Intracerebral Vascular Rupture

Abstract

In the past several years, most patients with severe head trauma at our hospital have been studied with emergency cerebral angiography. Recently, we have seen two cases of intracerebral vascular rupture associated with severe head trauma. Because of the rare nature of this occurrence, it was thought that a brief report was indicated. Case Histories Case I: T. B., a 60-year-old male, was admitted to the Boston City Hospital in coma. Multiple bruises about the head and neck suggested that he had sustained recent trauma. Neurological examination disclosed flaccid paralysis of all four extremities and a dilated fixed left pupil. Plain skull films were normal. Radiologic Findings: An emergency left common carotid angiogram (Fig. 1) taken two hours after admission showed cerebral herniation underneath the falx. The middle cerebral artery was medially displaced, and a crescentic avascular extracerebral collection, measuring 2 cm in width, was apparent over the convexity. Over the frontal operculum, above the midportion of the insula, a 7-mm round collection of contrast material was noted. This persisted for six seconds and disappeared in the late venous phase. Surgery: A large acute subdural hematoma was found. In the area of the angiographically noted “pseudoaneurysm” there was a tear in the arachnoidal meninges and a rupture of a medium-sized branch of the ascending frontoparietal group. A clot was adherent to the tear of the vessel. As the clot was removed, active bleeding was noted. Comment: This is an example of severe head trauma with rupture of one of the branches of the middle cerebral artery as well as a tear of the meninges. The blood in the subdural space in this case was felt to originate predominantly from the torn vessel with extravasation through the arachnoidal tear. Case II: P. C., an unidentified middle-aged male was brought to the emergency room in coma. No history was obtainable, but it appeared that he had recently been severely beaten about the head and neck. There were multiple fractures of the ribs and both lower extremities. The head was swollen, and the patient was bleeding into the soft tissues of the neck and scalp. Several units of blood replacement were required for profuse hemorrhage from the nasopharynx. Neurological examination disclosed the patient to be completely unresponsive, with fixed pupils and no localizing signs. Skull roentgenograms disclosed multiple linear fractures. Radiologic Findings: An emergency right brachial angiogram (Fig. 2) taken eight hours after admission showed normal vertebral and extracranial carotid vessels. There was marked herniation underneath the falx. The middle meningeal artery was markedly displaced inward in its low convexity at the level of the floor and lateral boundary of the middle cranial fossa. The middle cerebral artery was markedly elevated. The anterior choroidal artery approximated the midline, indicating severe uncal herniation.