Surgical Treatment of Traumatic Intracranial Aneurysms: Experiences at a Single Center over 30 Years

Traumatic middle meningeal artery aneurysm: a case report

INTRODUCTION

Traumatic intracranial aneurysms are rare, making up about 1% of all intracranial aneurysms. They can happen due to direct injury or blunt force, with the middle cerebral artery being the most frequent site. The middle meningeal artery (MMA) is the main artery that supplies the cranial dura mater, and, because of its location, is susceptible to damage after trauma. This article reported an unusual case of giant post-traumatic MMA pseudoaneurysm.

CASE

A 45 year-old man was referred to our department with a history of craniectomy. He complained of non-specific headache, but neurological examination was normal. A follow-up brain CT scan identified a right temporal fossa hyperdense mass. Digital subtraction angiography diagnosed a traumatic MMA aneurysm. The patient was treated with preoperative aneurysm embolization and surgical resection.

DISCUSSION

Traumatic MMA aneurysm is a rare presentation after head trauma. It can manifest as epidural hematoma, subdural hematoma or intraparenchymal hematoma, and sometimes resembles the present case, which was discovered incidentally.

CONCLUSION

Pseudoaneurysm is a rare complication of MMA trauma, with late presentation. It should be considered in patients with history of traumatic brain injury and temporal fossa extra-axial mass lesion with vascular characteristics.

Traumatic iatrogenic dissecting anterior cerebral artery aneurysms: conservative management as a therapeutic option

INTRODUCTION

Traumatic iatrogenic intracranial aneurysms (TICAs) are rare, but are important due to their risk of intracranial hemorrhage and complexity of management.

METHODS

Two adult patients, one with history of chronic sinusitis and nasal cavity polyposis undergoing functional endoscopic sinus surgery (FESS), and second during rhinoplasty, suffered subarachnoid hemorrhage (SAH) due to anterior cerebral artery (ACA) injury during the procedures.

RESULTS

Two women patients aged 17 and 38 years with SAH after nasal surgery were referred to our institute. Three small dissecting aneurysms were seen involving A2 segment of ACA of two patients. Both were managed conservatively. Follow-up angiography (after 2 months) demonstrated complete occlusion of the aneurysms. There was no rebleeding and the patients had a good outcome at the last follow-up.

CONCLUSIONS

Conservative management of traumatic iatrogenic dissecting cerebral aneurysms is a reasonable therapeutic option that can lead to favorable angiographic and clinical outcomes.

Interobserver reliability of computed tomography angiography in the assessment of ruptured intracranial aneurysm and impact on patient management

BACKGROUND

Aneurysmal subarachnoid hemorrhage is an emergency that can lead to a high mortality rate and many severe complications. It is critical to make a rapid radiological evaluation of ruptured intracranial aneurysms (RIAs) to determine the appropriate surgical treatment.

AIM

To assess the reliability of computed tomography angiography (CTA) in assessing different features of ruptured intracranial aneurysm and its impact on patient management.

METHODS

The final cohort of this study consisted of 146 patients with RIAs (75 male and 71 female) who underwent cerebral CTA. Their age ranged from 25 to 80, and the mean age ± SD was 57 ± 8.95 years. Two readers were asked to assess different features related to the aneurysm and perianeurysmal environment. Inter-observer agreement was measured using kappa statistics. Imaging data extracted from non-contrast computed tomography and CTA were considered to categorize the study population into two groups according to the recommended therapeutic approach.

RESULTS

The inter-observer agreement of both reviewers was excellent for the detection of aneurysms (K = 0.95, P = 0.001), aneurysm location (K = 0.98, P = 0.001), and (K = 0.98, P = 0.001), morphology (K = 0.92, P = 0.001) and margins (K = 0.95, P = 0.001). There was an excellent interobserver agreement for the measurement of aneurysm size (K = 0.89, P = 0.001), neck (K = 0.85, P = 0.001), and dome-to-neck ratio (K = 0.98, P = 0.001). There was an excellent inter-observer agreement for the detection of other aneurysm-related features such as thrombosis (K = 0.82, P = 0.001), calcification (K = 1.0, P = 0.001), bony landmark (K = 0.89, P = 0.001) and branch incorporation (K = 0.91, P = 0.001) as well as perianeurysmal findings including vasospasm (K = 0.91, P = 0.001), perianeurysmal cyst (K = 1.0, P = 0.001) and associated vascular lesions (K = 0.83, P = 0.001). Based on imaging features, 87 patients were recommended to have endovascular treatment, while surgery was recommended in 59 patients. 71.2% of the study population underwent the recommended therapy.

CONCLUSION

CTA is a reproducible promising diagnostic imaging modality for detecting and characterizing cerebral aneurysms.

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.

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 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.

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.

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.

Surgical treatment of traumatic distal anterior cerebral artery aneurysm: a report of nine cases from a single centre

BACKGROUND

Traumatic distal anterior cerebral artery (dACA) aneurysm is rare and can be easily neglected and misdiagnosed in patients with trauma. The aim of this study was to explore the radiologic characteristics of and therapeutic strategies for traumatic dACA aneurysm and to improve our understanding of unusual complications after trauma.

METHODS

The clinical data of nine cases of traumatic dACA aneurysm from our neurosurgical department from July 1, 2010, to July 1, 2018, were retrospectively analysed.

RESULTS

All 9 patients had a history of brain trauma. The initial computed tomography scan immediately after trauma showed subarachnoid haemorrhage in 8 cases. Among these cases, delayed intracranial haemorrhage occurred in 7 cases. The average interval between injury and diagnosis was 13.67 ± 9.43 days. All 9 cases were confirmed as traumatic dACA aneurysm by computed tomography angiography (CTA) and/or digital subtraction angiography. According to Lehecka's classification system, traumatic dACA aneurysm located in the A3 and A4 segment was found in 3 and 6 cases, respectively. Surgical treatment was performed in 8 cases, including neck clipping, with or without wrapping in 3 cases, trapping in 4 cases, aneurysm excision and suturing in 1 case and conservative treatment in 1 case. Three patients required a ventriculoperitoneal shunt due to severe hydrocephalus. According to the Glasgow Outcome Scale scoring system, good recovery was achieved in 4 cases, moderate disability in 2 cases, severe disability in 1 case, and death in 2 cases.

CONCLUSION

Traumatic dACA aneurysm is a rare complication of brain trauma. Delayed intracranial haemorrhage and the sudden deterioration of neurologic function were the typical characteristics in patients with traumatic dACA aneurysm. CTA is the first-line screening modality for patients who present with intracerebral haemorrhage in the corpus callosum after trauma, particularly for patients who are older, in a poorer or critical condition. When the aneurysm is located in the A4 segment or involves a small branch, surgical trapping is the preferred definitive therapy to prevent further growth and disastrous bleeding. Early diagnosis and prompt treatment could help to improve clinical outcomes.

Treatment of traumatic intracranial aneurysm: Experiences at a single center

OBJECTIVE

To report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China.

PATIENTS AND METHODS

All patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998.

RESULTS

A total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture.

CONCLUSION

Although the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.

Traumatic Pseudoaneurysm of the Distal Anterior Cerebral Artery Following Penetrating Brain Injury Caused by a Crossbow Bolt: A Case Report

Traumatic intracranial aneurysms are one possible complication after penetrating brain injury. A 25-year-old man with a history of major depression presented with a crossbow bolt penetrating the head. On arrival, Glasgow Coma Scale score was E4V5M6, with no apparent neurological deficit. Computed tomography (CT) of the head showed the crossbow bolt passing near the corpus callosum, with surrounding contusion. Three-dimensional rotational angiography showed no anterior cerebral artery injuries. The crossbow bolt was removed after bifrontal craniotomy, with no postoperative infection. Postoperative CT angiography (CTA) was repeatedly performed, and a 4 mm aneurysm was observed at the pericallosal artery-right posterior internal frontal artery (PIFA) bifurcation on postoperative day (POD) 35. Trapping and the right PIFA-left cortical branch side-to-side bypass were performed on POD38. A resected specimen confirmed a pathological diagnosis of pseudoaneurysm. The patient did not show any neurological deficit or cognitive dysfunction as of 8 months after admission. Traumatic anterior cerebral artery aneurysm might have formed due to proximity to the falx cerebri. As pseudoaneurysm was detected 4 weeks after trauma in our patient, follow-up CTA or digital subtraction angiography should be performed until at least 4 weeks after injury. In addition, neck clipping is occasionally unfeasible to treat traumatic pseudoaneurysm surgically, and a surgical strategy including bypass revascularization must be planned.