, have proved useful for distinguishing between arterial and venous causes of bithalamic infarctions. Bilateral thalamic venous infarctions can be treated with anticoagulation medication and with thrombolysis in more severe cases. Bilateral thalamic arterial infarctions may be treated with thrombolysis.

Prevalence of Asymptomatic Incidental Aneurysms: A Review of 2685 Computed Tomographic Angiograms

OBJECTIVE Intracranial aneurysms are a public health issue with a potential for rupturing, causing significant morbidity/mortality. The prevalence of unruptured intracranial aneurysms, including those that are asymptomatic, varies widely, as it has been determined through autopsy studies as well as conventional angiography. However, computed tomography angiography, a less invasive procedure, has replaced the use of conventional angiography in the recent decades. The objective of the present study is to determine the prevalence of incidental aneurysms. METHODS The present study reviews all computed tomography angiography cases within the past decade at a single institution. RESULTS Of 2195 cases included in the study, 39 (1.8%) were found to have asymptomatic unruptured aneurysms. CONCLUSIONS The numbers of asymptomatic incidental aneurysms have increased.

Current treatment strategies for epistaxis: a multidisciplinary approach

Epistaxis is a common clinical complaint with a spectrum of severity ranging from spontaneous cessation to unrelenting, life threatening hemorrhage requiring surgical treatment. Both otolaryngologic and neurointerventional techniques are discussed to provide a comprehensive paradigm to treat patients with epistaxis. An exhaustive review of the anatomic basis for the two main subtypes of epistaxis is provided as well as a graduated approach to appropriate clinical management.

Anomalous origin of the right vertebral artery from the right common carotid artery associated with an aberrant right subclavian artery

Vertebral artery origin anomalies are typically incidental findings during angiography or post mortem examination. We present two cases of vertebral origin from the right common carotid artery in association with an aberrant right subclavian artery. We also review the embryonic development and the clinical significance of this anomaly.