- Email: [email protected]
INFLAMMATORY ABDOMINAL AORTIC ANEURYSMS
1459 INFLAMMATORY ABDOMINAL AORTIC ANEURYSMS
McIntyre A, O’Donnell B, Clements GB, Desselberger U. HTLV-III antibody in drug abusers in the West of Scotland the Edinburgh connection. Lancet 1986; i: 446-47.
3. Follett EAC,
THUNDERCLAP HEADACHE AND UNRUPTURED CEREBRAL ANEURYSM
SIR,-Dr Day and Dr Raskin (Nov 29, p 1247) describe a patient with "thunderclap" headache attributed to an unruptured cerebral aneurysm with associated arterial vasospasm and conclude that cerebral angiography is probably indicated in all such patients, even when lumbar puncture and computerised tomography (CT) scans show no evidence of subarachnoid bleeding. Over a one year period we have collected prospective data on all patients presenting to our regional centre with sudden onset of severe headaches (thunderclap). All patients received a tentative diagnosis of subarachnoid haemorrhage on admission, and were investigated by cranial CT scan and/or lumbar puncture. Cerebral angiography was subsequently done where the consultant in charge of the patient thought it indicated. Subarachnoid blood was demonstrated in 35 of 49 patients in grade 1 or 2 (Hunt/Hess)l on admission. The remaining 14 patients had clear CSF at lumbar puncture, and the CT scan was normal in 12 (the other 2 were not scanned). There were 6 men and 8 women in this group, mean age 37-4 years, and none was significantly hypertensive. None had had headaches of this nature previously, and all said that it was the worst pain they had ever experienced. 6 spontaneously commented that it was like being hit behind the head with a cricket bat or other heavy object. 6 patients subsequently underwent four-vessel cerebral angiography with uniformly negative findings. None had evidence of vasospasm. All 14 made a rapid, uncomplicated recovery and none has had a recurrence of symptoms over a short follow-up (3-15
months). The mechanism of thunderclap headache in the absence of proven subarachnoid haemorrhage is poorly understood. Day and Raskin suggest that the headache in their patients related to a berry aneurysm, but at surgery there was no evidence of old or recent haemorrhage associated with it. They suggest that the vasospasm seen at angiography may have been the source of the pain,. although this was diffuse and not confined to the vessels related to the aneurysm. Thus the association between the aneurysm and the headache is speculative, and the aneurysm may have been
fortuitous. Our pilot study suggests that thunderclap headache without evidence of subarachnoid bleeding is not uncommon but it was not associated with aneurysm in this case. The 8 patients not studied by angiography will have to be followed up for a long time before conclusions can be made, but the findings to date suggest that it would be premature to suggest that all these patients should undergo the potentially hazardous procedure of angiography. More extensive studies are indicated.
SIR,-The diagnosis
Wakefield WF1 4DG
inflammatory abdominal
aortic
thickening is "not enhanced by contrast material". Surely one of the key points is that this circumferential rind of fibrotic thickening enhances avidly;so much so that leakage or dissection may be diagnosed in error by the inexperienced observer. Furthermore this enhancement, although characteristic, should not be regarded as a definite distinguishing feature between idiopathic fibrosis and that
secondary to tumour infiltration. Such distinction can be very difficult.3,4 Little reference was made to the range of names under which inflammatory abdominal aortic aneurysm masquerades. Periaortic fibrosis5 and aortic perianeurysmal fibrosis1.2 have been advocated. Periaortitis has been used for both idiopathic retroperitoneal fibrosis and inflammatory aneurysm: both have identical CT features.6 Indeed the disease may be associated with an auto-allergic reaction to atheromatous material.7 Department of Radiology, Addenbrooke’s Hospital, Cambridge CB2 2QQ
A. K. DIXON T. SHERWOOD
1. Vint VC, Usselman JA, Warmath MA, Dilley RB. Aortic perianeurysmal fibrosis CT
density enhancement and ureteral obstruction. Am J Roentgenol 1980; 134: 577-80. Feldberg MAM, van Waes PFGM, ten Haken GB. CT diagnosis of penaneurysmal fibrotic reactions in aortoiliac aneurysms. J Comput Assist Tomogr 1982; 6: 465-71. 3. Degesys GE, Dunnick NR, Silverman PM, Cohan RH, Ilescas FF, Castagno A. Retroperitoneal fibrosis: use of CT in distinguishing among possible causes. Am J Roentgenol 1986; 146: 57-60. 4. Chisholm RA, Coltart RS, Cooper P, Dixon AK. Circumferential para-aortic masses computed tomographic observations. Clin Radiol 1986, 37: 531-35 5 Baskerville PA, Blakeney CG, Young AE, Browse NI. The diagnosis and treatment of periaortic fibrosis ("inflammatory" aneurysm). Br J Surg 1983; 70: 381-85. 6. Dixon AK, Mitchinson MJ, Sherwood T. Computed tomographic observations in penaortitis: a hypothesis. Clin Radiol 1984; 35: 39-42 7. Mitchinson MJ. Retropentoneal fibrosis revisited. Arch Pathol Lab Med 1986; 110: 2.
783-86.
NEONATAL VARICELLA INFECTION
SIR,-Dr Holland and colleagues (Nov 15, p 1156) reported 3 deaths over a 5-year period in newbom babies who were exposed to varicella zoster infection and treated prophylactically with zoster immune globulin (ZIG) alone. We have seen 10 cases exposed to this infection in the past 18 months (table). All were delivered at term (case 7 was light for dates at 35 weeks’ gestation). Serology in the 6 mothers who were tested was negative at presentation and all denied a history of chickenpox. In the 5 infants who were tested (including 1 with mild disease), serology was negative at 1-3 months. MANAGEMENT OF INFANTS EXPOSED TO VARICELLA ZOSTER INFECTION
Address for correspondence: Department of Neurology, Leeds General Infirmary, Great George Street, Leeds LSI 3EX.
Departments of Neurology and Neurosurgery, Pinderfield General Hospital,
of
aneurysm at computed tomography (CT) is usually straightforward but we take issue with your Nov 29 editorial that the fibrotic
R.
J. ABBOTT P. VAN HILLE
1. Hunt
WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28: 14-20.
SiR,—The case for angiography in the diagnosis of headache, made by Dr Day and Dr Raskin, is not advanced by the use of melodramatic terms such as "thunderclap" headache and "crash" migraine. It is absurd to suggest that a normal cerebrospinal fluid excludes aneurysm and to assume that all headaches which precede subarachnoid haemorrhage are due to aneurysm. A major difficulty in assessing headache is that severity is determined by individual response as well as cause. I do not deny that unruptured aneurysm sometimes, though I suspect rarely, presents in the way described. This calls for good clinical judgment rather than the general use of angiography to "exclude" aneurysm. 13/5 Eildon Terrace,
Edinburgh EH3 5NL
BRYAN ASHWORTH
*Acyclovir, mg, kg per day: Case 2, 40 po for 2 days, then 80 po for 3 days; Case 4, 140 po days; Case 8, 5 iv for 5 days, then 10 iv for 3 days; Cases 9 and 10, 5 iv for 7 days. t!B.1other received po acyclovir. tmodier received iv acyclovir; labour at 37 weeks-postponed for 1 week with ritodrine.
for 5
McIntyre A, O’Donnell B, Clements GB, Desselberger U. HTLV-III antibody in drug abusers in the West of Scotland the Edinburgh connection. Lancet 1986; i: 446-47.
3. Follett EAC,
THUNDERCLAP HEADACHE AND UNRUPTURED CEREBRAL ANEURYSM
SIR,-Dr Day and Dr Raskin (Nov 29, p 1247) describe a patient with "thunderclap" headache attributed to an unruptured cerebral aneurysm with associated arterial vasospasm and conclude that cerebral angiography is probably indicated in all such patients, even when lumbar puncture and computerised tomography (CT) scans show no evidence of subarachnoid bleeding. Over a one year period we have collected prospective data on all patients presenting to our regional centre with sudden onset of severe headaches (thunderclap). All patients received a tentative diagnosis of subarachnoid haemorrhage on admission, and were investigated by cranial CT scan and/or lumbar puncture. Cerebral angiography was subsequently done where the consultant in charge of the patient thought it indicated. Subarachnoid blood was demonstrated in 35 of 49 patients in grade 1 or 2 (Hunt/Hess)l on admission. The remaining 14 patients had clear CSF at lumbar puncture, and the CT scan was normal in 12 (the other 2 were not scanned). There were 6 men and 8 women in this group, mean age 37-4 years, and none was significantly hypertensive. None had had headaches of this nature previously, and all said that it was the worst pain they had ever experienced. 6 spontaneously commented that it was like being hit behind the head with a cricket bat or other heavy object. 6 patients subsequently underwent four-vessel cerebral angiography with uniformly negative findings. None had evidence of vasospasm. All 14 made a rapid, uncomplicated recovery and none has had a recurrence of symptoms over a short follow-up (3-15
months). The mechanism of thunderclap headache in the absence of proven subarachnoid haemorrhage is poorly understood. Day and Raskin suggest that the headache in their patients related to a berry aneurysm, but at surgery there was no evidence of old or recent haemorrhage associated with it. They suggest that the vasospasm seen at angiography may have been the source of the pain,. although this was diffuse and not confined to the vessels related to the aneurysm. Thus the association between the aneurysm and the headache is speculative, and the aneurysm may have been
fortuitous. Our pilot study suggests that thunderclap headache without evidence of subarachnoid bleeding is not uncommon but it was not associated with aneurysm in this case. The 8 patients not studied by angiography will have to be followed up for a long time before conclusions can be made, but the findings to date suggest that it would be premature to suggest that all these patients should undergo the potentially hazardous procedure of angiography. More extensive studies are indicated.
SIR,-The diagnosis
Wakefield WF1 4DG
inflammatory abdominal
aortic
thickening is "not enhanced by contrast material". Surely one of the key points is that this circumferential rind of fibrotic thickening enhances avidly;so much so that leakage or dissection may be diagnosed in error by the inexperienced observer. Furthermore this enhancement, although characteristic, should not be regarded as a definite distinguishing feature between idiopathic fibrosis and that
secondary to tumour infiltration. Such distinction can be very difficult.3,4 Little reference was made to the range of names under which inflammatory abdominal aortic aneurysm masquerades. Periaortic fibrosis5 and aortic perianeurysmal fibrosis1.2 have been advocated. Periaortitis has been used for both idiopathic retroperitoneal fibrosis and inflammatory aneurysm: both have identical CT features.6 Indeed the disease may be associated with an auto-allergic reaction to atheromatous material.7 Department of Radiology, Addenbrooke’s Hospital, Cambridge CB2 2QQ
A. K. DIXON T. SHERWOOD
1. Vint VC, Usselman JA, Warmath MA, Dilley RB. Aortic perianeurysmal fibrosis CT
density enhancement and ureteral obstruction. Am J Roentgenol 1980; 134: 577-80. Feldberg MAM, van Waes PFGM, ten Haken GB. CT diagnosis of penaneurysmal fibrotic reactions in aortoiliac aneurysms. J Comput Assist Tomogr 1982; 6: 465-71. 3. Degesys GE, Dunnick NR, Silverman PM, Cohan RH, Ilescas FF, Castagno A. Retroperitoneal fibrosis: use of CT in distinguishing among possible causes. Am J Roentgenol 1986; 146: 57-60. 4. Chisholm RA, Coltart RS, Cooper P, Dixon AK. Circumferential para-aortic masses computed tomographic observations. Clin Radiol 1986, 37: 531-35 5 Baskerville PA, Blakeney CG, Young AE, Browse NI. The diagnosis and treatment of periaortic fibrosis ("inflammatory" aneurysm). Br J Surg 1983; 70: 381-85. 6. Dixon AK, Mitchinson MJ, Sherwood T. Computed tomographic observations in penaortitis: a hypothesis. Clin Radiol 1984; 35: 39-42 7. Mitchinson MJ. Retropentoneal fibrosis revisited. Arch Pathol Lab Med 1986; 110: 2.
783-86.
NEONATAL VARICELLA INFECTION
SIR,-Dr Holland and colleagues (Nov 15, p 1156) reported 3 deaths over a 5-year period in newbom babies who were exposed to varicella zoster infection and treated prophylactically with zoster immune globulin (ZIG) alone. We have seen 10 cases exposed to this infection in the past 18 months (table). All were delivered at term (case 7 was light for dates at 35 weeks’ gestation). Serology in the 6 mothers who were tested was negative at presentation and all denied a history of chickenpox. In the 5 infants who were tested (including 1 with mild disease), serology was negative at 1-3 months. MANAGEMENT OF INFANTS EXPOSED TO VARICELLA ZOSTER INFECTION
Address for correspondence: Department of Neurology, Leeds General Infirmary, Great George Street, Leeds LSI 3EX.
Departments of Neurology and Neurosurgery, Pinderfield General Hospital,
of
aneurysm at computed tomography (CT) is usually straightforward but we take issue with your Nov 29 editorial that the fibrotic
R.
J. ABBOTT P. VAN HILLE
1. Hunt
WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28: 14-20.
SiR,—The case for angiography in the diagnosis of headache, made by Dr Day and Dr Raskin, is not advanced by the use of melodramatic terms such as "thunderclap" headache and "crash" migraine. It is absurd to suggest that a normal cerebrospinal fluid excludes aneurysm and to assume that all headaches which precede subarachnoid haemorrhage are due to aneurysm. A major difficulty in assessing headache is that severity is determined by individual response as well as cause. I do not deny that unruptured aneurysm sometimes, though I suspect rarely, presents in the way described. This calls for good clinical judgment rather than the general use of angiography to "exclude" aneurysm. 13/5 Eildon Terrace,
Edinburgh EH3 5NL
BRYAN ASHWORTH
*Acyclovir, mg, kg per day: Case 2, 40 po for 2 days, then 80 po for 3 days; Case 4, 140 po days; Case 8, 5 iv for 5 days, then 10 iv for 3 days; Cases 9 and 10, 5 iv for 7 days. t!B.1other received po acyclovir. tmodier received iv acyclovir; labour at 37 weeks-postponed for 1 week with ritodrine.
for 5