Traumatic intracranial aneurysms

Vertebral Artery Pseudoaneurysm After Extreme Lateral Transcondylar Transodontoid Approach for Clival Chordoma: 2-Dimensional Operative Video

Chordomas can be treated surgically, with radiotherapy, and more recently, chemotherapy.1,2 A 22-year-old female patient presented with recurrence of a clival chordoma, after subtotal resection at an outside institution 3 months prior. MRI showed a predominantly midline lesion at the craniocervical junction with significant lateral extension eccentric to the left. A 3-staged operation was planned. A redo-endoscopic endonasal transclival transodontoid approach3-5 was used to resect the midline component, followed by an extreme lateral transcondylar transodontoid approach with transposition of the ipsilateral vertebral artery followed by drilling of the ipsilateral occipital condyle and C1 lateral mass to resect the lateral component, followed by occiput to C3 fusion given the induced craniocervical instability. Careful subperiosteal dissection with preservation of the periosteal sheath overlying the vertebral artery was performed. There was no overt evidence of vertebral artery injury intraoperatively or on immediate postoperative imaging. However, 3 weeks later, the patient presented with blood from the oral/nasal cavity. Computed tomography angiography showed an unexpected left vertebral artery pseudoaneurysm. Pseudoaneurysms can develop after microtears in the muscularis layer.6-8 Management is based on size, location, and vertebral artery dominance.9,10 This pseudoaneurysm was coiled. Postcoiling, the patient had left hypoglossal palsy. We demonstrate the step-by-step technique of an extreme lateral transcondylar transodontoid approach for a clival chordoma and the unfortunate complication of a vertebral artery pseudoaneurysm with discussion of its etiology and management options for this potentially devastating complication. The patient consented to the procedure/publication. Institutional Review Board approval not obtained as the patient was deidentified, and no additional risk is posed by the publication of this video.

Imaging of cerebrovascular complications from blunt skull base trauma

Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.

Post-Traumatic Intracranial Pseudoaneurysm Presenting as Epistaxis

Background

Epistaxis is a frequent presenting complaint in the Emergency Department (ED). Roughly 60% of the population will suffer from epistaxis in their lifetime. The most common causes of epistaxis include nose picking, facial trauma, foreign bodies, and coagulopathies. There are other causes that are much less common, such as intracranial pseudoaneurysms. There are multiple causes that precipitate intracranial pseudoaneurysm formation, with head trauma accounting for less than 1% of inciting events.

Case Report

A 24-year-old female with history of traumatic brain injury with associated skull fractures due to a gunshot wound to the head 6 months prior presented to the ED in hemorrhagic shock secondary to epistaxis. After stabilization with the administration of blood products, Computed Tomography with Angiography (CTA) imaging of the head and neck was obtained and revealed a 3.1 × 2.2 × 2.5 cm pseudoaneurysm of the cavernous portion of the right internal carotid artery penetrating through the base of the skull into the ethmoidal sinus. The patient was taken for formal angiography by interventional radiology-and a partially thrombosed daughter sac of the initial aneurysm was identified and believed to be the source of the hemorrhage. The aneurysm was successfully coiled and occluded using ONYX embolization. Postoperatively, the patient returned to her baseline mental status without any acute complaints. The patient was discharged back to her nursing home 2 days later with a 3-week follow-up CTA revealing persistent occlusion of the aneurysm and a patent internal carotid artery.

Conclusion

Awareness and consideration of intracranial vascular etiology for common complaints in the emergency room, such as Epistaxis, especially in patients with any history of head injury/trauma, known intracranial aneurysms or prosthetic devices from prior surgery may help guide decision-making in managing critically ill patients.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature

BACKGROUND

Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population.

METHOD

We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs.

RESULTS

Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis.

CONCLUSION

Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Traumatic Aneurysm Involving the Posterior Communicating Artery

Traumatic intracranial aneurysms (TICAs) are rare, accounting for less than 1% of all intracranial aneurysms. However, they are associated with a mortality rate of over 50%. The case presented herein focuses on a posterior communicating artery TICA caused by violent aggression. A 41-year-old man with massive subarachnoid hemorrhage (SAH), on admission to hospital, had a CT angiography that showed a ruptured left posterior communicating artery aneurysm with continuous blood loss and underwent neurosurgical cooling. The CT scan also showed fractures of the mandible, mastoid and left styloid process, as well as brain contusions caused by blows and kicks. Despite medical treatment and surgery, after four days, he died. The assault dynamics were recorded by a camera in the bar. The damage was caused by kicks to the neck and head. The forensic neuropathological examination showed the primary injury (SAH, subdural hemorrhage, cerebral contusions, head-neck fractures), as well as secondary damage following the attack (cerebral infarcts, edema, supratentorial hernia, midbrain hemorrhage). The coil was intact and well positioned. In this case, circumstantial information, medical records, and the type of injury could shed light on the mechanism of the production of a TICA. In addition, the CT angiography and histological investigations helped to distinguish a recent and traumatic aneurysm from a pre-existing one. Following precise steps, the study of aneurysms can be helpful in clarifying their traumatic origin even when the victim was taking drugs. The aim of this study is also to share the diagnostic process that we used in the forensic field for the assessment of suspected traumatic aneurysms.

Traumatic intracranial aneurysm in a distal posterior cerebral artery: A case report and literature review

Background

Traumatic intracranial aneurysms (TICAs) are rare and known to rupture easily and have a high mortality rate.

Case Description

An 87-year-old male patient with no neurological deficits presented to our hospital after head trauma. Computed tomography (CT) revealed a tentorial acute subdural hematoma (ASDH). The patient was managed conservatively and discharged home six days after hospitalization. Two days later, the patient returned with a severe headache. CT showed that the ASDH had enlarged and extended from the tentorium to the convexity. CT angiography and digital subtraction angiography revealed a pseudoaneurysm in a branch of the left posterior inferior temporal artery. The patient was diagnosed with an enlarged ASDH due to a ruptured TICA that arose from the P3 segment. We performed endovascular intervention with parent artery occlusion (PAO) using n-butyl-2-cyanoacrylate (NBCA). The parent artery was accessed through the left posterior communicating artery because left vertebral angiography revealed an aplastic left P1 segment. After navigating the microcatheter near the aneurysm, we injected 33% NBCA into the parent artery. The pseudoaneurysm disappeared after injection. The patient was discharged on hospital day 25 despite persistent delirium.

Conclusion

This is the first report of a TICA arising from the P3 segment that was treated with PAO using NBCA. TICAs are rare; however, a TICA must be considered when an enlarged hematoma caused by head injury is detected.

Flow diversion of a middle cerebral artery pseudoaneurysm secondary to a gunshot wound: A case report

Pseudoaneurysms are rare but devastating complications of penetrating head traumas. They require rapid surgical or endovascular intervention due to their high risk of rupture; however, complex presentations may limit treatment options. Our objective is to report a case of severe vasospasm, flow diversion, and in-stent stenosis complicating the treatment of a middle cerebral artery pseudoaneurysm following a gunshot wound. A 33-year-old woman presented with multiple calvarial and bullet fragments within the right frontotemporal lobes and a large right frontotemporal intraparenchymal hemorrhage with significant cerebral edema. She underwent an emergent right hemicraniectomy for decompression, removal of bullet fragments, and evacuation of hemorrhage. Once stable enough for diagnostic cerebral angiography, she was found to have an M1 pseudoaneurysm with severe vasospasm that precluded endovascular treatment until the vasospasm resolved. The pseudoaneurysm was treated with flow diversion and in-stent stenosis was found at 4-month follow-up angiography that resolved by 8 months post-embolization. We report the successful flow diversion of an middle cerebral artery (MCA) pseudoaneurysm complicated by severe vasospasm and later in-stent stenosis. The presence of asymptomatic stenosis is believed to be reversible intimal hyperplasia and a normal aspect of endothelial healing. We suggest careful observation and dual-antiplatelet therapy as a justified approach.

Iatrogenic pseudoaneurysm rupture of the middle cerebral artery after an intracranial pressure monitor placement: a case report and literature review

Thalamic hemorrhage (TH) is a devastating disease with a high mortality rate; however, no specific form of therapy has been proven to reduce mortality. Patients with hemorrhagic stroke undergo intracranial pressure (ICP) monitoring. However, cases involving pseudoaneurysms caused by ICP monitoring in patients with intracerebral hemorrhage have not been reported previously. Here, we report a case of pseudoaneurysm caused by an ICP monitor that was fitted due to hypertensive cerebral hemorrhage.

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.

Ruptured proximal middle cerebral artery traumatic pseudoaneurysm treated with bypass-assisted trapping surgery: A case report

BACKGROUND

Traumatic pseudoaneurysms are rare but have a high mortality rate; therefore, immediate diagnosis is vital. Most pseudoaneurysms are in the internal carotid artery or peripheral arteries, while proximal middle cerebral artery pseudoaneurysms have rarely been reported. We present a case of ruptured traumatic pseudoaneurysm located at the M1-M2 bifurcation.

CASE DESCRIPTION

A 42-year-old man was injured in a motorcycle accident and his Glasgow coma scale score on admission was 7 (Eye opening1, Verbal response2, Motor response4 [E1V2M4]). Head computed tomography (CT) showed thick subarachnoid hemorrhage (SAH). We suspected a ruptured aneurysm, but three-dimensional CT angiography (3D-CTA) did not detect any vascular defects. Head magnetic resonance angiography showed progressive right M1 stenosis suggesting arterial dissection. 3D-CTA on day 20 showed a small aneurysm in the proximal portion of the M2. Although surgery was scheduled for day 26, suddenly left hemiparesis appeared on day 24. Head CT detected fresh SAH and emergency surgery was performed on day 25. We dissected around the ruptured point under M1 temporary occlusion with superficial temporal artery-M2 assist bypass. Contrary to our expectations, there was only a small laceration in the right M2 superior trunk. We trapped the laceration and the proximal portion of the M2 superior trunk while preserving antegrade blood flow from the M1 to the M2 inferior trunk. On the 5-month follow-up, the patient was able to walk independently.

CONCLUSION

Unreasonably thick traumatic SAH or spastic stenosis after head injury may indicate a traumatic pseudoaneurysm and require repeated neurovascular evaluation. If a pseudoaneurysm is detected, immediate surgical intervention is mandatory.

Development of Anterior Cranial Fossa Dural Arteriovenous Fistula and Supraclinoid Internal Carotid Artery Pseudoaneurysm Following Frontobasal Trauma: A Case Report and Literature Review

Cerebrovascular injuries resulting from frontobasal head trauma represent a range of imaging and clinical presentations. Severe cerebrovascular injuries such as vessel transection commonly present with profound neurological deficits and are often easily identified with routine imaging. However, small intimal injuries and dissections may be challenging to detect and may be clinically silent or masked by additional injuries in the setting of polytrauma. The onset of symptoms and complications from cerebrovascular injuries may be delayed from the time of initial presentation, and failure to recognize and diagnose these injuries may result in devastating outcomes if management is delayed. In this case report, we present a case of frontobasal craniofacial trauma that resulted in an anterior cranial fossa dural arteriovenous fistula (ACF-dAVF) and supraclinioid segment internal carotid artery (ICA) pseudoaneurysm.

[Endovascular Treatment for Head and Neck Trauma]

Trauma to the head and neck region can have serious consequences for vital organs such as the brain, and injuries to blood vessels can cause permanent neurological damage or even death. Thus, prompt treatment of head and neck vessels is crucial. Although the level of evidence is moderate, an increasing amount of research indicates that endovascular treatments can be a viable alternative to traditional surgery or medical management. Embolization or reconstructive endovascular procedures can significantly improve patient outcomes. This article provides an overview of various endovascular options available for specific clinical scenarios, along with examples of cases in which they were employed.

Vascular Injuries in Head and Neck Trauma

Blunt and penetrating vascular injuries of the head and neck can represent life-threatening emergencies that require accurate detection to prevent devastating and long-lasting consequences. Implementing appropriate screening criteria to indicate imaging studies is crucial as there is a variable latent time before the onset of clinical manifestations. Computed tomography angiography, MR imaging, and digital subtraction angiography represent the imaging modalities of choice to evaluate vascular injuries. The aim of this review is to provide a description of the different types of vascular injuries, describe the importance of each imaging modality, and recognize the imaging appearance of traumatic vessel injury.

Traumatic posterior cerebral artery dissection and dissecting aneurysms: A systematic review with an illustrative case report

BACKGROUND

Traumatic posterior cerebral artery (tPCA) dissection and dissecting aneurysms are rare and constitute a challenging clinical entity.

OBJECTIVE

We analyze existing literature on tPCA dissection and present our institutional experience.

METHODS

We retrospectively queried our database for tPCA isolated dissection or dissecting aneurysms from 2008 until now and conducted a systematic literature review of published cases. We analyzed the clinical and radiographic characteristics and treatment outcomes of tPCA dissection.

RESULTS

Including our case, a total of 11 cases with either isolated dissection (n = 2) or dissecting aneurysms (n = 9) were included. The median age was 27 years, and 45% were females. The median interval between trauma and tPCA dissection diagnosis was nine days. Mental status declined in four (36%) patients. Half of the patients demonstrated tentorial subdural hematoma on head CT. Ischemic stroke was detected in three (43%) patients. Four (36%) patients were conservatively managed, one (9.1%) patient was treated with surgical clipping of the proximal PCA, and six patients underwent endovascular treatments. The complication rate was 20%. Immediate total occlusion was demonstrated in five patients (100%), and the conservatively managed case showed immediate, spontaneous thrombosis of the aneurysm. Glasgow Coma Scale scores were 15 in eight (89%) and 14 in one (11%) patients at the last clinical follow-up with a median of six months. The mortality and retreatment rates were null.

CONCLUSIONS

tPCA dissection is diagnosed late and commonly affects the young population. The clinical outcome for this condition is typically favorable. Current endovascular techniques showed considerable efficacy and safety.

Endovascular Management of Iatrogenic Vertebral Artery Pseudoaneurysm: A Case Report

Iatrogenic injury of the vertebral artery during cervical spine surgery though uncommon is critical. With advances in interventional endovascular techniques, the therapeutic approach for vertebral artery injuries has changed. Nonetheless, an established strategy for their management is lacking. We report a case of pseudoaneurysm due to vertebral artery injury, during cervical spine surgery for a tumor, that was treated successfully with endovascular coiling in a plug-and-patch fashion after triple stenting failed.

A complete thrombotic large aneurysm at the nonbranching segment of the distal anterior cerebral artery mimicking a cavernous malformation: illustrative case

BACKGROUND

Thrombotic aneurysms at the nonbranching segment of the distal anterior cerebral artery (ACA) are extremely rare and difficult to differentiate from cavernous malformations by radiographic features alone.

OBSERVATIONS

Computed tomography and magnetic resonance imaging of a 30-year-old female patient with a chronic headache complaint revealed a 22-mm frontal lobe mass. The mass showed heterogeneous mixed intensity and hemosiderin deposits on magnetic resonance images. It was not visualized by conventional angiography, indicating that the mass and ACA/other vessels were not connected. The patient was preoperatively diagnosed with a cavernous malformation. However, during resection, the mass surface was white and smooth, different from a cavernous malformation. Although the mass was adherent to the pericallosal artery branch, no luminal continuity was observed. After detachment, the mass was completely resected. Pathological and immunohistochemical findings indicated a vessel wall and interior thrombus. The patient was rediagnosed with a thrombotic aneurysm at the distal ACA nonbranching segment and discharged 10 days postsurgery without neurological deficits.

LESSONS

Because radiographic findings of thrombotic aneurysm and cavernous malformation are similar, mass lesions in contact with major arteries should be differentiated as thrombotic aneurysms, even when the artery lumen appears disconnected from the mass.

Double jeopardy - pituitary apoplexy complicated by ruptured aneurysm of the internal carotid artery within an adenoma: a case report

BACKGROUND

Sudden onset of severe headache is the most common presentation of a ruptured intracranial aneurysm. Similar symptoms can be caused by pituitary apoplexy, and radiological examination is needed to distinguish between the two. Development of infarction and/or haemorrhage of the hypophysis with concomitant unruptured cerebral aneurysm has been described. However, intratumoural aneurysm within a pituitary adenoma presenting with the ictus of both pathologies is extremely rare.

CASE PRESENTATION

A 64-year-old man presented with classic symptoms of pituitary apoplexy. His symptoms improved after a few days, and he was discharged. However, he subsequently developed further episodes of sudden and severe headache together with visual decline and ophthalmoplegia. Radiographs demonstrated an enlarging sellar mass with suspicion of a ruptured internal carotid artery aneurysm, within the apoplectic pituitary macroadenoma. Although an endovascular procedure was planned, the patient developed massive subarachnoid haemorrhage resulting in brain death.

CONCLUSION

This case report describes an intratumoural aneurysm of the cavernous internal carotid artery as a potential cause or result of pituitary apoplexy. Despite its rarity, this possible life-threatening complication of pituitary apoplexy should be recognised for prompt diagnosis and early management.

Traumatic intracranial aneurysms (TICA) in children: a description of two clinical cases of successful treatment and review of literature

OBJECTIVE

Traumatic intracranial aneurysms (TICA) across all age groups make up less than 1% of all aneurysms. Traumatic aneurysms in children occur from 10 to 39%, and their treatment requires special considerations. Even though readily diagnosed, the management of traumatic intracranial aneurysms in children is still a subject for discussion. Two cases of traumatic aneurysms following penetrating and blunt trauma are presented.

CASE DESCRIPTION

Two cases of traumatic aneurysms are presented. The first patient presented with an aneurysm of the distal M4 segment of the left middle cerebral artery (MCA) 1 week following blunt traumatic brain injury with skull fractures. The aneurysm was excised without complications. The second patient presented with a saccular aneurysm of the A2 segment of the left anterior cerebral artery (ACA) following penetrating traumatic brain injury with a metal rod. The aneurysm was discovered incidentally on computed tomography angiography (CTA) performed to exclude a brain abscess when the patient developed a persistent fever. After numerous unsuccessful attempts at endovascular embolization, microsurgical aneurysm clipping was performed without complications.

CONCLUSION

Traumatic intracerebral aneurysms are relatively more common in childhood. They commonly occur in the first 21 days post-trauma but can also occur in the late period. We, therefore, recommend that CTA or direct cerebral angiography should be performed within the first 3 weeks to exclude TICA and in all patients with sudden deterioration in the early postoperative period. Considering the high mortality rate associated with conservative management, surgical and/or endovascular management should be performed once the diagnosis is made.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients

OBJECTIVE

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children.

METHODS

This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed.

RESULTS

Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae.

CONCLUSIONS

Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Traumatic pseudoaneurysm resulting from avulsion of the falcine branch of an azygos anterior cerebral artery: a case report

Traumatic anterior cerebral artery (ACA) aneurysms are extremely rare. Traumatic anterior ACA aneurysms are thought to develop when the ACA at the pericallosal segment travel adjacent to immobile falx cerebri. As the majority of aneurysms are pseudoaneurysms, direct neck clipping is usually not possible, and it is often necessary to carry out direct or endovascular trapping in conjunction with proficient bypass techniques. The authors describe the first reported case of a traumatic ACA pseudoaneurysm resulting from avulsion of the falcine branch of an azygos ACA. In this case, the lacerated aneurysm wall was successfully sutured, without the need for a bypass. Neurosurgeons should be aware that avulsion of the falcine branch arising from the ACA can occur, and that this may cause a traumatic aneurysm on the distal ACA. Furthermore, direct suturing of a lacerated arterial wall should be considered a treatment option for this type of traumatic intracranial aneurysm.

Bioglue endovascular treatment of fusiform aneurysm rupture of the distal anterior temporal artery of the middle cerebral artery: a case report

The treatment of a ruptured fusiform distal anterior temporal artery aneurysm is a challenge for the stroke physician, however surgical closure and coil endovascular intervention are options. A total blockage can result in memory problems as well as object-related questions. We'd like to provide the clinical example of a 56-year-old woman with many underlying medical illnesses who was admitted to the hospital with a grade 7/10 headache and a Glasgow score of 15, but no focal neurological deficits, and was diagnosed with a ruptured distal temporal artery aneurysm. The aneurysm is positioned in the distal region, making endovascular intervention difficult to perform. As a result, we used an endovascular approach to repair with bioglue. When a patient develops fusiform aneurysms of the distal temporal artery, our findings provide an additional therapy option.

Flow Preserving Endovascular Treatment of Traumatic Pseudoaneurysms of the Distal Anterior Cerebral Artery-Case Reports and Review of Literature

Traumatic intracranial pseudoaneurysms (tIPAs) are a very rare pathology caused by blunt or penetrating head trauma. Diagnostic and therapeutic challenges of tIPAs are due to their unpredictable onset during the initial injury, or in a delayed manner, their unclear traumatic mechanism. Moreover, the presence of subarachnoid, subdural, or intraventricular hematoma may often cause them to be overlooked, which can potentially be followed by lethal rebleeding. Treatment of these lesions is controversial and on a case-by-case basis with regard to endovascular therapy or open surgery. We report two cases of three tIPAs of the distal anterior cerebral artery (dACA) with immediate and delayed onset after the trauma. Endovascular therapy resulted in complete obliteration of lesions with flow preservation in the parent artery using the flow diverter-assisted coiling strategy. The aim of this manuscript is to discuss the mechanism, angioanatomical characteristics, and current treatment options for these exceptional lesions.

Willis Covered Stent for Treating Intracranial Pseudoaneurysms of the Internal Carotid Artery: A Multi-Institutional Study

OBJECTIVE

This work aimed to retrospectively analyze Willis covered stent (WCS)'s therapeutic efficacy in intracranial pseudoaneurysms (PSAs) of the internal carotid artery (ICA).

METHODS

Between June 2018 and July 2021, 56 individuals with intracranial PSAs of the ICA treated with WCS in three centers were included to analyze information regarding medical records, operative parameters, imaging findings and follow-up data.

RESULTS

All WCSs were successfully targeted to the ICA lesions. Total exclusion of PSA was found in 53 cases (94.6%) right upon surgery, and mild endoleak into the aneurysm remained in 3 cases (5.4%). Intraoperative thrombosis occurred in 1 case (1.8%), and tirofiban was utilized for recanalization. Follow-up by angiography showed total aneurysm occlusion in the total number of individuals, including in the 3 above cases with residual endoleak. In-stent stenosis occurred in 7 (12.5%) patients. No stent-related ischemic event was encountered. Predictive factors of late in-stent stenosis following WCS implantation in this patient group were irregular post-operative antiplatelet treatment (p = 0.015) and C4-C5 segment of the ICA (p = 0.043).

CONCLUSION

WCSs are effective in treating intracranial PSAs of the ICA.

Traumatic aneurysm at the superior cerebellar artery: illustrative case

BACKGROUND

Traumatic aneurysms at the superior cerebellar arteries after head injury are extremely rare and may be overlooked. Rupture of these aneurysms can cause fatal intracranial hemorrhages; thus, early identification of the entity helps prevent detrimental outcomes.

OBSERVATIONS

A patient suffered from sudden severe headache and decreased consciousness level several weeks after a blunt head injury. He received surgery to remove a progressive enlarging subdural hematoma. The diagnosis of a traumatic aneurysm at the superior cerebellar artery was delayed, made only after a recurrent subdural hemorrhage occurred. He received another surgery to obliterate the aneurysm.

LESSONS

The patient could have been treated earlier if traumatic aneurysm had been suspected in the beginning. In addition to the case, the authors also reviewed the literature to clarify the pathophysiology, clinical presentation, diagnosis, and management of the disease.

Delayed Tentorial Subdural Hematoma Caused by Traumatic Posterior Cerebral Artery Aneurysm: A Case Report and Literature Review

BACKGROUND Subdural hematoma (SDH) caused by traumatic intracranial aneurysm (TICA) is rare. TICAs are known to rupture easily, resulting in a high morbidity and mortality rate. Therefore, accurate diagnosis and treatment are crucial for preserving life. We describe a case of delayed SDH in the setting of posterior cerebral artery (PCA) aneurysm. CASE REPORT A 42-year-old man presented with sustained head injury from a traffic accident, and was being followed-up conservatively for traumatic SDH and subarachnoid hemorrhage. Three weeks after the head trauma, the patient developed a sudden deterioration of mental status and disorientation. Computed tomography revealed de novo SDH at the cerebellar tentorium. Computed tomography angiography and magnetic resonance imaging demonstrated TICA in the PCA. The patient was diagnosed with SDH due to a ruptured PCA aneurysm at the quadrigeminal segment. To avoid SDH growth due to re-rupture of the aneurysm, parent artery occlusion was subsequently performed with no complications. The patient was discharged home 2 months after endovascular treatment, with moderate disability. Follow-up angiography 2 years after the operation showed no recanalization, and the patient had returned to work. CONCLUSIONS TICA in the PCA can cause tentorial SDH with or without the presence of subarachnoid hemorrhage. Routine cerebrovascular assessment is crucial for head trauma with hematoma adjacent to the cerebellar tentorium. Parent artery occlusion via an endovascular procedure is an alternative treatment for TICA in the PCA that is less invasive than other approaches.

Post-traumatic intracranial pseudo-aneurysms of posterior circulation: a comprehensive review of an under-diagnosed and rare entity

Traumatic aneurysms are rare and the total number of cases involving the posterior circulation (TIPC) is even smaller. Traumatic brain injury (TBI) may be responsible not only of rupture in brain aneurysm (BrA) pre-existing to trauma, but it has been identified also as a possible pathogenetic cause of TIPC formation in patients not affected by intracranial vascular lesions. A complete literature review was performed of all reported cases regarding rupture of BrA with SAH resulting from TIPC not previously identified at the first radiological screening. A representative case of a left posterior inferior cerebellar artery (PICA) pseudo-aneurysm caused by left vertebral artery’s dissection is reported. We show a unique complete collection of all 34 cases. Despite their rarity, TIPCs are associated with a significant morbidity and mortality rate, as high as 40–60%. Of the 22 patients with good neurological status (64.7%), we did not notice a significant correlation with regard to the location of the aneurysm, type of treatment, or clinical onset. Early recognition of a pseudo-aneurysm and adequate treatment seem to be the most important prognostic factor for these patients. Despite their rarity, TIPCs are associated with a significant morbidity and mortality rate. A TIPC should be suspected in case of delayed deterioration in head‐injured patient and should be investigated with angiography. Conservative management is worsened by poor prognosis and the goal of treatment is to exclude the aneurysm from circulation with surgical or endovascular methods as soon as possible.

Delayed diagnosis of intracranial aneurysm in pediatrics: the risk of misdiagnosis-a case report

BACKGROUND

Aneurysms in the pediatric population are uncommon, requiring a high index of suspicion for diagnosis. We report a case of a child with head trauma and delayed diagnosed cerebral aneurysm.

METHODS

A 2-year-old girl was brought to the emergency room with seizures. Head imaging showed acute intraventricular hemorrhage, hydrocephalus, and paraclinoid aneurysm of the right internal carotid artery. She had been hospitalized elsewhere 1 month prior for traumatic brain injury after falling to the ground with subarachnoid and intraventricular hemorrhage and good recovery, but without diagnosis of aneurysm.

RESULTS

The child was treated with aneurysm embolization and ventriculoperitoneal shunt, being discharged asymptomatic.

CONCLUSION

Most primary intraventricular hemorrhage in pediatric population has identifiable etiology. A high rate of clinical suspicion, associated with a low threshold for vascular neuroimaging studies for children with spontaneous or atypical intracranial hemorrhage allow accurate diagnosis, appropriate treatment, and improved outcome.

Endovascular Parent Artery Occlusion for Intracranial Aneurysms is a Viable, Cost-Effective Alternative: An Institutional Experience from Northeast India

Purpose.

Endovascular parent artery occlusion (PAO) may be an alternative approach for complex intracranial aneurysm with potentially life-threatening complications. Moreover, the long-term follow-up of the PAO for an intracranial aneurysm is reported sparingly, limited to the case series. It is therefore important to carry out more research on long-term follow-up of the implication of PAO of intracranial aneurysm. The aim of the study was to analyses our experience of PAO for intracranial aneurysms with emphasis on long-term follow-up.

Materials and Methods.

The data of patients treated with PAO for intracranial aneurysms were reviewed. The outcome was evaluated based on aneurysmal occlusion on immediate angiography, follow-up magnetic resonance angiography (MRA), and complications. The modified Rankin score (mRS) was used to evaluate the functional outcome during the last follow-up. The mean, range, and standard deviation were reported for other variables – the patient’s age, number, and percentage.

Results.

Endovascular treatment was performed in 178 patients including PAO in 18 patients. Of these 18 (eighteen) patients, there were 13 dissecting aneurysms, 4 mycotic aneurysms, and one traumatic aneurysm.

10 (ten) patients underwent PAO for proximal intracranial artery aneurysm and 8 (eight) patients for distal cerebral aneurysms. Complete occlusion of the aneurysm was achieved in 16patients (88.89%) and retrograde filling of the aneurysm was seen in 2 (11.11%) patients. One patient had intraprocedural coil migration resulting in a major infarct with an mRS of 2. Another patient (5.56%) had recanalization of the aneurysm and presented with rupture and intracranial hemorrhage with an mRS score of 4. The mRS of the other 16 patients (88.89%) was zero.

Conclusions.

Endovascular PAO for cerebral aneurysms was highly feasible and achieved complete occlusion. The morbidity and mortality rates were at the long-term follow-up also acceptable with negligible complications.

Aneurysmal Subarachnoid Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series

Objective

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a pressing public health issue. Although most cases do not result in severe illness requiring hospitalization, there is increasing evidence that SARS-CoV-2–induced inflammation can exacerbate pre-existing diseases. We sought to describe the characteristics of patients with aneurysmal subarachnoid hemorrhage who were actively or very recently infected with SARS-CoV-2.

Methods

We reviewed subarachnoid hemorrhage cases of patients who also were positive for SARS-CoV-2 at 5 high-volume cerebrovascular centers in the United States from March 2020 to January 2021. Cases of aneurysmal subarachnoid hemorrhage were analyzed.

Results

A total of 10 patients were identified, consisting of 5 women (50%) and 5 men (50%). Median age was 38.5 years. Four of the 10 patients (40%) were asymptomatic with respect to SARS-CoV-2–related symptoms, 3 patients (30%) had mild-to-moderate symptoms, and 3 patients (30%) had severe coronavirus disease 2019 (COVID-19), with pneumonia and sepsis. Of the 10 cases, 4 had dissecting pseudoaneurysms (40%), 3 in the posterior circulation and 1 in the anterior circulation. Among 6 saccular/blister aneurysms, 4 (67%) were ≤4 mm in largest diameter.

Conclusions

Our experience with aneurysmal subarachnoid hemorrhage in patients positive for COVID-19 reveals a possibly distinct pattern compared with traditional aneurysmal subarachnoid hemorrhage, namely a high frequency of small aneurysms, dissecting pseudoaneurysms, and young patients.

Treatment of Traumatic Intracranial Pseudoaneurysms: A Single-Center Experience

Background and Purpose: As a rare lesion secondary to brain trauma, traumatic intracranial aneurysms (TICAs) lead to high mortality and morbidity, and multiple treatment modalities have been applied for TICAs. All patients diagnosed with TICAs in our institution from 2010 to 2020 were included in the report, and their clinical features, treatment, and outcomes are described in detail. The purpose of this study is to illustrate the characteristic of different therapeutic methods of TICAs, and focus on the endovascular treatment.

Methods: A total of 20 patients were included in this study. The 3 patients who declined treatment all died. Five of the other 17 patients were treated surgically, including clipping, wrapping, and trapping with or without EC-IC high-flow bypass, with only 1 case of parent artery preservation. Twelve patients underwent endovascular treatment, including bare coil embolization (1 case), stent-assisted coiling (2 cases), balloon-assisted coils/Onyx glue embolization (1 case) and covered stents (8 cases), with only 1 case of parent artery sacrifice.

Results: 20 patients were included in the present study with 17 males, and the mean of age on 27 years (IQR: 22, 44 years). Eight patients presented with epistaxis, followed by 5 patients with coma, 3 patients with visual defects and 2 patients with CSF leakage. There were 18 TICAs located at the internal carotid artery (ICA); The other 2 TICAs located at pericallosal artery and A1 segment anterior cerebral artery (ACA). One case of diplopia occurred due to sacrifice of the ICA. Occlusion of the ophthalmic artery occurred in 3 patients after placement of a covered stent, with 1 patient suffering an irreversible vision decrease. None of the other patients who underwent the treatment have experienced an aggravation of their symptoms since the treatment; During the imaging follow-up, 1 case of recurrence and 1 case of endoleak occurred in this case series.

Conclusions: TICAs are associated with significant morbidity and mortality, and endovascular treatment has emerged as a valuable option, which may be promising to improve the clinical outcomes due to their advantages of preserving the parent artery if occlusion of the side branch artery can be avoided.

Traumatic rupture of the circle of Willis with closed head injury: Its pathology and possible pathogenesis

Massive and fatal subarachnoid hemorrhage (SAH) with an injury on the circle of Willis may be caused by blunt force to the head; however, it is extremely rare, and the precise mechanism of arterial rupture remains unclear. We investigated the clinicopathologic appearance of four rare autopsy cases of massive SAH associated with the rupture of the circle of Willis. All four cases were men aged 17-75 years who presented with a loss of consciousness within a short interval after the injury. Autopsy revealed that the rupture site was located in the vertebral artery in two cases and in the anterior cerebral artery (ACA) in two cases. During our literature review, we found no previous report on traumatic ACA rupture. Based on the correlation of the autopsy findings and the circumstance of injury, we determined that the accidental excessive stretching of the selected artery by neck anteflexion or rotation after a blunt trauma to the posterior head might have caused this rare lethal injury. These cases demonstrated the diversity of the traumatic rupture site of the circle of Willis after a blunt head and/or neck injury. The topographical features of the circle of Willis, particularly in correlation with the surrounding tissue, might account for the occurrence and site of these rare injuries.

Traumatic Distal Anterior Cerebral Artery Aneurysms - Pathomechanism and Revascularisation Strategies

Traumatic intracranial aneurysms (TICA) of the distal anterior cerebral artery (dACA) are exceptionally rare and display therapeutic challenges due to their angioanatomical characteristics. The objective of this work was to discuss the mechanisms of TICA formation of the dACA and to elucidate the best treatment and revascularization strategies in these patients based on two illustrative cases. Case 1: 20-year-old patient with a traumatic, partially thrombosed 14 × 10 mm aneurysm of the right pericallosal artery (rPericA), distal to the origin of the right callosomarginal artery (rCMA). Complete trapping of the right dissection A3 aneurysm and flow replacement extra-to-intracranial (EC-IC) bypass (STA - radial artery - A4) was performed. Case 2: 16-year-old patient with a traumatic polylobulated, partially thrombosed 16 × 10 mm aneurysm of the rPericA. Microsurgical excision of the A3- segment harboring the aneurysm and flow replacement intra-to-intracranial (IC-IC) bypass via reimplantation of the right remaining PericA on the contralateral PericA (end-to-side anastomosis) was performed (in situ bypass). TICA of the dACA are exceptionally rare. Mechanical vessel wall injury and aneurysm formation of the dACA in blunt head trauma is very likely due to the proximity of the dACA with the rigid free edge of the falx. Given their nature as dissecting (complex) aneurysm, trapping and revascularization is a very important strategy. The interhemispheric cistern offers multiple revascularization options with its numerous donor vessels. The IC-IC bypass is often the simplest revascularization construct.

Craniocerebral nail gun injuries: a definitive review of the literature

AIM

Nail guns are important time saving devices but are associated with morbidity and mortality. Specifically, craniocerebral injuries have been reported in the literature since 1963 and have increased in frequency as the use of these tools has become commonplace. There remains a paucity of literature comprehensively assessing nail gun injuries, as compared with other penetrating craniocerebral injuries like those from firearms.

METHOD

A literature review of PubMed, Medline (Ovid), Cochrane library, and Google Scholar for articles published between 1960 and 2018 reporting craniocerebral nail gun injuries.

RESULTS

In total, 96 individual cases were identified, with 80 meeting inclusion criteria. These were categorized as accidental and intentional injuries. The demographic was overwhelmingly young males (97.5%), and intentional self-inflicted injuries (54%) was the most frequent mechanism of injury. Overall mortality was 10%. Mortality was more common in patients with intentional injuries, but morbidity rates were similar between the accidental and intentional injury cohorts. Post-operative complications rate was 23.8%.

CONCLUSION

Craniocerebral nail gun injuries are associated with lower rates of both mortality and residual neurological deficits than craniocerebral firearms injuries. There is limited data to inform clinical prognostication about long-term neurological impairments and the time to recovery which should be addressed in future studies.

Treatment of Intracranial Pseudoaneurysms With a Novel Covered Stent: A Series of 19 Patients With Midterm Follow-Up

Background: The optimal treatment for intracranial pseudoaneurysm is unclear. This study aims to analyze the outcome of treating intracranial pseudoaneurysm with a novel covered stent.

Materials and Methods: The institutional imaging and clinical databases were retrospectively reviewed for patients with intracranial pseudoaneurysms treated with Willis covered stent from January 2017 to December 2019. The clinical presentations, etiology, intraoperative complications, and immediate and follow-up outcomes were analyzed.

Results: A total of 19 patients with 20 pseudoaneurysms were enrolled for analysis. Seventeen patients presented with vision loss and two with epistaxis. Nineteen Willis covered stents were used with one for each patient without technical failure. Intraoperative thrombosis was encountered in one patient (5.3%), which was recanalized by tirofiban. During clinical follow-up, no further epistaxis occurred, and visual acuity improved in three (17.6%) patients. Endoleak occurred in seven (36.8%) patients after the initial balloon inflation and persisted in one (5.3%) patient after balloon re-inflation. This endoleak disappeared at 8 month follow-up. Finally, during angiographic follow-up (median 13 months), parent artery occlusion and in-stent stenosis occurred in one (5.3%) patient. No stent-related ischemic event was encountered.

Conclusions: The Willis covered stent is feasible, safe, and efficient in treating intracranial pseudoaneurysms.

Neurovascular disease, diagnosis, and therapy: Brain aneurysms

Unruptured intracranial aneurysms (UIAs) have a prevalence of 3% in the adult population worldwide. The majority of UIAs are incidental findings, but some UIAs cause cranial nerve palsies, brainstem compression, ischemic events, or epileptic seizures. The most frequent clinical presentation of intracranial aneurysms is, however, rupture and thereby subarachnoid hemorrhage (SAH). To avoid SAH with its fatal consequences, patients with UIAs require counseling by dedicated and interdisciplinary neurovascular specialists. For the purpose of assessment and decision-making for the management of patients with UIAs, numerous aspects have to be considered: radiological characteristics, clinical symptoms, estimated rupture risk of an individual aneurysm as well as patient- and aneurysm-related risks of preventive repair. Generally, two management options exist: observation with follow-up imaging or preventive repair. This chapter discusses current data on pathogenesis, clinical presentation, diagnostics, risk factors for rupture and preventive repair, and guidance tools for the management of patients with UIAs according to current evidence.

A3-A3 Anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: Experience With in Situ Bypass and Lessons Learned From Pseudoaneurysm Cases

BACKGROUND

A3-A3 side-to-side bypass is an intracranial-to-intracranial (IC-IC) revascularization option when aneurysm treatment involves occlusion of one anterior cerebral artery (ACA).

OBJECTIVE

To describe applications of A3-A3 side-to-side bypass in the management of ACA true and pseudoaneurysms along with a review of pertinent literature.

METHODS

Six consecutive patients undergoing an A3-A3 bypass as part of their aneurysm management, representing a single-surgeon experience in a 2-yr period, were included in this retrospective review of a prospectively collected database.

RESULTS

Three male and three female patients with a median (range) age of 41.5 (11-69) years representing four ruptured and two unruptured aneurysms were included. Two of the aneurysms were communicating while four were postcommunicating from which three were pseudoaneurysms. Complete aneurysm obliteration was achieved in 5/6 cases. Bypass patency was evaluated in all cases intra- and postoperatively. Good outcomes (modified Rankin Scale score ≤ 2) at follow-up were observed in 4/6 patients. An improvement in mRS scores at the most recent follow-up as compared to preoperative status was achieved in three while scores remained the same in two patients. Ischemic complications related to aneurysm treatment were observed in two patients, both of which achieved good functional recovery upon follow-up. One patient deceased postoperatively due to progression of vasospasm-related infarcts.

CONCLUSION

A3-A3 bypass in the management of true as well as pseudoaneurysms of the ACA can achieve good postoperative outcomes in selected patients. Prompt diagnosis and aggressive surgical treatment needs to be pursued if a vessel injury with pseudoaneurysm formation is suspected.

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.

Traumatic cerebrovascular injury: clinical characteristics and illustrative cases

OBJECTIVE

Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries.

METHODS

The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail.

RESULTS

The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%.

CONCLUSIONS

The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.

Iatrogenic Intracranial Aneurysm After External Ventricular Drain Placement: Traumatic or Mycotic Origin? Case Report and Literature Review

BACKGROUND

Intracranial iatrogenic aneurysms (IIAs) developing after external ventricular drain (EVD) placement or removal have been only rarely reported. Most of these reports assumed a traumatic etiology; however, some have demonstrated an inflammatory origin. We have presented the case of an IIA that developed after an EVD had been inserted to treat acute hydrocephalus secondary to a ruptured arteriovenous malformation. We also performed a literature review and discussed how these IIAs might have an inflammatory rather than a traumatic etiology and how they might lie behind some of the cases of idiopathic hemorrhage observed after EVD manipulation.

CASE DESCRIPTION

A 48-year-old woman had presented with acute hydrocephalus secondary to bleeding from a vermian arteriovenous malformation. The EVD inserted for hydrocephalus management required several revisions because of malfunction. Four weeks later, a diagnostic arteriogram had incidentally revealed the existence of a 5-mm aneurysm in an anterior branch of the right callosomarginal artery, coincidental to the EVD trajectory. The patient underwent emergent endovascular treatment of the aneurysm, with complete occlusion and no complications deriving from the procedure.

CONCLUSIONS

IIAs associated with EVD placement or removal have been described as a rare complication of the procedure. Despite the scarce number of cases reported and the lack of histological examinations, common features such as a distal location, an incidental diagnosis, and a benign clinical course might suggest a mycotic or inflammatory origin rather than a traumatic etiology. Considering the high volume of EVDs placed annually, this complication might be more frequent than reported. Further studies investigating the association of risk factors for inflammatory aneurysms and hemorrhage incidence after EVD could provide information on this intriguing topic.

Vascular Trauma in the Head and Neck and Endovascular Neurointerventional Management

Traumatic vascular injuries of the head and neck can pose life-threatening emergencies, and therefore, the detection and accurate characterization of these injuries by the radiologist is essential. Computed tomographic angiography (CTA) is commonly performed as part of the initial imaging work-up of patients who have sustained blunt or penetrating craniocervical injuries and are suspected to have or are at risk for vascular injuries. This pictorial essay reviews the CTA and conventional angiographic imaging appearance of various vascular injuries that can occur from trauma in the head and neck and also explores the neurointerventional management of these types of injuries.

Intracranial Pseudoaneurysms: Evaluation and Management

Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.

Complications, outcomes, and management strategies of non-missile penetrating head injuries

OBJECTIVE

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors.

METHODS

Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed.

RESULTS

One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge.

CONCLUSIONS

The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Parent Artery Occlusion for Treatment of a Traumatic Pericallosal Artery Aneurysm: Case Report and Review of the Literature

BACKGROUND

Traumatic intracranial aneurysms are rare complications after head trauma. This report describes the case of a patient with a traumatic pericallosal aneurysm.

CASE DESCRIPTION

A 73-year-old man developed headache and lower limb paresis, and emergency computed tomography scan revealed a hematoma in the corpus callosum. We performed coil embolization for a pericallosal aneurysm, but follow-up angiography showed recurrence of the aneurysm 6 days after the surgery. We diagnosed this as a traumatic aneurysm and subsequently performed parent artery occlusion without any complications.

CONCLUSIONS

We performed parent artery occlusion for a traumatic aneurysm of the pericallosal artery without complications. Pericallosal aneurysms are rare, but we must consider them when encountering a delayed hematoma around the corpus callosum.

Treatment of unusually located traumatic intracranial aneurysms and severe vasospasm following a gunshot wound to the head: A case report

Background:

Traumatic intracranial aneurysms (TICAs) represent up to 1% of all intracranial aneurysms. They can be the result of non-penetrating and penetrating brain injury (PBI). Approximately 20% of TICA are caused by PBI. Endovascular treatments as well as surgical clipping are reported in the literature. Other vascular complications of PBI include vasospasm although the literature is lacking on this topic.

Case Description:

The authors present a unique case of multiple TICAs after a PBI in a 15-year-old patient who sustained a gunshot wound to the head. The patient sustained injury through the middle cranial fossa and was taken emergently for a right-sided decompressive hemicraniectomy. Diagnostic cerebral angiogram (DCA) identified multiple TICAs along the right internal carotid artery (ICA) terminus and right middle cerebral artery as well as severe vasospasm. The patient was taken for clipping of those aneurysms and intraoperative treatment of vasospasm. Intraoperative blood flow measurements were taken before and after administration of intracisternal papaverine and arterial soft tissue dissection showing a significant increase in blood flow and improvement of vasospasm.

Conclusion:

While the literature has shifted towards endovascular treatment for TICAs, surgery still offers a safe and efficacious treatment strategy especially when TICAs present at large vessel bifurcation points where parent vessel sacrifice and stent assisted coiling are less favorable strategies. Severe flow limiting vasospasm can be seen in post-traumatic setting specifically PBI. Vasospasm can be treated during open surgery with intracisternal papaverine and arterial soft dissection as confirmed in this case report with intraoperative micro-flow probe measurements.

Acute Tentorial Subdural Hematoma Caused by Rupture of the Posterior Cerebral Artery after Minor Trauma-A Case Report

Acute subdural hematoma (aSDH) is a common pathology encountered after head trauma. Only a minority of aSDHs have an arterial source. In this article, we report a case of aSDH originating from a traumatic pseudoaneurysm of the distal segment of posterior cerebral artery (PCA), diagnosed several days after the initial minor trauma and successfully treated with endovascular coiling. This case emphasizes the importance of searching for vascular pathology when the localization, severity or relapsing course of the intracranial hemorrhage does not fully correspond to the severity of initial trauma and when the bleeding has a delayed onset. Characteristics, diagnostics and treatment possibilities of traumatic cerebral aneurysms, an important cause of arterial aSDH, are described in the article.