From aneurysm to aneurysmal vasculopathies

Today, aneurysms raise a number of challenges. Medical challenge: The emergency and severity of the pathology have led to passionate debates that unfortunately stall progress in our knowledge of the underlying disease (or diseases). Indeed we can suppose that some measure of bleeding, perhaps even early recurring hemorrhage, has gone undiscovered and that some patients have bled several times before ever reaching the hospital. Decision-making challenge: Far from emergency and immediate action, this is a challenge of knowledge versus superstition. The decision concerns the therapeutic objective and the choice of a specific technique in a given place, whether surgical or endovascular. The choice of the treatment should first take into consideration the patient's needs, and second, the quality of the treatment available. Ethical challenge: Preventing rupture has a cost in terms of public finances, ethics, and outcomes. The former is a choice of society, while the latter is a result of the invasiveness of the treatment, regardless of the location of the aneurysm. Permanent self-assessment is not a recent suggestion, but today it has become more relevant than ever on account of the publication of medical data considered as universally applicable because it is internationally available. Academic and nosologic challenge: It is difficult to refrain from thinking that aneurysms, though they may be discovered in a variety of contexts (bacterial or viral infection, traumatic or spontaneous dissection, dysplasia, familial or isolated aneurysms, flow-related in cerebral arteriovenous malformations or in cases of anastomoses for revascularization, giant basilar fusiform aneurysms or smaller aneurysms of the P2 segment of the posterior cerebral artery, giant carotid aneurysms or serpentine aneurysms of the distal cerebral arteries, multifocal unilateral or mirror aneurysms, multiple, supra- or infratentorial aneurysms, etc) do not result from entirely different diseases. Therefore, diagnosed aneurysms should be considered the result of 2 simultaneous processes: the production of aneurysms and the failure to repair them. Age and life of aneurysms should be thought of as having a symptomatic clinical stage, an asymptomatic stage, a biological stage, and a prepathological stage (applying to somatic mutations).