Thromboangitis Obliterans Resulting in Multisystem Aneurysms: A Case Report (P4.370)

Objective: To present a case of a middle-aged woman with multiple aneurysms involving intracranial, extracranial, and multi-system arteries. Serial vascular-imaging over a nine-year-period demonstrated development of new aneurysms and evolution of existing aneurysms. Diagnosis of Thromboangitis Obliterans(TAO) was confirmed by biopsy of cerebral aneurysms. Background: Multi-system aneurysms have been reported in vasculopathies, connective tissue disorders and infections. TAO is an inflammatory condition promoted by smoking, affecting arteries and veins of distal extremities. Pathology usually shows the inflammatory and cellular response involving a thrombus but vessel wall is usually spared. Involvement of cerebral arteries is rare, and usually causes ischemic infarction. Methods: In 2006, at age 40, an African American female, heavy smoker, presented with an acute left midbrain infarct, a basilar artery aneurysm and a chronic right pontine infarct. She underwent coiling of the aneurysm. In 2007, the coiled aneurysm recanalized and in addition 20 other aneurysms were detected. Over the course of nine years, an active disease process was documented, with evolution of known aneurysms and formation of new aneurysms. Follow-up cerebral angiograms in 2008, 2009, 2010, 2011 and 2012 revealed 13, 6, 10, 16 and 19 aneurysms, respectively. In addition to intracranial aneurysms, multiple systemic aneurysms were detected. Histopathologic analysis of the resected cerebral aneurysms suggested cerebral TAO. Results: Vascular imaging-studies over nine years documented aneurysms in intracranial arteries, extracranial cerebral, vertebral, superficial temporal, anterior spinal, ascending cervical, middle meningeal, thyroid, inferior pancreaticojejunal, transverse pancreatic, scapular arteries, mesenteric and bilateral renal arteries. TEE, toxicology, serologic and immunologic markers were negative. Histology revealed mixed inflammatory intraluminal thrombi overlying intact or inflamed arterial media. Conclusion: Compared to prior reports that suggest that TAO spares the vessel wall, this case of TAO clearly demonstrates vessel wall inflammation and thrombosis, and should therefore be considered in the differential diagnosis of multi-system aneurysms.