Traumatic Intracranial Aneurysms Research Articles

Multiple Traumatic Intracranial Aneurysms Presenting as a Subacute Hemorrhagic Mass Lesion 14 Years After Trauma

Cohen, Jose E. MD, PhD; Grigoriadis, Savvas MD, PhD; Gomori, John Moshe MD, PhD Author Information

Delayed post-traumatic saccular aneurysm of PICA in an adolescent

Delayed traumatic intracranial aneurysms of the posterior circulation caused by nonpenetrating head injury are rare, especially in pediatric patients. The true incidence and natural history of these aneurysms are poorly understood. We report a case of a 15-year-old boy who initially presented with subarachnoid hemorrhage of the posterior fossa without any evidence of associated aneurysm. On a routine computed tomography of the head, however, he was found to have a saccular aneurysm of the proximal posterior inferior cerebellar artery. The patient was treated successfully by microsurgical clipping and PICA/PICA bypass.

RESULTS OF ENDOVASCULAR TREATMENT OF TRAUMATIC INTRACRANIAL ANEURYSMS

To present results of early angiographic diagnosis and endovascular treatment of traumatic intracranial aneurysms (TICA). From June 2002 to December 2006, diagnostic angiography was performed on patients with moderate to severe traumatic brain injury that involved a cranial base fracture or a penetrating brain injury with a tract from the penetrating agent that entered at the pterional area, went through the middle cerebral artery candelabra, and crossed the midline. TICAs were treated by various endovascular techniques during the same angiographic procedure. Thirty-four patients with traumatic brain injury underwent angiography (25 penetrating brain injuries, nine blunt injuries); 13 TICAs were diagnosed (10 penetrating brain injuries, three blunt injuries). The Glasgow Coma Scale score at diagnosis ranged from 5 to 15. Angiography was performed for screening in eight patients and for clinical indications in five patients; 11 TICAs were diagnosed before rupture. Seven aneurysms were located on branches of the middle cerebral artery, two on pericallosal branches of the anterior cerebral artery, and four on the internal carotid artery. No recanalization was detected in 12 patients. One patient treated with a bare stent and coiling had a growing intracavernous pseudoaneurysm; therefore, internal carotid artery occlusion with extracranial-intracranial microvascular bypass was performed. Six patients refused angiographic follow-up, but computed tomographic angiography has failed to show recanalization. No patient presented with delayed bleeding (mean follow-up, 2.6 yr). There were no procedure-related complications or mortality. Early angiographic diagnosis with immediate endovascular treatment provided an effective approach for TICA detection and management. Endovascular therapy is versatile and offers a valuable alternative to surgery, allowing early aneurysm exclusion with excellent results.

P 476] Results of Endovascular Treatment of Traumatic Intracranial Aneurysms

p 476] Results of Endovascular Treatment of Traumatic Intracranial Aneurysms

Interventional radiology in the treatment of intracranial vascular injuries and fistulae

Traumatic intracranial vascular injuries are uncommon. However prompt diagnosis and management is essential because of the high morbidity and mortality associated with these conditions. The imaging evaluation and potential endovascular management of traumatic intracranial aneurysms and traumatic intracranial fistulae is discussed.

Traumatic intracranial aneurysms after gunshot injuries. Anaesthetic and endovascular management may be a prompt safe-to-use technique and a valuable option: about two cases reports

Departement of Anaesthesia, Groupement Hospitalier Est, Hôpital Neurologique P. Wertheimer, Bron, France

Traumatic middle cerebral artery aneurysm: case report and review of the literature

Traumatic intracranial aneurysms are rare. A case of traumatic middle cerebral artery aneurysm was presented. A 66-year-old man sustained a severe head injury in a bicycle accident. Serial computed tomography and angiography showed the delayed intracerebral hemorrhage caused by the traumatic middle cerebral artery aneurysm. The aneurysm was trapped and removed. Histological examination clearly revealed the pseudoaneurysm. Traumatic middle cerebral aneurysms were reviewed.

Traumatic pericallosal artery aneurysm: a rare complication of transcallosal surgery

Traumatic intracranial aneurysms are rare in adults but account for up to 33% of all aneurysms encountered in a pediatric population. The most common location of such lesions in children is the pericallosal or adjacent branch of the anterior cerebral artery, where a head impact exerts sudden decelerating shearing forces on the arteries tethered on the brain surface against an immobile falx cerebri, weakening the arterial wall. This action can lead to dissection of the damaged vascular layers, with resultant expansion of the affected site into a fusiform aneurysm. Pericallosal aneurysms following a penetrating intracranial injury have also been described, and the resultant lesion in some cases can be a pseudoaneurysm. The incidence of iatrogenic pericallosal artery aneurysms, however, is extremely rare. The authors describe the first reported case of a traumatic pericallosal artery aneurysm following transcallosal surgery. This 6-year-old boy underwent resection of a hypothalamic pilocytic astrocytoma, which was approached via the transcallosal corridor. A follow-up magnetic resonance image obtained within 1 year of surgery disclosed a small flow void off the right pericallosal artery, which was initially interpreted as residual tumor. Serial investigations showed the lesion enlarging over time, and subsequent angiography revealed a round 7-mm pericallosal artery aneurysm with an irregularly shaped 2- to 3-mm lumen. The aneurysm was difficult to treat with clip reconstruction or suturing of the affected segment, and an excellent outcome was ultimately achieved with resection of the lesion and autogenous arterial graft interposition. The authors also discuss the likely pathophysiology of the aneurysm and the surgical procedures undertaken to treat it.

Delayed rupture of traumatic aneurysm after civilian craniocerebral gunshot injury in children

There are few published large series on civilian craniocerebral gunshot injuries in children. Traumatic intracranial aneurysms (TICAs) are rare and highly unstable lesions. They represent less than 1% of all aneurysms and can either rupture within minutes after formation or remain quiescent for several weeks or years, manifesting with delayed hemorrhage and neurologic deterioration. We report the case of a 10-year-old girl who was referred for coma after high-velocity craniocerebral gunshot wound and neurological deterioration 7 days after the initial injury. A massive right posterior occipital hematoma caused by the rupture of an unsuspected right posterior cerebral artery TICA was discovered. TICA was treated by coil embolization, with a good neurological recovery at 6-month follow-up. We discuss the pathogenesis and the management of TICA in a child after civilian craniocerebral gunshot injuries. TICAs should be suspected in patients with civilian craniocerebral gunshot injuries, presenting with secondary neurological deterioration, to carry out emergent CT scan and angiographic exploration before contemplating definitive endovascular treatment. Endovascular management may be a prompt safe-to-use technique and a valuable option, especially when surgery is highly risky.

Endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery

Traumatic intracranial aneurysms are rare complications of closed and penetrating head injuries and may also be related to a variety of neurosurgical procedures. The primary goals in the treatment of patients harboring these lesions are early identification and intervention to prevent bleeding. Traumatic aneurysms are fragile, prone to rupture, and represent a challenging subset of vascular lesions for either surgery or endovascular therapy. Surgical approaches to aneurysms located at the pericallosal arteries are associated with higher rates of morbidity and mortality than approaches to other supratentorial aneurysms. Current endovascular treatment most often involves occlusion of the parent artery with the potential of added morbidity. The authors present their experience in the endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery achieved by primary coil embolization with parent vessel preservation. For patients harboring traumatic pericallosal aneurysms with favorable anatomical characteristics, in which the morbidity caused by parent vessel occlusion is not acceptable, endosaccular coil placement may be a valuable option.

Clinical Experiences of Traumatic Intracranial Aneurysms

Clinical Experiences of Traumatic Intracranial Aneurysms

806 Penetrating Head Injuries from Terrorist Bomb Blasts: The Jerusalem Experience

INTRODUCTION: From December 2000 to March 2004, we treated 24 patients with penetrating head injuries caused by terrorist bomb blasts. A variety of objects are placed in these bombs to maximize tissue damage and penetrate the cranium, including ball bearings, metal bolts, hexagonal nuts, segments of metal rods, and nails. METHODS: Data on consective injured patients were collected prospectively. Three patients presented with a Glasgow Coma Scale (GCS) score of between 3 and 5, six patients with a GCS score of 6 to 9, four patients with a GCS score of 10 to 12, and 11 patients with a GCS score of 13 to 15. Fifteen patients underwent craniotomy, ventriculostomy, intracranial pressure (ICP) monitoring, or a combination immediately after injury. RESULTS: Of the 13 patients who underwent ICP monitoring, the mean ICP at insertion was 20.3 mm Hg, with a range of 8 to 30 mm Hg. The peak ICP in these patients was 33.5 mm Hg and ranged from 12 to 70 mm Hg. Of the patients who did not obey commands at presentation, the mean time to return to consciousness was 5.4 days (range, 2–12 d). Three patients died, and 21 survived. At a mean follow-up of 18.2 months (range, 2–28 mo), 14 surviving patients achieved a GOS score of 5, six a GOS score of 4, and one patient had a GOS score of 3. Two patients developed a traumatic intracranial aneurysm, and two patients had documented migration of a metallic fragment within the brain. One patient developed a fatal ventriculitis. Four patients underwent delayed removal of a metallic fragment with the aid of an image-guided surgical navigation system with good results. CONCLUSION: Patients with penetrating head injuries from bomb blasts can achieve good functional outcomes. Complications including infection, traumatic intracranial aneurysm, and migration of fragments must be anticipated and treated aggressively. In a subgroup of patients, delayed removal of metallic fragments may be warranted.

Endovascular Treatment of Traumatic Intracranial Aneurysm in an Infant

Traumatic intracranial aneurysms in children are rare and mostly related to skull fracture or rapid decelerating closed head injury.We report the case of an infant who developed intracranial aneurysm after minor head trauma and managed by endovascular treatment. A seven-month-old infant presented with delayed intracranial hemorrhage following minor head trauma. Cerebral angiography disclosed a multilobulated fusiform aneurysm involving the right anterior cerebral artery (ACA) distal to the anterior communicating artery. Endovascular treatment of the aneurysm was performed and the infant made an excellent recovery during six months clinical and radiological follow-up. Delayed presentation of intracranial hemorrhage with acute deterioration in the infant after head trauma warrants angiography for proper diagnosis and management of the traumatic aneurysm, which has a high mortality rate after rupture and rebleeding. Endovascular treatment of traumatic aneurysm is feasible in infants, and occlusion of distal intracranial arterial aneurysms can be safely and precisely achieved using current coil technology.

Traumatic Intracranial Aneurysms in Children

Purpose: To describe the imaging findings of traumatic intracranial aneurysms (TICA) in children. Materials and Methods: Five boys aged 3-15 (mean, 7) years with surgically confirmed TICA were included in this study. All had a history of nonpenetrating head trauma, and they underwent precontrast CT imaging immediately after the injury and follow-up CT or MRI. In all cases, angiography revealed the presence of aneurysms, which at surgery were shown to be pseudoaneurysms with severe adhesions. Results: Angiography demonstrated that all aneurysms were located in the anterior cerebral artery (ACA) or its branches. The precise locations were the A2 segment of the ACA, the site of origin of the callosomarginal artery or its first branch, or of the anterior internal frontal artery, or between the first and second branch of the pericallosal artery. In all patients, precontrast CT performed immediately after trauma depicted subarachnoid hemorrhage (SAH) in the anterior interhemispheric fissure (AIHF). Follow-up precontrast CT showed nodular high density around the anterior falx in three, recurrent SAH in the AIHF in two, and intracerebral hemorrhage (ICH) with intraventricular hemorrhage in two. In two patients with a nodular high-density lesion, nodular enhancement was demonstrated at postcontrast CT, and in one, follow-up MRI revealed a nodular signal void around the anterior falx; nodular enhancement was seen at postcontrast imaging, and MR angiogram depicted a saccular aneurysm. In one patient, MRI demonstrated infarction in the caudate nucleus and ACA territory. Conclusion: If, after head injury, an area of nodular high density is revealed by CT, or a signal void by MRI, or if SAH or ICH is present around the anterior falx, the possibility of TICA should be considered.

Traumatic intracranial aneurysm after blunt trauma

Traumatic intracranial aneurysms are rare and represent less than 1% of all cerebral aneurysms. This type of aneurysm develops after blunt or penetrating head trauma. Surgical clipping and/or endovascular occlusion are the definitive treatments. This report describes the very unusual case of a patient who has survived for 2 years with conservative management alone.

Traumatic intracranial aneurysm in infancy

An anterior cerebral artery traumatic aneurysm in a 15-month-old infant is described. The diagnosis was confirmed by computed tomographic angiography. The patient recovered fully after successful clipping of the aneurysm. As the signs of traumatic intracranial aneurysm may be subtle especially in young children, a high degree of suspicion is essential in patients presenting with delayed neurological deterioration after head trauma.

Traumatic intracranial aneurysms

Traumatic intracranial aneurysms are rare, occurring in fewer than 1% of patients with cerebral aneurysms. They can occur following blunt or penetrating head trauma and are more common in the pediatric population. Traumatic aneurysms can be categorized histologically as true, false, or mixed, with false aneurysms being the most common. These aneurysms can present in a variety of ways, but are typically associated with an acute episode of delayed intracranial hemorrhage with an average time from initial trauma to aneurysm hemorrhage of approximately 21 days. The mortality rate for patients harboring these aneurysms may be as high as 50%. Prompt diagnosis based on arteriography and aggressive surgical management are associated with better outcome than conservative treatment. The authors describe a classification scheme for traumatic aneurysms based on their anatomical location and conclude that 1) posttraumatic aneurysm must be considered in patients with acute neurological deterioration following closed head injury; 2) they can occur following mild closed head injury; 3) they occur more commonly in children than in adults; and 4) surgical clipping and/or endovascular occlusion is the definitive treatment.

Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds

BACKGROUND Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects. METHODS We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly. RESULTS All patients had successful obliteration of their lesions using a variety of therapeutic modalities aimed at preserving neurologic function while at the same time eliminating the aneurysm from the circulation. CONCLUSION Both microneurosurgery and endovascular surgery have important roles to play in the management of TICAs. In some cases, both methods can be combined to eliminate lesions and maximize patient recovery in a safe, efficient, and effective fashion.

Aneurysmal Disease in Children

Twenty children (13 males, 7 females), referred to our group with non traumatic intracranial aneurysms between 1978 and January 1997, were included in this study. Their angiograms were reviewed to assess number, location, type of aneurysms and evolution before and after treatment. Their ages ranged from 1 month to 15 years. Seven patients (35%) presented with subarachnoid haemorrhage (SAH). Eleven patients (55%) presented with focal neurological deficits or seizures: epileptic seizures occurred in five patients, neurologic deficits or focal symptoms due to mass effect occurred in six. Total number of diagnosed intracranial aneurysms was 24. The most common sites involved were internal carotid (37%) and vertebrobasilar (32%) systems. The aetiology of the aneurysms was infective in four patients and unknown in the remaining 16 patients (80%). Endovascular treatment was successful in seven patients (37%). Three patients (15%) were surgically treated. Seven patients (35%) were conservatively treated. Two patients (10%) had spontaneous thrombosis of the aneurysm. SAH was more frequent in males, and never occurred in children under five years old. Frequent presentations such as focal symptoms or mass effect and less prevalence of aneurysm rupture are probably due to the high prevalence of large or giant aneurysms (25%) in our series. In conclusion, radiological findings and the natural history of symptomatic arterial aneurysms in children are clearly different from those in adults. Probably pathogenetic factors and aetiology are also different. Shear stresses, haemodynamic and hormonal factors do not appear to be dominant to reveal such defects, though their correction favours repair. Since repair is frequent, conservative treatment has a major role in their aneurysm management.

Pediatric traumatic intracranial aneurysms.

During the past 17 years, 7 children have been treated at Children's Hospital Los Angeles (CHLA) for traumatic intracranial aneurysms. These patients presented with subarachnoid or intraparenchymal hemorrhage (5 cases), growing fracture (1 case), and behavioral change (1 case). All patients were managed with surgery, and no patient died or was made neurologically worse as a result of such management. The existence of a traumatic aneurysm should be considered when new neurological symptoms develop in a patient with a history of head injury.