A traumatic pseudoaneurysm of the vertebral artery

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.

Spinal Pseudoaneurysms Mimicking an Osteogenic Tumor: A Case Report

AIM

This study presents a rare case of pseudoaneurysm mimicking a tumor on the back, with no history of fever, trauma, or surgical intervention. In which no identifiable symptoms or warning signs were present. This pseudoaneurysm arises from intercostal arteries and segmental arteries. Both of which, to the limit of our knowledge, have not been discussed before.

METHOD

This study was done using chart and literature review. We present a case of a 46-year-old man with a known case of left-sided intracranial hemorrhage due to hypertension and an old cerebrovascular accident. The patient has a positive history of hypertension, which could have attributed to the pseudoaneurysm; however, he has no history of vascular disease otherwise. The patient reports of back swelling and intermittent back pain for the past 3 years. On MRI, the mass showed a pulsating pattern around it. It also showed a layering effect because of different wall thicknesses and enhanced patterns, and the enhancement ratio was increased. In addition, it showed flow artifacts with T1 hyperintense areas because of associated thrombus and blood products. These changes noted on the MRI prompted the team to do a color Doppler study to confirm the presence of an aneurysm and if present, to do a CT angiography. The color Doppler showed a turbulent flow, that is, there was a bidirectional pulsatile flow which further confirms the presence of a pseudoaneurysm. Spine CT with contrast showed a right paraspinal lesion at the T9-T11 level. It had contrast enhancement and flow inside, consistent with a partially thrombosed aneurysm. The CT also showed evidence of bone remodeling in the adjacent thoracic vertebrae. The patient opted for spinal vascular emobilization and vascular sheath removal. The right and left intercostal arteries were selected at the level of left and right T4, left T8, bilateral T9, and bilateral T10.

CONCLUSION

Differentiating between pseudoaneurysms and osteogenic tumors is essential to target later investigations accordingly. In addition, if pseudoaneurysms are left untreated, they could cause bony erosions of the vertebra, which lead to compression fractures. They can further compress the adjacent neurovasculature, which worsens the morbidity.

Two cases with giant pseudo-aneurysm of vertebral artery secondary to shrapnel injury

INTRODUCTION

Due to their locations, vertebral arteries (VA) are structures that are rarely injured after traumas. Formation of vertebral pseudo-aneurysm (PA) because of pieces of shrapnel is also rare. It causes clinical findings like cervical mass after the injury CASES PRESENTATION: Two Syrian 12- and 17-year-old male patients were admitted to the Department of Ear, Nose and Throat with the complaint of swelling in the left lower cervical region. In their USG examination which was ordered to investigate the cervical lesion, a lesion consistent with PA which shows a prominently thick wall structure due to circumferential thrombus formation and fibrotic tissue, chaotic flow, and ying-yang appearance in the centrally located cavity of the lesion in a color Doppler examination was detected. Later, multi-detector computed tomography angiography (MDCTA) was planned to demonstrate pseudo-aneurysms (PAs).

CONCLUSION

Because there was no report on the development of giant pseudo-aneurysms secondary to shrapnel injury to date and because we thought these cases are demonstrative, we found the cases suitable for presenting as case reports.

Subarachnoid haemorrhage secondary to traumatic intracranial aneurysm of the posterior cerebral circulation: case series and literature review

Background

To identify the clinical features, rebleed risk, timing and method of diagnosis, complications and outcome for subarachnoid haemorrhage (SAH) from traumatic intracranial aneurysm (TICA) of the posterior circulation. Subjects included 26 patients aged 3–54 (mean 24.8).

Methods

Case series and literature search to identify all reported cases.

Results

In our series, two of three cases were fatal as a result of rebleed, and one case had a good outcome with no deficit, following prompt diagnosis and embolisation. Our key findings from the literature review were: 30.7 % of patients were age 16 and under; 88 % had an acute drop in consciousness, 46 % in a delayed manner; the mean time to diagnosis was 7.5 days; initial cerebrovascular imaging was normal in 23 %; the rebleed rate was 23 %; 61 % required emergency diversion of cerebrospinal fluid; 11 % developed vasospasm requiring treatment; 19.2 % had deficits that rendered them unable to live independently. The mortality rate was 27 %.

Conclusions

SAH from ruptured posterior circulation TICA is associated with significant morbidity and mortality. A high index of suspicion as well as prompt diagnosis, repeat imaging in selected cases, and treatment of any associated TICA can be crucial to a favourable outcome.

Post Traumatic Pseudoaneurysm Arising from V4 Segment of Vertebral Artery: A Case Report

This case report describes a traumatic pseudoaneurysm arising from the right V4 segment of the vertebral artery, near the origin of the posterior inferior cerebellar artery. Post-traumatic vertebral artery pseudoaneurysm is rare, but associated with a high mortality rate. We report on an extremely rare case of post-traumatic pseudoaneurysm of the vertebral artery with delayed manifestation. A 9-year-old child was admitted to the emergency room after a pedestrian car accident. A computed tomography (CT) scan showed subarachnoid hemorrhage with intraventricular hemorrhage (IVH), multiple facial bones, and temporal bone fracture. External ventricular drainage and decompressive suboccipital craniectomy were performed for acute hydrocephalus and posterior fossa swelling. The patient's clinical condition became suddenly aggravated on the 15th hospital day, and brain CT confirmed appearance of a new 4th ventricle IVH. Digital subtraction angiography revealed a ruptured pseudoaneurysm arising from the right V4 segment of the vertebral artery. Parent artery occlusion using detachable coils was achieved. Despite intensive care, the patient's clinical condition showed continuous deterioration and the patient died of respiratory complications on the 52nd hospital day.