9. de Sousa AA, Dantas FL, de Cardoso GT, Costa BS: Distal ante- rior cerebral artery ... Hentschel S, Toyota B: Intracranial malignant glioma presenting.
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Endovascular management of traumatic and iatrogenic aneurysms of the pericallosal artery Report of two cases JOSÉ E. COHEN, M.D., GUSTAVO RAJZ, M.D., EYAL ITSHAYEK, M.D., YIGAL SHOSHAN, M.D., FELIX UMANSKY, M.D., AND JOHN M. GOMORI, M.D. Department of Neurosurgery and Department of Radiology, Section of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah Stroke Center, Hadassah University Hospital, Jerusalem, Israel √ 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.
KEY WORDS • traumatic aneurysm • pericallosal artery • endovascular therapy • tumor • complication
intracranial aneurysms are rare and constitute less than 1% of all aneurysms in large series. The real incidence of these lesions, however, is uncertain and the discovery of a traumatic intracranial aneurysm may depend on the timing of diagnostic angiography.1,6 Most peripherally located aneurysms are more often associated with a closed head injury than with a penetrating injury, but they may also be caused by an iatrogenic arterial injury.4 Traumatic intracranial aneurysms usually present with subarachnoid, intraparenchymal, subdural, or intraventricular hemorrhage. Infrequently, they can be diagnosed incidentally at routine follow-up examinations for penetrating head trauma.1,10 Surgical approaches to traumatic aneurysms are challenging. Because most traumatic intracranial aneurysms are not true aneurysms, clip placement without sacrifice of the parent artery may not be possible.3,10 Because nontraumatic saccular aneurysms of the pericallosal artery carry higher rates of surgery-related morbidity and mortality than other supratentorial aneurysms, endovascular techniques have also been considered a valuable alternative.9,14 We report our experience with primary coil placement in two cases of traumatic intracranial aneurysms of the periA with preservation of the parent arteries.
T
Case Reports
RAUMATIC
Abbreviations used in this paper: CT = computerized tomography; ICA = internal carotid artery; ICP = intracranial presence; PeriA = pericallosal artery.
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Case 1 Examination and Initial Treatment. This 17-year-old girl was admitted to the emergency department suffering from a penetrating head injury and multiple trauma, which she sustained in a terrorist bomb attack. On admission to our institution, the patient was intubated and in a coma (Glasgow Coma Scale Score 5); cranial CT scans demonstrated hemorrhagic signs of the penetrating injury in the frontal region (Fig. 1 left). A foreign body had entered through the left temporal lobe and crossed the midline in an ascending direction. Surgical debridement was performed at the orifice of the entry wound and a right-sided ventriculostomy was created for ICP monitoring. The patient’s neurological condition improved; she opened her eyes and obeyed simple commands with a dense right hemiparesis. A screening angiogram obtained 10 days after hospital admission revealed a small wide-necked right periA aneurysm (Fig. 1 center). Endovascular Procedure. The procedure was performed with the patient in a state of neuroleptic anesthesia. At the start of the procedure, the patient received a heparin bolus (6000 IU). A No. 6 French guiding catheter (Guider Softip; Boston Scientific Corp., Natick, MA) was placed on the left cervical ICA. Selective angiography was performed and the targeted periA segment was outlined in multiple projections 555
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FIG. 1. Case 1. Left: A CT scan of the head revealing the frontal hemorrhagic track of the penetrating missile and an intraventricular hemorrhage. Center: Right ICA angiogram, anteroposterior view, demonstrating a small right periA aneurysm. Right: Unsubtructed angiogram depicting coil placement.
by performing rotational three-dimensional angiography. The diameter of the aneurysm measured 1.5 mm and the lesion had a wide neck; the diameter of the parent vessel was 0.8 mm. An Excel microcatheter (Boston Scientific Corp.) covering a tapered 0.014-in guidewire (Transend; Boston Scientific Corp.) was used selectively to microcatheterize the aneurysm lumen. A 2 3 1.5–mm soft helical coil (Micrus Corp., Mountain View, CA) was placed in the aneurysm, occluding the lesion and preserving the patency of the parent vessel (Fig. 1 right). Posttreatment Course. After a 12-month convalescence, the patient returned to her university studies with minor residual paresis in her right arm. Case 2 History. This 35-year-old woman was admitted to the
FIG. 2. Case 2. Upper Left: A CT scan revealing left frontal and biventricular rebleeding. Upper Right: Left ICA angiogram revealing a left periA false aneurysm. Lower Left: Angiogram depicting endosaccular microcatheterization and coil placement. Lower Right: Angiogram demonstrating complete aneurysm occlusion.
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neurosurgery department with a history of progressive cognitive deterioration and behavioral disturbances. Contrastenhanced CT and magnetic resonance images of her head revealed a right frontal intraaxial mass with considerable mass effect, which were diagnostically compatible with a glioblastoma multiforme. Macroscopic resection was performed with the assistance of intraoperative neuronavigation. Symptoms and Examination. On the 2nd postoperative day, the patient’s condition suddenly deteriorated and she required repeated intubation. A CT scan of the head revealed a delayed postoperative intraventricular hemorrhage. An ICP monitoring system was placed. After 12 hours, a sudden increase in ICP motivated her caregivers to obtain a follow-up CT scan, which disclosed an acute episode of rebleeding (Fig. 2 upper left). A diagnostic angiogram revealed a left periA pseudoaneurysm (Fig. 2 upper right). Endovascular Procedure. The procedure was performed with the patient in a state of general anesthesia. At the start of the procedure, she received a heparin bolus (8000 IU). A No. 6 French guiding catheter (Guider Softip; Boston Scientific Corp.) was positioned on the left cervical ICA. Selective angiography was performed and the targeted periA segment was outlined in multiple projections. The diameter of the aneurysm measured 11 mm and the lesion had a wide neck; the diameter of the parent vessel was 1.1 mm. An Excel microcatheter (Boston Scientific Corp.) covering a tapered 0.014-in guidewire (Transend; Boston Scientific Corp.) was used selectively to catheterize the aneurysm lumen. Seven helical coils (Micrus Corp.) were placed in the aneurysm, occluding the lesion and preserving the patency of the parent vessel (Fig. 2 lower). Postoperative Course. One year later the patient died of recurrent glioblastoma multiforme. Discussion After a patient has sustained a closed head injury the periA is prone to formation of a traumatic aneurysm due to its close relationship to the free edge of the falx cerebri.8 Less frequently, a direct penetrating vascular injury is caused by projectiles or iatrogenically, as seen in the cases we present in this article.4 Missile head wounds that J. Neurosurg. / Volume 102 / March, 2005
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Traumatic pericallosal aneurysms penetrate temporal areas, cause intracerebral hematomas, or cross the midline have a significant chance of producing a traumatic aneurysm.2 Case 1 illustrates an example of a penetrating missile that entered the temporal region and crossed the midline, producing a true periA traumatic aneurysm. True aneurysms caused by partial disruption of the arterial wall occur infrequently. Vessel wall fragility and a very small aneurysm size (, 2 mm) are risk factors for sac perforation during endovascular therapy. Pericallosal aneurysm microcatheterization may be performed by advancing the microguidewire distal to the aneurysm while placing the preshaped microcatheter tip in front of the aneurysm opening and then removing the guidewire. In Case 1 we describe a patient with a right hemiparesis (left temporofrontal contusion) and a right periA aneurysm. In this situation preservation of the patency of the right periA was crucial to avoid paraparesis. Gliomas are associated with a significant rate of hemorrhage; bleeding is almost exclusively intraparenchymal, and rarely extends to the subarachnoid space.5,11 Postoperative hemorrhage is a well-known but serious complication of glioma resection and usually occurs at the site of the operation. When significant subarachnoid hemorrhage coexists with intraparenchymal bleeding, cerebral angiography is mandatory to rule out an iatrogenic traumatic aneurysm. Case 2 illustrates a traumatic false aneurysm of iatrogenic origin. Most traumatic aneurysms can be designated false aneurysms caused by a full-thickness arterial tear and are associated with high bleeding and rebleeding rates.16 Traumatic aneurysms represent a surgical challenge due to unusual locations, thin walls, and poorly defined necks in a frequently unfavorable clinical scenario and in the context of multiple cerebral lesions and scarring from trauma or previous surgery. When dealing with a traumatic intracranial aneurysm, clip placement may not be possible and thus trapping or excision of the aneurysm has become the accepted technique.7,12,13,18 Because aneurysms located at the distal anterior cerebral artery have higher rates of surgeryrelated morbidity and mortality than other supratentorial aneurysms,9 endovascular parent vessel occlusion and endosaccular coil placement have emerged as valid therapeutic alternatives.14,15,17 The endovascular route makes use of blood vessels as pathways to the aneurysm, providing a less invasive approach than open surgery. This technique avoids craniotomy, brain retraction, surgical vessel manipulation, and postoperative infection and epilepsy. It is becoming especially useful in the management of complex clinical conditions in patients presenting with traumatic aneurysms. The goal of endovascular therapy is to achieve complete aneurysm occlusion with parent artery preservation. Nevertheless, this goal is dependent on the anatomical characteristics of the aneurysm (that is, a high dome/neck ratio without incorporation of the parent vessel). Although new techniques permit the treatment of wider-necked aneurysms—that is, balloon- and stent-assisted coiling—these are not appropriate for the pericallosal location. The endovascular approach for pericallosal aneurysms remains difficult because of the distal aneurysm location, the small size of the lesion, the fragility of the aneurysm wall, and the reduced caliber of the lumen of the parent vessel (minimal coil protrusion may completely occlude the periA). Although current treatment options for peripherally lo-
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cated traumatic aneurysms involve endovascular occlusion of the parent artery, in selected cases primary coil placement may provide exclusion of the aneurysm with preservation of the parent vessel. References 1. Aarabi B: Management of traumatic aneurysms caused by highvelocity missile head wounds. Neurosurg Clin N Am 6: 775–797, 1995 2. Aarabi B: Traumatic aneurysms of brain due to high velocity missile head wounds. Neurosurgery 22:1056–1063, 1988 3. Amirjamshidi A, Rahmat H, Abbassioun K: Traumatic aneurysms and arteriovenous fistulas of intracranial vessels associated with penetrating head injuries occurring during war: principles and pitfalls in diagnosis and management. A survey of 31 cases and review of the literature. J Neurosurg 84:769–780, 1996 4. Asari S, Nakamura S, Yamada O, Beck H, Sugatani H: Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg 46:795–803, 1977 5. Batjer H, Kopitnik TA, Friberg L: Spontaneous intracerebral and intracerebellar hemorrhage, in Youmans J (ed): Youmans’ Neurological Surgery. Philadelphia: WB Saunders, 1997 6. Benoit BG, Wortzman G: Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 36: 127–138, 1973 7. Buckingham M, Crone KR, Ball WS, Tomsick TA, Berger TS, Tew JM Jr: Traumatic intracranial aneurysms in childhood: two cases and a review of the literature. Neurosurgery 22:398–408, 1988 8. Casey AT, Moore AJ: A traumatic giant posterior cerebral artery aneurysm mimicking a tentorial edge meningioma. Br J Neurosurg 8:97–99, 1994 9. de Sousa AA, Dantas FL, de Cardoso GT, Costa BS: Distal anterior cerebral artery aneurysms. Surg Neurol 52:128–136, 1999 10. Haddad FS, Haddad GF, Taha J: Traumatic intracranial aneurysms caused by missiles: their presentation and management. Neurosurgery 28:1–7, 1991 11. Hentschel S, Toyota B: Intracranial malignant glioma presenting as subarachnoid hemorrhage. Can J Neurol Sci 30:63–66, 2003 12. Holmes B, Harbaugh RE: Traumatic intracranial aneurysms: a contemporary review. J Trauma 35:855–860, 1993 13. Horowitz MB, Kopitnik TA, Landreneau F, Ramnani DM, Rushing EJ, George E, et al: Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds. Surg Neurol 51:31–42, 1999 14. Menovsky T, van Rooij WJ, Sluzewsky M, Wijnalda D: Coiling of ruptured pericallosal artery aneurysms. Neurosurgery 50: 11–15, 2002 15. Pierot L, Boulin A, Castaings L, Rey A, Moret J: Endovascular treatment of pericallosal artery aneurysms. Neurol Res 18:49–53, 1996 16. Soria ED, Paroski MW, Schamann ME: Traumatic aneurysms of cerebral vessels: a case study and review of the literature. Angiology 39:609–615, 1988 17. Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC, et al: Traumatic intracranial carotid tree aneurysms. Neurosurgery 43:1314–1322, 1998 18. Ventureyra EC, Higgins MJ: Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature. Childs Nerv Syst 10:361–379, 1994 Manuscript received June 13, 2004. Accepted in final form October 4, 2004. Address reprint requests to: José E. Cohen, M.D., Kiryat Hadassah, P.O. Box 12000, 91120 Jerusalem, Israel. email: jcohenns@ yahoo.com.
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