Surgical management of traumatic intracranial pseudoaneurysms: A report of 12 cases

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.

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.

Craniofacial Trauma and Vascular Injury

Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.

Onyx Embolization of a Distal Middle Cerebral Artery Pseudoaneurysm in a Five-Week-Old: A Case Report and Review of Current Treatment Options

Intracranial pseudoaneurysms secondary to traumatic birth are a rare finding in infants. Definitive diagnosis of such findings is challenging, and no standard management is delineated for management of pseudoaneurysms in the pediatric population. Commonly attempted treatments include endovascular embolization or surgical clipping. A 5-week-old female presented with a two day history of right hand focal seizures. The patient was found to have a dysplastic superficial intra-axial aneurysm arising from the distal left middle cerebral artery (MCA) branch in the setting of a left posterior frontal lobe hemorrhage noted on brain magnetic resonance imaging/magnetic resonance angiography (MRI/MRA). The patient underwent diagnostic cerebral angiogram demonstrating a left distal MCA pseudoaneurysm, which was treated with Onyx embolization. Post-embolization period was complicated by recurrent left central localized seizures and a left hemispheric temporoparietal hemorrhagic infarction. The patient was managed on levetiracetam, phenytoin, phenobarbital with stable seizure control. Herein, we highlight the youngest case to date of a 5-week-old infant with a left distal MCA pseudoaneurysm treated with Onyx embolization. Pseudoaneurysmal incidence, diagnosis and accepted management is discussed.

Intracranial Pseudoaneurysm Caused by Cerebral Paragonimiasis in Pediatric Patients

BACKGROUND

We investigated the proportion of pediatric patients with cerebral paragonimiasis and intracranial hemorrhage who have intracranial pseudoaneurysms.

METHODS

Images of 17 pediatric patients with cerebral paragonimiasis that first manifested as secondary intracranial hemorrhage were evaluated. All patients underwent computed tomographic angiography before surgery. A diagnosis of cerebral paragonimiasis was confirmed based on a positive Paragonimus-specific antibody test in serum samples from all 17 patients. Cerebral paragonimiasis in five of the 17 patients was further confirmed by histopathological examination of surgical specimens.

RESULTS

Computed tomographic angiographic images for six of the 17 patients (35.3%) showed the presence of intracranial pseudoaneurysms. Follow-up computed tomographic angiographic scans two years later showed that two of the six patients had persistent pseudoaneurysms and underwent aneurysmectomy. The diagnosis of pseudoaneurysm was confirmed by histopathological examination postsurgery. In another two of the six patients, the pseudoaneurysm lesions were absorbed and could no longer be seen on three- to six-month follow-up scans. The final two patients with pseudoaneurysms are still under follow-up. Intracranial pseudoaneurysms with various degrees of surrounding hemorrhage were frequently observed at first manifestation.

CONCLUSIONS

The rupture of intracranial pseudoaneurysms is a common characteristic feature of secondary intracranial hemorrhage caused by cerebral paragonimiasis in pediatric patients.

The Role of digital subtraction angiography in the ventricular spot sign on the computed tomography angiography

Objective

The spot sign on computed tomography angiography is little known about the relationship between the spot sign and the results of cerebral angiography We retrospectively analyzed the spot sign, digital subtraction angiography results, and other factors.

Material and Methods

From December 2009 to May 2014, DSA was performed in 52 ICH patients with non-specific location or abnormalities on CTA findings. 26 of those patients, whose initial CTA showed the spot sign, were analyzed. Two groups, one with the spot sign in the ventricle (Group A) and others with the spot sign in another location (Group B) were statistically compared.

Results

The mean age of the study subjects was 46.9 years (range, 15 to 80 years) and the percentage of males was 53.8%. Thirteen of 26 patients had ICH without intraventricular hemorrhage, and 6 patients had co-existing IVH. In 17 cases, the DSA results were negative. Seven patients were diagnosed with pseudoaneurysms, and two cases showed developmental venous anomalies. Group A consisted of the 8 patients (30.8%) who showed the spot sign in a ventricle. The number of pseudoaneurysms was statistically significantly higher in Group A than in Group B (71.4% versus 28.6%; OR, 13.3; 95% CI, 1.7-103.8 P = 0.014). All three patients who underwent endovascular treatment were members of Group A (P = 0.022), whereas most (92.3%) of those in Group B underwent surgical evacuation. (P = 0.030).

Conclusion

When CTA shows the spot sign in a ventricle, it is a clue that an existing underlying vascular lesion requires endovascular treatment.

Recurrent Pituicytoma with Pseudoaneurysm: Report of a Challenging Case

BACKGROUND

Pituicytoma is a rare tumor originating from glial cells of the adult neurohypophysis and infundibulum. Surgical removal is the treatment of choice for this neoplasm. In recent years the endoscopic endonasal approach has proven to be a viable and effective alternative to standard craniotomy.

CASE DESCRIPTION

We report a case of a patient submitted to surgical treatment for a recurrence of pituicytoma, which was operated on transcranially at another hospital approximately 5 years previously. After transcranial surgery, the patient developed a symptomatic recurrence and an undisclosed intrasellar pseudoaneurysm that were treated with an endoscopic endonasal approach, but still required an intracranial approach to complete the resection.

CONCLUSIONS

An intrasellar pseudoaneurysm can endanger the endoscopic removal of the pituicytoma, forcing the surgeon to reevaluate a microscopic transcranial approach or to consider a staged procedure.

Nontraumatic, posterior circulation pseudoaneurysm of the basilar artery summit with complete spontaneous resolution: Case report and literature review

Background:

Intracranial pseudoaneurysms are rare vascular defects of arterial walls that are classically the result of traumatic injury, iatrogenic causes, or infection. Idiopathic pseudoaneurysms are seen even less frequently and are often related to atherosclerosis. Pseudoaneurysms are most commonly found along the distal wall of the internal carotid artery, however, can occur at any location in the cerebrovascular circulation. Treatment of these arterial defects is often challenging due to their frail nature.

Case Description:

A 61-year-old male with a history of hypertension presented with a severe, atypical headache without history of trauma. Computed tomography (CT) and computed tomography angiography (CTA) demonstrated diffuse subarachnoid hemorrhage. Imaging demonstrated a 3.5 mm pseudoaneurysm projecting distally from the basilar artery at the apex. Repeated imaging (CTA, digital subtraction angiography) demonstrated decreased size and flow associated within the aneurysm over the following 2 weeks; as such, the patient was managed conservatively. The patient was discharged in neurologically intact condition when imaging at 14 days confirmed complete and spontaneous resolution of the pseudoaneurysm.

Conclusion:

Idiopathic pseudoaneurysms that are commonly associated with atherosclerosis are most commonly managed surgically or endovascularly. Conservative approach may be considered in a select group of patients that exhibit decreased size and/or flow within the aneurysm in repeated imaging; spontaneous resolution was seen in the present case.

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

OBJECTIVE

Traumatic intracranial aneurysm (tIA) is rare and is associated with high rates of morbidity and mortality. We describe our experiences with tIA at our institution.

METHODS

We retrospectively reviewed records from patients who underwent treatment for tIA between January 1986 and December 2015.

RESULTS

Data from 5532 patients with cerebral aneurysms between January 1986 and December 2015 were reviewed. Of these, 13 cases (0.23%) were tIA. Most occurred after blunt brain trauma (12/13; 92%). The most common location was the distal anterior cerebral artery (7/13; 53%) followed by the internal carotid artery (5/13; 38%). One patient had a tIA in the distal middle cerebral artery. Delayed intracerebral hemorrhage was the major presentation at the time of aneurysmal rupture (70%). Most patients underwent surgical treatment (10/12; 83.3%), which included clipping (5/10), trapping (3/10), aneurysmal excision and bypass (1/10), and aneurysmal excision and coagulation (1/10). In 2 cases, tIA located in the internal carotid artery was treated with coil embolization and detachable balloon occlusion, respectively. Most patients had good recovery (5/12; 41.7%); 3 patients and 1 patient had moderate and severe disability, respectively; 1 patient was in a vegetative state; and 2 patients died.

CONCLUSIONS

tIA is an uncommon complication of head trauma. tIA should be considered when unexpected new symptoms develop in patients with head trauma. Early diagnosis and prompt treatment could help to improve final clinical outcomes.

Clinical Analysis of Traumatic Cerebral Pseudoaneurysms

Objective

Traumatic pseudoaneurysms are rare but life-threatening lesions. We investigated the patients with these lesions to clarify their clinical characteristics and therapeutic strategies and we also reviewed the literatures on the treatment principles, possible options, and outcomes.

Methods

There were a total of 8 patients who were treated with traumatic intracranial pseudoaneurysms between April 1980 and January 2009. Medical charts and the imaging studies were reviewed for analysis. The outcome was measured with modified Rankin Scale (mRS) score at 6 months after treatment.

Results

All 8 patients were male and the mean age was 25 years old. Six of those were located at the cavernous segment of the internal carotid artery (ICA) and the other 2 was located at the M2 segment of middle cerebral artery. The causes of trauma were car accidents in 6, penetrating injury through the orbit in 1, and slip down injury in 1 patient. Massive epistaxis or hematemesis occurred in all patients with a pseudoaneurysm at the cavernous and ophthalmic segment of the ICA. All 6 patients of the cavernous and ophthalmic ICA group showed favorable outcome of mRS 0 to 1. The outcome of patients with middle cerebral artery pseudoaneurysm was mRS 2 to 3.

Conclusion

Upon prompt diagnosis and proper treatment planning, it is possible to achieve favorable outcome in these patients. Lesions located at the cavernous segment of the ICA favored endovascular treatment while those at the middle cerebral artery favored surgical treatment.

A successful case of multiple stereotactic radiosurgeries for ipsilateral recurrent trigeminal neuralgia

Trigeminal neuralgia is a common pain syndrome primarily managed medically, although many patients require surgical or radiotherapeutic intervention. Stereotactic radiosurgery has become a preferred method of treatment given its high efficacy rates and relatively favorable toxicity profile. However, many patients have refractory pain even after repeat courses of stereotactic radiosurgery. Historically, 2 courses have been the limit in such patients. The authors present a case of multiply recurrent trigeminal neuralgia treated with a third course of radiosurgery in which the patient had successful pain control and no additional toxicity. Meticulous attention to the therapeutic technique allows the continued application of stereotactic radiosurgery in patients.

Traumatic intracranial aneurysm in blunt trauma

INTRODUCTION

Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions.

METHODS

A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI.

RESULTS

A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs.

CONCLUSION

The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI.

Visualization of a Traumatic Pseudoaneurysm at Internal Carotid Artery Bifurcation due to Blunt Head Injury: A Case Report

Traumatic intracranial pseudoaneurysms occurring after blunt head injuries are rare. We report an unusual case of subarachnoid hemorrhage (SAH) caused by rupturing of the traumatic pseudoaneurysm of the internal carotid artery (ICA) bifurcation that resulted from a non-penetrating injury. In a patient with severe headache and SAH in the right sylvian cistern, which developed within 7 days after a blunt-force head injury, a trans-femoral cerebral angiogram (TFCA) showed aneurysmal sac which was insufficient to confirm the pseudoaneurysm. We obtained a multi-slab image of three dimensional time of flight (TOF) of magnetic resonance angiography (MRA). The source image of the gadolinium-enhanced MRA revealed an intimal flap within the intracranial ICA bifurcation, providing a clue for the diagnosis of a dissecting pseudoaneurysm at the ICA bifurcation due to blunt head trauma. We performed direct aneurysmal neck clipping, without neurological deficit. A follow-up TFCA did not show either aneurysm sac or luminal narrowing. We suggest that in the patient with a history of blunt head injury with SAH following shortly, multi-slab image of 3D TOF MRA can give visualization of the presence of a pseudoaneurysm.

Proposal for evaluating the quality of reports of surgical interventions in the treatment of trigeminal neuralgia: the Surgical Trigeminal Neuralgia Score

OBJECT

The aim of this study was to design a checklist with a scoring system for reporting on studies of surgical interventions for trigeminal neuralgia (TN) and to validate it by a review of the recent literature.

METHODS

A checklist with a scoring system, the Surgical Trigeminal Neuralgia Score (STNS), was devised partially based on the validated STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) criteria and customized for TN after a literature review and then applied to a series of articles. These articles were identified using a prespecified MEDLINE and Embase search covering the period from 2008 to 2010. Of the 584 articles found, 59 were studies of interventional procedures for TN that fulfilled the inclusion criteria and 56 could be obtained in full. The STNS was then applied independently by 3 of the authors.

RESULTS

The maximum STNS came to 30, and was reliable and reproducible when used by the 3 authors who performed the scoring. The range of scores was 6-23.5, with a mean of 14 for all the journals. The impact factor scores of the journals in which the papers were published ranged from 0 to 4.8. Twenty-four of the studies were published in the Journal of Neurosurgery or in Neurosurgery. Studies published in neurosurgical journals ranked higher on the STNS scale than those published in nonneurosurgical journals. There was no statistically significant correlation between STNS and impact factors. Stereotactic radiosurgery (n = 25) and microvascular decompression (n = 15) were the most commonly reported procedures. The diagnostic criteria were stated in 35% of the studies, and 4 studies reported subtypes of TN. An increasing number of studies (46%) used the recommended Kaplan-Meier methodology for pain survival outcomes. The follow-up period was unclear in 8 studies, and 26 reported follow-ups of more than 5 years. Complications were reported fairly consistently but the temporal course was not always indicated. Direct interview, telephone conversation, and questionnaires were used to measure outcomes. Independent assessment of outcome was only clearly stated in 7 studies. Only 2 studies used the 36-Item Short Form Health Survey to measure quality of life and 4 studies reported on the severity of preoperative pain. The Barrow Neurological Institute pain questionnaire was the most commonly used outcome measure (n = 13), followed by the visual analog scale.

CONCLUSIONS

Similar to the STROBE criteria that provide a checklist of items that should be included in reports of observational studies in general, the authors' suggested checklist for the STNS could help editors and reviewers ensure that quality reports are published, and could prove useful for colleagues when reporting their results specifically on the surgical management of TN. It would help the patient and clinicians make a decision about selecting the appropriate neurosurgical procedure.

Timing of operation for poor-grade aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

BACKGROUND

Subarachnoid hemorrhage is a common and dangerous disease with an unfavorable prognosis. Patients with poor-grade subarachnoid hemorrhage (Hunt & Hess Grades 4-5) are unconscious on admission. Because of the high mortality and disability rate associated with poor-grade subarachnoid hemorrhage, it is often treated conservatively. Timing of surgery for poor-grade aneurysmal subarachnoid hemorrhage is still controversial, therefore this study aims to identify the optimal time to operate on patients admitted in poor clinical condition.

METHODS/DESIGN

Ninety-nine patients meeting the inclusion criteria were randomly assigned into three treatment groups. The early surgery group received operation within 3 days after onset of subarachnoid hemorrhage (day of SAH = day 1); the intermediate surgery group received operation from days 4 to 7, and surgery was performed on the late surgery group after day 7. Follow-up was performed 1, 3, and 6 months after aneurysm clipping. Primary indicators of outcome included the Extended Glasgow Outcome Scale and the Modified Rankin Scale, while secondary indicators of outcome were assessed using the Barthel Index and mortality.

DISCUSSION

This is the first prospective, single-center, observer-blinded, randomized controlled trial to elucidate optimal timing for surgery in poor-grade subarachnoid hemorrhage patients. The results of this study will be used to direct decisions of surgical intervention in poor-grade subarachnoid hemorrhage, thus improving clinical outcomes for patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-12002917.

Potential intracranial applications of magnetic resonance–guided focused ultrasound surgery

Magnetic resonance–guided focused ultrasound surgery (MRgFUS) has the potential to create a shift in the treatment paradigm of several intracranial disorders. High-resolution MRI guidance combined with an accurate method of delivering high doses of transcranial ultrasound energy to a discrete focal point has led to the exploration of noninvasive treatments for diseases traditionally treated by invasive surgical procedures. In this review, the authors examine the current intracranial applications under investigation and explore other potential uses for MRgFUS in the intracranial space based on their initial cadaveric studies.

Transcranial magnetic resonance–guided focused ultrasound surgery for trigeminal neuralgia: a cadaveric and laboratory feasibility study

Object

Transcranial MR-guided focused ultrasound surgery (MRgFUS) is evolving as a treatment modality in neurosurgery. Until now, the trigeminal nerve was believed to be beyond the treatment envelope of existing high-frequency transcranial MRgFUS systems. In this study, the authors explore the feasibility of targeting the trigeminal nerve in a cadaveric model with temperature assessments using computer simulations and an in vitro skull phantom model fitted with thermocouples.

Methods

Six trigeminal nerves from 4 unpreserved cadavers were targeted in the first experiment. Preprocedural CT scanning of the head was performed to allow for a skull correction algorithm. Three-Tesla, volumetric, FIESTA MRI sequences were performed to delineate the trigeminal nerve and any vascular structures of the cisternal segment. The cadaver was positioned in a focused ultrasound transducer (650-kHz system, ExAblate Neuro, InSightec) so that the focus of the transducer was centered at the proximal trigeminal nerve, allowing for targeting of the root entry zone (REZ) and the cisternal segment. Real-time, 2D thermometry was performed during the 10- to 30-second sonication procedures. Post hoc MR thermometry was performed on a computer workstation at the conclusion of the procedure to analyze temperature effects at neuroanatomical areas of interest. Finally, the region of the trigeminal nerve was targeted in a gel phantom encased within a human cranium, and temperature changes in regions of interest in the skull base were measured using thermocouples.

Results

The trigeminal nerves were clearly identified in all cadavers for accurate targeting. Sequential sonications of 25–1500 W for 10–30 seconds were successfully performed along the length of the trigeminal nerve starting at the REZ. Real-time MR thermometry confirmed the temperature increase as a narrow focus of heating by a mean of 10°C. Postprocedural thermometry calculations and thermocouple experiments in a phantom skull were performed and confirmed minimal heating of adjacent structures including the skull base, cranial nerves, and cerebral vessels. For targeting, inclusion of no-pass regions through the petrous bone decreased collateral heating in the internal acoustic canal from 16.7°C without blocking to 5.7°C with blocking. Temperature at the REZ target decreased by 3.7°C with blocking. Similarly, for midcisternal targeting, collateral heating at the internal acoustic canal was improved from a 16.3°C increase to a 4.9°C increase. Blocking decreased the target temperature increase by 4.4°C for the same power settings.

Conclusions

This study demonstrates focal heating of up to 18°C in a cadaveric trigeminal nerve at the REZ and along the cisternal segment with transcranial MRgFUS. Significant heating of the skull base and surrounding neural structures did not occur with implementation of no-pass regions. However, in vivo studies are necessary to confirm the safety and efficacy of this potentially new, noninvasive treatment.

Traumatic intracranial aneurysms due to blunt brain injury-a single center experience

BACKGROUND

Traumatic intracranial aneurysms (TICAs) have previously been described in literature. However, the evidence of TICAs secondary to blunt brain injury have not been elucidated well, with most of the conclusions coming from isolated case reports. We have attempted to examine the epidemiology, classification, clinical presentation, therapeutic modalities, and outcomes of TICAs with our series of patients at the neurosurgery department of Xuanwu Hospital, China.

METHODS

We reviewed our aneurysm database from January 1, 2005 to December 31, 2011. In particular, patients with TICAs secondary to blunt brain injury were reviewed. Variables assessed included age, sex, causes of blunt brain injury, skull fracture, location, classification, clinical presentation, time elapsed to arrive at diagnoses, treatment, and eventual outcome. Based on our assessment, we arrived at a modified classification scheme to categorize these aneurysms.

RESULTS

We reviewed 2335 patients with cerebral aneurysm from January 1, 2005 to December 31, 2011. Of these, 15 patients (0.64 %) with traumatic aneurysms secondary to blunt brain injury were identified.Motor vehicle accidents (MVA) were observed to be the most common cause of injury (10 patients, 66.7 %), followed by TICAs sustained after falling down (5 patients, 33.3 %). The most common symptom at presentation was epistaxis (6 patients, 40 %), followed by ophthalmic problems (6 patients, 40 %), with both presentations seen in 1 patient. The most common diagnostic modality used was DSA in 12 patients (80 %) followed by CTA in 2 patients (13.3 %). Infraclinoid TICAs were seen in 9 patients (60 %), whereas supraclinoid TICAs were seen in 5 patients (33.3 %), with perifalx TICAs seen in 1 patient. Endovascular intervention therapies were performed in 11 patients (73.3 %), bypass surgery and trapping in 2 (13.3 %), transnasal endoscopic approach in combination with balloon assisted in 2 patients. At discharge, 2 patients had poor clinical outcomes (13.3 %), 5 had fair (33.3 %),and 8 resulted with good outcomes (53.3 %).

CONCLUSIONS

TICAs arising secondary to blunt brain injury account for 0.64 % of all cerebral aneurysms. Infraclinoid, supraclinoid ICA and perifalx TICAs are the most common aneurysms arising from blunt brain injury. Our study further shows that traumatic patients presenting with recurrent epistaxis, oculomotor nerve palsy, and delayed intracranial hemorrhage should receive cerebroangiography as soon as possible. An early diagnosis and proper treatment could prove to be helpful in terms of improving final clinical outcome.

Acute formation of a pseudoaneurysm adjacent to a previously clipped anterior communicating artery aneurysm

Background:

Cerebral pseudoaneurysms, especially of the anterior communicating artery (ACoA), are rare.

Case Description:

Herein, the authors report a 66-year-old patient who underwent successful clip ligation of a small ruptured ACoA aneurysm. Eighteen days after surgery, he suffered from another episode of subarachnoid hemorrhage due to the rupture of a newly formed pseudoaneurysm adjacent to the previously clipped aneurysm. This pseudoaneurysm was treated through clip ligation as well.

Conclusion:

A pseudoaneurysm may rarely form adjacent to a previously clipped cerebral aneurysm and should be included in the differential diagnosis of recurrent subarachnoid hemorrhage. Potential mechanisms of formation and management strategies for this challenging problem will be discussed.

The use of routine imaging data in diagnosis of cerebral pseudoaneurysm prior to angiography

PURPOSE

A false aneurysm is rare and underdiagnosed complication of intracranial hemorrhage. Objective of the study was to point out diagnostic imaging signs of false aneurysm and to determine frequency and diagnostic significance of these signs.

MATERIALS AND METHODS

Cerebral arteriography performed in our center from November 2007 to September 2010 revealed the false aneurysm in 8 patients (4 male, 4 female, mean age was 38 years). During the same angiographic procedure 6 patients were treated by endovascular embolization using coils, mixture of Histoacryl and Lipiodol or Onyx (liquid embolic material). Authors retrospectively analyzed preprocedural studies (computed tomography, magnetic resonance imaging) and angiographic findings to identify signs specific to false aneurysm.

RESULTS

Computed tomographic findings that are not specific but should raise suspicion of the false aneurysm include: enlargement of parenchymal hematoma dimensions, unusual or delayed evolution of hematoma and spot sign associated with acute hematoma expansion. More specific signs can be revealed in digital subtraction angiography that shows a globular shaped neckless aneurysmal sac, delayed filling and emptying of contrast agent and stagnation of contrast with regard to the head position.

CONCLUSION

Although preangiographic imaging studies findings in patients with false aneurysms are not specific, they should lead to angiographic validation, especially enlarging parenchymal hematoma and atypical hematoma evolution. Digital subtraction angiography makes it possible to diagnose the lesion and to use endovascular embolization techniques, which are currently the method of choice for treatment of pseudoaneurysms.

Stent-assisted coiling treatment of pediatric traumatic pseudoaneurysm resulting from tumor surgery

BACKGROUND

Traumatic intracranial pseudoaneurysms in children are typically the result of blunt or penetrating head injury. There are isolated reports of pseudoaneurysm as the result of intracranial aneurysm surgery in both adults and children. Treatment of these lesions, both surgically and endovascularly, can be complicated due to the known variability of arterial wall thickness in traumatic pseudoaneurysms.

CASE REPORT

We describe a child who underwent successful craniopharyngioma resection following staged surgical procedures. Follow-up imaging 8 months after the operation demonstrated an enlarging pseudoaneurysm of the left supraclinoid carotid artery. The lesion was successfully treated with stenting of the vessel and coil placement between the stent and the aneurysmal segment of the artery. Follow-up angiographic imaging 6 months later revealed complete obliteration of the aneurysm and normalization of the carotid artery lumen.

CONCLUSION

To our knowledge, this is the first report of a pseudoaneurysm secondary to a surgical intervention in childhood that was treated with stent-assisted coiling. This strategy of vascular reconstruction is increasingly used in adults and appears safe to implement in the pediatric population. However, the long-term outcomes and the value of using an antiplatelet regimen in this young population are still to be determined.

Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis

OBJECT

Because the incidence of trigeminal neuralgia (TN) increases with age, neurosurgeons frequently encounter elderly patients with this disorder. Although microvascular decompression (MVD) is the only etiological therapy for TN with the highest initial efficacy and durability of all treatments, it is nonetheless associated with special risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the commonly performed ablative procedures. Thus, the safety of MVD in the elderly remains a concern. This prospective study and systematic review with meta-analysis was conducted to determine whether MVD is a safe and effective treatment in elderly patients with TN.

METHODS

In this prospectively conducted analysis, 36 elderly patients (mean age 73.0 ± 5.9 years) and 53 nonelderly patients (mean age 52.9 ± 8.8 years) underwent MVD over the study period. Outcome and complication data were recorded. The authors also conducted a systematic review of the English literature published before December 2009 and providing outcomes and complications of MVD in patients with TN above the age of 60 years. Pooled complication rates of stroke, death, cerebellar hematoma, and permanent cranial nerve deficits were analyzed.

RESULTS

Thirty-one elderly patients (86.1%) reported an excellent outcome after MVD (mean follow-up 20.0 ± 7.0 months). Twenty-five elderly patients with Type 1 TN were compared with 26 nonelderly patients with Type 1 TN, and no significant difference in outcomes was found (p = 0.046). Three elderly patients with Type 2a TN were compared with 12 nonelderly patients with Type 2a TN, and no significant difference in outcomes was noted (p = 1.0). Eight elderly patients with Type 2b TN were compared with 15 nonelderly patients with Type 2b TN, and no significant difference in outcomes was noted (p = 0.086). The median length of stay between cohorts was compared, and no significant difference was noted (2 days for each cohort, p = 0.33). There were no CSF leaks, no cerebellar hematomas, no strokes, and no deaths. Eight studies (1334 patients) met the inclusion criteria for the meta-analysis. For none of the complications was the incidence significantly more frequent in elderly patients than in the nonelderly.

CONCLUSIONS

Although patient selection remains important, the authors' experience and the results of this systematic review with meta-analysis suggest that the majority of elderly patients with TN can safely undergo MVD.

Endovascular embolization of intracranial iatrogenic pseudoaneurysms. A report of two cases and review of the literature

Iatrogenic pseudoaneurysm is a rare but severe complication of intracranial surgery. Treatment of the condition is difficult. The purpose of this report is to draw attention to the fact that endovascular embolization of pseudoaneurysms with parent artery preservation is possible. We describe two cases of endovascular embolization and review the literature. The conclusion is that endovascular treatment can be safe and curative.

Gamma Knife radiosurgery for trigeminal neuralgia: the impact of magnetic resonance imaging–detected vascular impingement of the affected nerve

Object

Trigeminal neuralgia is believed to be related to vascular compression of the affected nerve. Radiosurgery has been shown to be reasonably effective for treatment of medically refractory trigeminal neuralgia. This study explores the rate of occurrence of MR imaging–demonstrated vascular impingement of the affected nerve and the extent to which vascular impingement affects pain relief in a population of trigeminal neuralgia patients undergoing Gamma Knife radiosurgery (GKRS).

Methods

The authors performed a retrospective analysis of 106 cases involving patients treated for typical trigeminal neuralgia using GKRS. Patients with or without single-vessel impingement on CISS MR imaging sequences and with no previous surgery were included in the study. Pain relief was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at the last follow-up. Degree of impingement, nerve diameter preand post-impingement, isocenter placement, and dose to the point of maximum impingement were evaluated in relation to the improvement of BNI score.

Results

The overall median follow-up period was 31 months. Overall, a BNI pain score of 1 was achieved in 59.4% of patients at last follow-up. Vessel impingement was seen in 63 patients (59%). There was no significant difference in pain relief between those with and without vascular impingement following GKRS (p > 0.05).

In those with vascular impingement on MR imaging, the median fraction of vessel impingement was 0.3 (range 0.04–0.59). The median dose to the site of maximum impingement was 42 Gy (range 2.9–79 Gy). Increased dose (p = 0.019) and closer proximity of the isocenter to the site of maximum vessel impingement (p = 0.012) correlated in a statistically significant fashion with improved BNI scores in those demonstrating vascular impingement on the GKRS planning MR imaging

Conclusions

Vascular impingement of the affected nerve was seen in the majority of patients with trigeminal neuralgia. Overall pain relief following GKRS was comparable in those with and without evidence of vascular compression on MR imaging. In subgroup analysis of those with MR imaging evidence of vessel impingement of the affected trigeminal nerve, pain relief correlated with a higher dose to the point of contact between the impinging vessel and the trigeminal nerve. Such a finding may point to vascular changes affording at least some degree of relief following GKRS for trigeminal neuralgia.

Microvascular decompression after failed Gamma Knife surgery for trigeminal neuralgia: a safe and effective rescue therapy?

Object

Stereotactic radiosurgical rhizolysis using Gamma Knife surgery (GKS) is an increasingly popular treatment for medically refractory trigeminal neuralgia. Because of the increasing use of GKS for trigeminal neuralgia, clinicians are faced with the problem of choosing a subsequent treatment plan if GKS fails. This study was conducted to identify whether microvascular decompression (MVD) is a safe and effective treatment for patients who experience trigeminal neuralgia symptoms after GKS.

Methods

From their records, the authors identified 29 consecutive patients who, over a 2-year period, underwent MVD following failed GKS. During MVD, data regarding thickened arachnoid, adhesions between vessels and the trigeminal nerve, and trigeminal nerve atrophy/discoloration were noted. Outcome and complication data were also recorded.

Results

The MVD procedure was completed in 28 patients (97%). Trigeminal nerve atrophy was noted in 14 patients (48%). A thickened arachnoid was noted in 1 patient (3%). Adhesions between vessels and the trigeminal nerve were noted in 6 patients (21%) and prevented MVD in 1 patient. At last follow-up, 15 patients (54%) reported an excellent outcome after MVD, 1 (4%) reported a good outcome, 2 (7%) reported a fair outcome, and 10 patients (36%) reported a poor outcome. After MVD, new or worsened facial numbness occurred in 6 patients (21%). Additionally, 3 patients (11%) developed new or worsened troubling dysesthesias.

Conclusions

Thickened arachnoid, adhesions between vessels and the trigeminal nerve, and trigeminal nerve atrophy/discoloration due to GKS did not prevent completion of MVD. An MVD is an appropriate and safe “rescue” therapy following GKS, although the risks of numbness and troubling dysesthesias appear to be higher than with MVD alone.

Endovascular treatment and radiographic follow-up of proximal traumatic intracranial aneurysms in adolescents: case series and review of the literature

PURPOSE

Traumatic intracranial aneurysms are rare lesions that are relatively more common in the pediatric population. Proximal traumatic aneurysms occur near the skull base. Direct surgical repair of these lesions is difficult due to the anatomically confined area, clinical status of a head injury patient, and the transmural nature of the injury. These lesions often lack a definable neck or wall suitable for clipping. While the indications and capabilities of endovascular treatment continue to expand, there are unanswered questions about the durability of treatment, especially in young patients. There are few reports examining the radiographic outcomes of endovascular treatment specifically for traumatic intracranial aneurysms. Therefore, we examined our experience treating these rare proximal lesions in an adolescent population.

METHODS

A retrospective review of prospectively collected data from 2000-2008 in a large, multidisciplinary neurovascular and trauma center was performed.

RESULTS

Three pediatric patients received endovascular treatment for traumatic intracranial aneurysms near the skull base. All patients had successful obliteration of their lesion without vessel sacrifice; however, two patients required multiple procedures for coil compaction or refilling of the aneurysm. There were no complications or ischemic events related to treatment. Follow-up imaging ranged from 6 months to 3.5 years.

CONCLUSIONS

Traumatic intracranial aneurysms at the skull base can be successfully treated with endovascular methods; however, close follow-up is necessary.

Stent-graft repair of a large cervical internal carotid artery pseudoaneurysm causing dysphagia

Pseudoaneurysms of the cervical internal carotid artery (ICA) are rare and most frequently result from trauma, infection, or sometimes spontaneously. They have the potential to cause life-threatening hemorrhage; thus, their immediate management is necessary. Endovascular treatment by stent graft placement in the affected artery appears to be a safe and effective treatment option. We present a case of a child who presented with neck swelling and dysphagia caused by a ruptured cervical ICA pseudoaneurysm which was managed by stent graft placement.