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Takeda K, Oda K, Fukumoto H, Kobayashi H, Morishita T, Takemoto K, Iwaasa M, Abe H. Repeated coil embolization of traumatic basilar artery pseudoaneurysm accompanied by bilateral traumatic internal carotid artery stenosis following severe head injury in a pediatric patient: A case report and literature review. Surg Neurol Int 2023; 14:199. [PMID: 37404524 PMCID: PMC10316180 DOI: 10.25259/sni_267_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Background Few cases of pediatric traumatic intracranial aneurysms (pTICAs) in the posterior circulation involving the basilar artery (BA) following severe head trauma have been reported. Here, we describe a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic internal carotid artery (ICA) stenosis following blunt head trauma. Case Description A 16-year-old boy presented to our emergency department after being hit by a car. The patient was initially diagnosed with multiple skull base fractures underlying traumatic subarachnoid hemorrhage and left acute epidural hematoma. Seven days following emergency craniectomy, magnetic resonance imaging revealed bilateral ICA stenosis, BA stenosis, and BA pseudoaneurysm. We decided to perform coil embolization, resulting in body filling and a volume embolization ratio of 15.7%. Twenty-eight days after coil embolization, digital subtraction angiography revealed aneurysmal rupture. We performed repeated coil embolization, resulting in body filling and a volume embolization ratio of 20.9%. Conclusion We reported a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic ICA stenosis following a severe head injury treated with repeated coil embolization. Considering the risk of further brain injury due to high incidence of rupture, early vascular survey and appropriate treatment may be the most important prognostic factors in pTICAs.
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Affiliation(s)
| | - Kazunori Oda
- Corresponding author: Kazunori Oda, Department of Neurosurgery, Fukuoka University, Fukuoka, Japan.
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Sujijantarat N, Pierson MJ, Kemp J, Coppens JR. Staged Trapping of Traumatic Basilar Trunk Pseudoaneurysm: Case Report and Review of Literature. World Neurosurg 2017; 108:991.e7-991.e12. [PMID: 28866061 DOI: 10.1016/j.wneu.2017.08.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) of the posterior circulation in the pediatric populations are rare. Only a few reports in the literature document basilar artery TICA in the pediatric population. These cases were typically associated with a clival fracture and commonly diagnosed weeks to months after trauma. We present a case of a patient with a basilar TICA diagnosed after a motor vehicle collision treated with staged trapping and review of the literature. CASE DESCRIPTION We present a case of a 14-year-old boy who sustained a high-speed motor vehicle collision and developed a basilar trunk TICA identified on admission. Initially, the patient underwent craniotomy for proximal sacrifice of the basilar artery in hope for spontaneous thrombosis of the aneurysm through flow reversal. Endovascular options were reviewed and felt to be less feasible than surgical trapping. Due to continued filling through the right posterior communicating artery, the second surgery was performed to distally trap the aneurysm. The aneurysm was opened, showing some thrombosis and the absence of flow. Repeat magnetic resonance imaging did not reveal any new infarction, and the patient was discharged with neurologic improvement over time. At 1 year, he was able to ambulate unassisted and had a modified Rankin Scale score of 3. CONCLUSION Development of a TICA may be more acute than literature previously suggested. Treatment consists of a wide range of options and should be considered, especially in the pediatric population, to prevent rupture. Trapping can be performed safely if adequate collateral flow is present in the setting of a large basilar artery aneurysm.
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Affiliation(s)
| | - Matthew J Pierson
- Department of Neurosurgery, Saint Louis University, Saint Louis, Missouri, USA
| | - Joanna Kemp
- Department of Neurosurgery, Saint Louis University, Saint Louis, Missouri, USA
| | - Jeroen R Coppens
- Department of Neurosurgery, Saint Louis University, Saint Louis, Missouri, USA.
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Ko HC, Koh JS, Shin HS, Lee SH, Ryu CW. Staged Endovascular Occlusion of a Posterior Communicating Artery-Cavernous Sinus Fistula and a Basilar Artery-Cavernous Sinus Fistula Associated with Traumatic Pseudoaneurysms: Technical Consideration and Literature Review. World Neurosurg 2017; 107:1051.e7-1051.e11. [PMID: 28842235 DOI: 10.1016/j.wneu.2017.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic injury of the posterior communicating artery or the basilar artery causing arteriovenous fistulae is rare. CASE DESCRIPTION Here we report an unusual case of the coincidence of a posterior communicating artery-cavernous sinus fistula and a basilar artery-cavernous sinus fistula associated with traumatic pseudoaneurysms of the posterior communicating and basilar arteries. The fistulas and pseudoaneurysms were obliterated completely after staged endovascular surgery via a transarterial and transvenous route. CONCLUSIONS To our knowledge, this is the first such report worldwide.
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Affiliation(s)
- Hak Cheol Ko
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Korea
| | - Jun Seok Koh
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Korea.
| | - Hee Sup Shin
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Korea
| | - Seung Hwan Lee
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Korea
| | - Chang Woo Ryu
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Gangdong-gu, Seoul, Korea
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Turan N, Butler S, Larson TC, Mason A. Nontraumatic, posterior circulation pseudoaneurysm of the basilar artery summit with complete spontaneous resolution: Case report and literature review. Surg Neurol Int 2017; 8:50. [PMID: 28480112 PMCID: PMC5402333 DOI: 10.4103/sni.sni_452_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/23/2017] [Indexed: 12/02/2022] Open
Abstract
Background: Intracranial pseudoaneurysms are rare vascular defects of arterial walls that are classically the result of traumatic injury, iatrogenic causes, or infection. Idiopathic pseudoaneurysms are seen even less frequently and are often related to atherosclerosis. Pseudoaneurysms are most commonly found along the distal wall of the internal carotid artery, however, can occur at any location in the cerebrovascular circulation. Treatment of these arterial defects is often challenging due to their frail nature. Case Description: A 61-year-old male with a history of hypertension presented with a severe, atypical headache without history of trauma. Computed tomography (CT) and computed tomography angiography (CTA) demonstrated diffuse subarachnoid hemorrhage. Imaging demonstrated a 3.5 mm pseudoaneurysm projecting distally from the basilar artery at the apex. Repeated imaging (CTA, digital subtraction angiography) demonstrated decreased size and flow associated within the aneurysm over the following 2 weeks; as such, the patient was managed conservatively. The patient was discharged in neurologically intact condition when imaging at 14 days confirmed complete and spontaneous resolution of the pseudoaneurysm. Conclusion: Idiopathic pseudoaneurysms that are commonly associated with atherosclerosis are most commonly managed surgically or endovascularly. Conservative approach may be considered in a select group of patients that exhibit decreased size and/or flow within the aneurysm in repeated imaging; spontaneous resolution was seen in the present case.
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Affiliation(s)
- Nefize Turan
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Shannon Butler
- Faculty of Health, University of Canberra, Canberra, Australia
| | - Theodore C Larson
- Department of Neurosciences, Centura Health Physician Group Neuroscience and Spine, Lakewood, Colorado, USA
| | - Alexander Mason
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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5
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Cheng KM, Chan CM, Cheung YL, Liang CC, Lee MK, Leung CL, Chiu HM, Chan CH. Transvenous Embolisation of Spontaneous Carotid-Cavernous Fistulas by Sequential Occlusion of the Cavernous Sinus. Interv Neuroradiol 2016; 5:225-34. [PMID: 20670515 DOI: 10.1177/159101999900500305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/1999] [Accepted: 07/25/1999] [Indexed: 11/17/2022] Open
Abstract
There are two important pathological features associated with carotid-cavernous fistula (CCF): the retrograde cortical venous drainage that can cause intracranial haemorrhage and non haemorrhagic neurological deficit and the retrograde ophthalmic venous drainage that causes orbital venous congestion and visual impairment. We propose a sequential embolisation strategy by the selective occlusion of these two pathological features as the initial steps followed by occlusion of the rest of the cavernous sinus. Eight patients with spontaneous CCF were treated by transvenous embolisation using our embolisation strategy. The clinical features, angiographic findings, embolisation procedures, and clinical and angiographic outcomes were analyzed. The follow-up period ranged from one to 21 months. Clinical cure was achieved in six patients at one to two month follow-ups. One patient with bilateral CCFs had clinical cure of the right eye and clinical improvement of the left eye at three-month follow-up. Another patient had clinical cure at one-month follow-up except residual VI nerve palsy. Two patients had complete angiographic obliteration of the fistula immediately after the embolisation procedure. Another three patients underwent follow-up angiography at one to 16 months and all showed angiographic cure. There were no immediate or late complications. Our embolisation strategy offers a safe and effective option in the embolisation of spontaneous CCF as demonstrated by the clinical results of our eight patients.
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Affiliation(s)
| | - C.-M. Chan
- Department of Radiology and Imaging;Queen Elizabeth Hospital, Hong Kong, China
| | - Y.-L. Cheung
- Department of Radiology and Imaging;Queen Elizabeth Hospital, Hong Kong, China
| | | | | | | | | | - C.-H. Chan
- Department of Radiology and Imaging;Queen Elizabeth Hospital, Hong Kong, China
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6
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Kim BC, Lee JI, Cho WH, Nam KH. Fatal Traumatic Subarachnoid Hemorrhage due to Acute Rebleeding of a Pseudoaneurysm Arising from the Distal Basilar Artery. J Korean Neurosurg Soc 2014; 56:428-30. [PMID: 25535522 PMCID: PMC4273003 DOI: 10.3340/jkns.2014.56.5.428] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/25/2014] [Accepted: 08/18/2014] [Indexed: 11/27/2022] Open
Abstract
Isolated traumatic pseudoaneurysms of the basilar artery are extremely rare but often fatal resulting in a mortality rate as high as 50%. A 51-year-old man presented with craniofacial injury after blunt trauma. A brain computed tomography (CT) scan showed thick basal subarachnoid hemorrhage associated with multiple craniofacial fractures, while CT angiography revealed contrast extravasation at the distal basilar artery with pseudoaneurysm formation. After this primary survey, the condition of the patient suddenly deteriorated. Conventional angiography confirmed the contrast extravasation resulted from pseudoaneurysm formation, which was successfully treated with endovascular coil embolization. Decompressive craniectomy and coma therapy with propofol were also performed. However, the patient died on the 7th hospital day because of the poor initial clinical condition. The current case is the first report of acute pseudoaneurysm rupture arising from the basilar artery within the first day after trauma. Our findings suggest the possibility that pseudoaneurysm rupture should be considered if brain CT shows thick traumatic subarachnoid hemorrhage on the basal cistern with a basal skull fracture.
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Affiliation(s)
- Byung Chul Kim
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Won Ho Cho
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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7
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Gelesko S, Markiewicz MR, Bell RB. Responsible and Prudent Imaging in the Diagnosis and Management of Facial Fractures. Oral Maxillofac Surg Clin North Am 2013; 25:545-60. [DOI: 10.1016/j.coms.2013.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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8
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Li T, Zhang Y, Gu Z, Ma X, Yang X. Traumatic pseudoaneurysm of the basilar artery presenting with fatal epistaxis: A rare case report. Brain Inj 2013; 27:1316-9. [PMID: 23924339 DOI: 10.3109/02699052.2013.812242] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tong Li
- Department of Neurosurgery, West Campus, Beijing Chaoyang Hospital afflicted of Capital Medical University
BeijingPR China
| | - Yisen Zhang
- Department of Neurosurgery, West Campus, Beijing Chaoyang Hospital afflicted of Capital Medical University
BeijingPR China
| | - Zheng Gu
- Department of Neurosurgery, West Campus, Beijing Chaoyang Hospital afflicted of Capital Medical University
BeijingPR China
| | - Xiangke Ma
- Department of Neurosurgery, West Campus, Beijing Chaoyang Hospital afflicted of Capital Medical University
BeijingPR China
| | - Xijian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital
BeijingPR China
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9
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Ray CE, Spalding SC, Cothren CC, Wang WS, Moore EE, Johnson SP. State of the art: noninvasive imaging and management of neurovascular trauma. World J Emerg Surg 2007; 2:1. [PMID: 17212833 PMCID: PMC1796545 DOI: 10.1186/1749-7922-2-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 01/09/2007] [Indexed: 11/10/2022] Open
Abstract
Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries.
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Affiliation(s)
- Charles E Ray
- Diagnostic and Interventional Radiology, Denver Health Medical Center, 777 Bannock St, Denver, CO80204, USA
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Shaun C Spalding
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - C Clay Cothren
- Surgery, Denver Health Medical Center, 777 Bannock St., Denver, CO80204, USA
- Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Wei-Shin Wang
- University of Colorado School of Medicine, 4200 East Ninth Street, Denver, CO80220, USA
| | - Ernest E Moore
- Surgery, Denver Health Medical Center, 777 Bannock St., Denver, CO80204, USA
- Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Stephen P Johnson
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
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10
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Abstract
Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.
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MESH Headings
- Aneurysm, False/diagnosis
- Aneurysm, False/diagnostic imaging
- Angiography/methods
- Angiography, Digital Subtraction/methods
- Blood Vessels/injuries
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Craniocerebral Trauma/diagnosis
- Craniocerebral Trauma/diagnostic imaging
- Diagnosis, Differential
- Humans
- Intracranial Arteriovenous Malformations/diagnosis
- Intracranial Arteriovenous Malformations/diagnostic imaging
- Magnetic Resonance Angiography/methods
- Magnetic Resonance Imaging/methods
- Neck/blood supply
- Neck Injuries/diagnosis
- Neck Injuries/diagnostic imaging
- Tomography, X-Ray Computed/methods
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/diagnostic imaging
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/diagnostic imaging
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Affiliation(s)
- M J B Stallmeyer
- Division of Diagnostic and Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD 21208, USA.
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11
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Weaver KD, Ewend MG, Solander S. Successful transarterial Guglielmi detachable coil embolization of posttraumatic posterior communicating artery-cavernous sinus fistula: technical note. Neurosurgery 2003; 52:458-60; discussion 460-1. [PMID: 12535380 DOI: 10.1227/01.neu.0000043817.55770.f8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2002] [Accepted: 09/06/2002] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Carotid-cavernous fistulae are uncommon but well-documented sequelae of craniofacial trauma. A rare subset may arise from the posterior communicating artery instead of from the carotid artery proper. The presentation is similar to that of carotid-cavernous fistulae, with ocular pain, chemosis, and proptosis being the common symptoms. The first successful transarterial coil embolization of this type of lesion is described. METHODS A 42-year-old man presented with severe craniocerebral injury, including multiple craniofacial fractures, after an industrial accident. He required emergent craniotomy for an open depressed cranial fracture and epidural hematoma. Six weeks after presentation, the patient began to exhibit progressive chemosis and proptosis. Magnetic resonance imaging revealed findings consistent with a carotid-cavernous fistula. RESULTS Angiography revealed a fistula between the posterior communicating artery and the cavernous sinus. The origin of the fistula in the posterior communicating artery was successfully obliterated with Guglielmi detachable coiling. Subsequent studies demonstrated no flow through the fistula and good opacification of the ipsilateral posterior cerebral artery by the vertebrobasilar system. CONCLUSION Posterior communicating artery-cavernous fistulae are a rare sequel of trauma. They may be treated successfully with the use of transarterial coil embolization.
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Affiliation(s)
- Kyle D Weaver
- Division of Neurosurgery, Department of Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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12
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Abstract
Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.
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Affiliation(s)
- Donald W Larsen
- Department of Neurological Surgery and Radiology, Keck School of Medicine, University of Southern California, Department of Interventional Neuroradiology, University of Southern California Medical Center, Los Angeles, CA, USA.
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13
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Hemphill JC, Gress DR, Halbach VV. Endovascular therapy of traumatic injuries of the intracranial cerebral arteries. Crit Care Clin 1999; 15:811-29. [PMID: 10569123 DOI: 10.1016/s0749-0704(05)70089-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Traumatic intracranial arterial injuries represent uncommon complications of both closed-head injury and penetrating head trauma. These injuries include arterial dissections, pseudoaneurysms, and fistulas, both direct and indirect. Although these lesions may be identified while still asymptomatic, they usually present in a delayed fashion with intracranial hemorrhage, focal cerebral ischemia, or, occasionally, severe epistaxis. Endovascular therapy has assumed a major role in the management of this diverse group of lesions. Embolization of pseudoaneurysms with balloons or detachable coils, the use of embolic particles for small arterial injuries, and large vessel occlusion with detachable balloons represent current treatment strategies that have evolved over the past three decades. Angioplasty and stent deployment may have a future role to play in the management of arterial dissection. Principles of neurologic critical care that minimize secondary brain injury are essential adjuncts in the management of these patients before, during, and after endovascular treatment.
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Affiliation(s)
- J C Hemphill
- Department of Neurology, University of California, San Francisco, USA
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