Delayed intracerebral hematoma caused by traumatic intracavernous aneurysm: case report

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.

Gunshot wounds of the internal carotid artery at the skull base: management with vein bypass grafts and a review of the literature

BACKGROUND

Penetrating trauma to the skull base and distal cervical internal carotid artery (ICA) can result in occlusion or pseudoaneurysm formation. The appropriate management strategy for these rare lesions is controversial and includes observation, anticoagulation, carotid ligation, balloon occlusion, or revascularization.

METHODS

We present the management and outcomes of four consecutive patients, two with pseudoaneurysms and two with acute occlusions, after injury to the distal cervical/petrous ICA from gunshot wounds. Preoperative assessment determined intracranial collateral flow patterns and the patency of the distal portion of the petrous ICA.

RESULTS

Two patients underwent cervical-to-petrous ICA vein bypass grafts without neurologic complications. Both grafts remain patent without evidence of emboli at 2 years and 3 months, respectively. Both of the conservatively managed patients died, one from a massive cerebral infarction and the other from intracerebral hemorrhage.

CONCLUSIONS

These cases underscore the need for an aggressive approach to the assessment and management of patients with penetrating vascular skull-base injuries. Although the optimal treatment of remains controversial, when the goal is exclusion of the injured portion of the carotid artery and revascularization, the cervical to petrous ICA vein bypass graft is a valuable management option that can reduce the potential morbidity and mortality from acute ischemic or delayed embolic or hemorrhagic complications, provide immediate restoration of high flow, and allow good surgical access with minimal risk to intracranial structures.