ANEURYSM

DEFINITION
A localized abnormal dilation of a blood vessel that occurs most commonly in the aorta or the
heart.
CLASSIFICATION
I. Location in the walls
1. True aneurysm
- bounded by complete often attenuated arterial wall components
- qualitative or quanitative structural alteration
- Blood is within con nes of the circulatory system
2. False aneurysm
- extravascular haematoma
- wall is composed of outer arterial or periarterial tissues
II. Aetiology
1. Atherosclerotic aneurysm - in complicated atheroma
2. Syphilitic aneurysm - in tertiary syphilis
3. Mycotic aneurysm - d/t infection (IE)
4. Congenital aneurysm eg. Berry aneurysm of Willis
5. Vasculitis - eg. PAN, Kawasaki d/s
6. Traumatic eg. Arterio - venous aneurysm
7. Cystic medial degeneration or Dissecting aneurysm
III. Morphology
1. Berry aneurysm - small spherical, 1-1.5 cm in Diameter, most frequent brain (Circle of Willis)
2. Saccular aneurysm - spherical, only a portion of vessel wall a ected, 5-
20 cm Diameter.
3. Fusiform aneurysm - gradual progressive dilatation, involve complete circumference, size is
up to 20 cm in Diameter, seen in aorta & iliac arteries
4. Aortic dissection - blood dissects b/t layers of wall creating a cavity within wall

ATHEROSCLEROTIC ANEURYSM
• Most common aneurysm
• A ected males > 50 yrs of age, M:F - 5:1
• Great preponderance in abdominal aorta usually below renal arteries
• May be accompanied by iliac artery aneuryam

Pathogenesis
• Multifactorial causation
• Risk factors for atherosclerosis increased chance of aneurysm In atherosclerotic vessel,
atheromatous plaque compresses the underlying
layers → weakening of the wall → dilatation
• Familial - m/b asso: with aortic structural connective tissue components
• Haemodynamic factors - H/T & turbulent ow

Morphology
Gross
Site
• Abdominal aorta, below the renal arteries, above the bifurcation of aorta
• Common iliac arteries
• Occasionally ascending arch & descending part of thoracic aorta.
• s/t accompanied by fusiform or saccular arterial dilatation
ff
fi
fl
ff
 • Atheromatous ulcers with mural thrombi
• Site for atheroemboli - kidney, lower extremities
• Laminated thrombus may ll entire aneurismal sac
• Thinning & destruction of media

Complications
1. Rupture into peritoneal cavity or retroperitoneum massive fatal hemorrhage
Risk of rupture related to size
< 4cm _2% risk
> 5cm _5-10% risk, 50% die within 10 yrs
Mortality rate after surgery: 5% in unruptured aneurysm, 50% after rupture
2. Impingement on adjacent structure
such as compression of ureter _obstructive uropathy, uremia erosion of vertebra _back pain,
paraplegia erosion of gut wall _intestinal obstruction trachea_ dyspnoea
oesophagus_ dysphagia
3. Occlusion of vessel
- by direct pressure
- by thrombus at ostia → Occlusion of artery,
Iliac artery occlusion → gangrene L.E
Renal artery occlusion → renal infarct
Mesenteric artery occlusion gangrene S.I
Vertebral artery occlusion (that supply the spinal cord) → paraplegia
4. Embolism from atheroma or mural thrombus
5. Large pulsatile abdominal masses can mimic with tumour
6. Acompained by wide spread coronary atherosclerosis → increased risk of IHD

SYPHILITIC ANEURYSM (LEUTIC ANEURYSM)

• Seen in tertiary state of syphilis
• 15 - 20 yrs after initial infection
• Age - 40-55 yrs
• Male: female - 3:1
Basic pathology
• Obliterative endarteritis e ecting vasa vasorum of aorta → aortitis
→ aneurysmal dilatation
• Perivascular cu ng by in ammatory cells esp: plasma cells with some
lymphocytes
• Narrowing of the vasa vasorum→ischemic injury to media → loss of elastic bers & m/s cells
→ in ammation, scarring & vascularization of media → contraction of brous scar → wrinkling
of intima ( Tree Breaking appearance)
• Superimposed atherosclerosis → occlusion of coronary ostia
• Syphilitic heart d/s - Aortitis → aortic value ring dilatation → AI →
Volume overload → LVH → massively enlarged heart (Cor Bovinum or cow's heart) > 3 times
than normal weight → Heart failure

Complications
1. Enchorachment on mediastinal structures
2. Lungs & airways - respiratory di culty
3. Oesophageal compression - dysphagia
4. Pressure of recurrent laryngeal nerve - persistent cough, horseness of voice
5. Pain d/t rib & vertebral erosion
6. Syphilitic heart d/s - heart lure
7. Rupture - massive h'ge & fatal
fl
ffi
ff
fl
fi
fi
ffi
fi
fi
 AORTIC DISSECTION (DISSECTING ANEURYSM )
(AORTIC ANEURYSM)
DEFINITION
• A catastrophic illness characterized by dissection of blood along the laminar plane of aortic
media with formation of blood lled channel within aortic wall that often ruptures causing the
massive h'ge.

INCIDENCE
• 1/3 of pts die within 1st
day of onset
• M:F - 3:1 at any age
• Not usually asso: with marked dilatation of aorta
• Better use the term aorta dissection

Etiology
Association
1. Most common group - Male, 40 - 60 yrs, 90% preceded by H/T
2. ½ of female cases < 40 yrs occur d/r pregnancy esp: 3rd trimester
3. Asso: with systemic or localized abnormality of connective tissue E.g. Marfan's syndrome &
Ehler- Danlos Syndrome
4. As complication of arterial cannulation
5. Unusual in AS
6. Other predispoditions - bicuspid AV, coarctation of aorta

PATHOGENESIS
• Cystic medial degeneration - accumulation of basophilic amorphous materials in the media
with formation of cyst like mucoid pool
• Asso: with Marfan's syndrome → possible connective t/s defect
• Copper de ciency → cystic medial degeneration
• H/T → may damage aortic media & enhance progression of dissection, trigger for intimal tear &
intramural aortic hemorrhage
• Unknown in most cases

MORPHOLOGY
Gross :
• Intimal tear - extend into media of aorta within 10 cm of aortic value (usu:/not always)
• Tears are traverse / oblique, 1-5 cm long with sharp or jagged edges
• Dissection extends → proximal towards heart, distally along aorta s/t up to iliac & femoral
artery.
• Blood re ruptures into lumen → 2nd distal tear
• New vascular channel connecting the proximal & distal tear → Double barreled aorta avoid
fatal h'ge & channel may be endothelialized
• H'ge (dissecting intramural haematoma): Occurs b/t middle & 1/3 of media

Histology:
• Mild elastic fragmentation to cystic medial degeneration seen as focal separation of elastic &
bromuscular elements in media
• Small cyst like spaces lled with amorphous ground substance like connective t/s
• Large losses of elastic lamina
fi
fi
fi
fi
 CLINICAL FEATURES
Classic cases
• Sudden excruciating pain beginning in anterior chest, radiate to back & downward (tearing or
ripping pain)
• Pain may be episodic or recurrent in bouts of advancing dissection
• Readily confused with AMI
Clinical features d/t progressive dissection (complications)
1. Due to retrograde dissection into aortic root → murmur
2. Unequal compression of major aortic branch → sudden changes or inequalities in B.P b/t 2
arms.
3. Compression of vertebral branches → sensory & motor changes in lower
½ of the body.
4. Compression of spinal artery → Transverse myelitis
5. Compression of renal artery → Renal failure
6. Mesenteric artery comprise → Abdominal pain
7. Dissection into coronary artery → MI
8. Rupture into pericardial cavity → Cardiac temponade
9. Rupture into pleural cavity → Lung collapse
10. Rupture into peritoneal cavity & periadventitial tissues → Fatal hemorrhage

DIAGNOSIS
I. ANTEMORTEM DIAGNOSIS -10%
1. Radiography - subtle but not aneurymal widening ( Aorta angiography )
2. Computed tomography (CT)
3. Echocardiograpy
4. MRI ( can see thickening of the wall)
II. POSTMORTEM DIAGNOSIS: 90%
PROGNOSIS
• Without treatment - 1/3 die within 24 hrs
• 90% die within 1 3 months
• With surgery - prosthetic graft + anti H/T drugs overall 10 yrs survival is 40%

Vasculitis
In ammation of wall of blood vessels.

Causes
1. Infections
• Bacterial, Rickettsial, Syphilis
• Fungal (Aspergillosis), Viral (Herpes zoster - varicella)
2. Immunologic
• Immune complex mediated
• Antineutrophil cytoplasmic Ab (ANCA) mediated
• Direct Ab attack (Good Pasture syndrome & Kawasaki disease)
• Cell mediated
3. Unknown
• Giant cell (temporal) arteritis
• Takayasu artertis
fl
 • Polyarteritis nodosa
Takayasu arteritis
• Ocular disturbances
• Weakening of upper extremity pulse (pulseless disease)
• Aortic arch brous narrowing
Polyarteritis nodosa
• Small or medium sized m/s arteries
• Renal & visceral vessels
• Aneurysm, nodularitiy, vascular obstruction
Kawasaki syndrome
• Arteritis
• Mucocutaneous lymph node syndrome
• Young children & infants
• Epidemic in Japan
Giant Cell (Temporal) arteritis
• Most common vasculitis
• Acute or chronic granulomatous in ammation of medium sized arteries
• A ects mainly arteries in the head esp: temporal artery
• Vertebral & ophthalmic

VASCULAR TUMOURS
I. Benign tumours
1. Haemangioma
• Capillary Haemangioma - c/o narrow thin walled bld v/s resembling capillaries - lined by
endothelium
• Cavernous Haemangioma - Formation of large cavernous vascular channels
• Granuloma pyogenicum - Polypoid form of capillary hemangioma with presence of acute &
chronic in ammatory cells & stromal oedema
2. Glomus tumour (Glomangioma)
• Painful, arise from modi ed smooth m/s cells of glomous body
• In digits under nger nails
• c/o two components ( branching vascular channels & masses & nests of glomus cell)
Il. Intermediate grade tumours
1. Haemangiopericytoma - masses of endothelial cells
2. Epitheloid haemangioendothelioma - tumour cells are plump de resemble epithelial cells.
III. Malignant tumour
1. Angiosarcoma (Haemangiosarcoma)
• Asso: with arsenic, thorotrast, PVC
• c/o anaplastic endothelial cells
2. Haemangiopericytoma
• c/o thin wall capillary channels surrounded by masses of spindle cells (pericytes)
3. Kaposi Sarcoma
• Classic Europen form - epidemic in E Europe & Mediterraneum
• African Kaposi sarcoma - in Africa (children & younger man)
• Transplant associated Kaposi sarcoma
• AIDS asso: Kaposi sarcoma
• 1/3 of AIDS pts, male homosexuals
ff
fl
fi
fi
fi
fl