Delayed rupture of traumatic aneurysm after civilian craniocerebral gunshot injury in children

Endovascular Management of Pediatric Traumatic Intracranial Pseudoaneurysms: A Systematic Review and Case Series

OBJECTIVE

This study aims to systematically review the management and outcomes of pediatric patients who develop intracranial pseudoaneurysm (IPA) following head trauma or iatrogenic injury.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed. Additionally, a retrospective analysis was conducted on pediatric patients who underwent evaluation and endovascular treatment for IPA originating from head trauma or iatrogenic injury at a single institution.

RESULTS

Two hundred twenty-one articles in the original literature search. Fifty-one met inclusion criteria resulting in a total of 87 patients with 88 IPAs including our institution. Patients ranged in age from 0.5 months to 18 years. Parent vessel reconstruction was used as first-line treatment in 43 cases, parent vessel occlusion in 26, and direct aneurysm embolization (DAE) in 19. Intraoperative complications were observed in 3.00% of procedures. Complete aneurysm occlusion was achieved in 89.61% of cases. 85.54% of cases resulted in favorable clinical outcomes. The mortality rate after treatment was 3.61%. The DAE group had higher rates of aneurysm recurrence than other treatment strategies (P = 0.009). Patients with SAH had overall worse outcomes compared to patients who did not (P = 0.024). There were no differences in favorable clinical outcomes (P = 0.274) or complete aneurysm occlusion (P = 0.13) between primary treatment strategies.

CONCLUSIONS

IPAs were successfully obliterated, and favorable neurological outcomes were achieved at a high rate regardless of primary treatment strategy. DAE had a higher rate of recurrence than the other treatment groups. Each described treatment method in our review is safe and viable for the treatment of IPAs in pediatric patients.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury

BACKGROUND

This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome.

METHODS

We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome.

RESULTS

Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI.

CONCLUSION

Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging

BACKGROUND

Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking.

METHODS

We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience.

RESULTS

Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping.

CONCLUSIONS

We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.

Management of Craniocerebral Gunshot Injuries: A Review

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Case Report: Traumatic anterior cerebral artery aneurysm in a 4-year old child

Traumatic intracranial aneurysm in the proximal part of the anterior cerebral artery in the pediatric population has not been documented so far. Here we report the case of a 4 year-old child who developed a pseudo-aneurysm after minor head trauma and was managed successfully with trapping of the aneurysm. A ventriculo-peritoneal shunt was placed as the child became dependent on extraventricular drain during the post-operative period. The patient made excellent recovery in neurological status within 1 month of post-operative clinical follow up.

Arteriovenous fistula and pseudoaneurysm of the anterior spinal artery caused by an epidural needle in a 5-year-old patient

Authors present the case of a 5-year-old patient with a spinal arteriovenous fistula (AVF) and pseudoaneurysm of the anterior spinal artery (ASA) caused by a traumatic epidural needle stick injury. A discussion and relevant review of the literature follow. The boy had a remote history of a liver transplant and required neuraxial blockade for an unrelated abdominal surgical procedure. Initial insertion of the epidural needle at the T9-10 interspace yielded blood. A second attempt at T10-11 was successful. Delayed left leg weakness developed on postoperative Day 8, with an MR image showing a track injury through the cord and a ventral subarachnoid hematoma. Laminectomies from T-9 to T-11were performed emergently to decompress the spinal cord. The dura mater was opened, the ventral hematoma was evacuated, and brisk venous bleeding was controlled with cauterization. Postoperative spinal angiography demonstrated an AVF and pseudoaneurysm of the ASA. Repeat angiography at postoperative Week 4 demonstrated complete resolution of the AVF and pseudoaneurysm, probably due to intraoperative cauterization of the draining vein. The patient underwent a short course of rehabilitation and had no clinical or electrophysiological evidence of spinal cord damage at the 20-month follow-up. One should be cognizant of the possibility of a cord injury in a patient with new-onset neurological deficits following an interventional spine procedure. Neuroimaging is essential for prompt diagnosis and treatment.

The evolution of the treatment of traumatic cerebrovascular injury during wartime

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.

Endovascular treatment and radiographic follow-up of proximal traumatic intracranial aneurysms in adolescents: case series and review of the literature

PURPOSE

Traumatic intracranial aneurysms are rare lesions that are relatively more common in the pediatric population. Proximal traumatic aneurysms occur near the skull base. Direct surgical repair of these lesions is difficult due to the anatomically confined area, clinical status of a head injury patient, and the transmural nature of the injury. These lesions often lack a definable neck or wall suitable for clipping. While the indications and capabilities of endovascular treatment continue to expand, there are unanswered questions about the durability of treatment, especially in young patients. There are few reports examining the radiographic outcomes of endovascular treatment specifically for traumatic intracranial aneurysms. Therefore, we examined our experience treating these rare proximal lesions in an adolescent population.

METHODS

A retrospective review of prospectively collected data from 2000-2008 in a large, multidisciplinary neurovascular and trauma center was performed.

RESULTS

Three pediatric patients received endovascular treatment for traumatic intracranial aneurysms near the skull base. All patients had successful obliteration of their lesion without vessel sacrifice; however, two patients required multiple procedures for coil compaction or refilling of the aneurysm. There were no complications or ischemic events related to treatment. Follow-up imaging ranged from 6 months to 3.5 years.

CONCLUSIONS

Traumatic intracranial aneurysms at the skull base can be successfully treated with endovascular methods; however, close follow-up is necessary.

Wartime Traumatic Aneurysms

OBJECTIVE

Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management.

METHODS

A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study.

RESULTS

A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically.

CONCLUSION

The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve.