Traumatic Distal Anterior Cerebral Artery Aneurysms - Pathomechanism and Revascularisation Strategies.

Traumatic intracranial aneurysms (TICA) of the distal anterior cerebral artery (dACA) are exceptionally rare and display therapeutic challenges due to their angioanatomical characteristics. The objective of this work was to discuss the mechanisms of TICA formation of the dACA and to elucidate the best treatment and revascularization strategies in these patients based on two illustrative cases. Case 1: 20-year-old patient with a traumatic, partially thrombosed 14 × 10 mm aneurysm of the right pericallosal artery (rPericA), distal to the origin of the right callosomarginal artery (rCMA). Complete trapping of the right dissection A3 aneurysm and flow replacement extra-to-intracranial (EC-IC) bypass (STA - radial artery - A4) was performed. Case 2: 16-year-old patient with a traumatic polylobulated, partially thrombosed 16 × 10 mm aneurysm of the rPericA. Microsurgical excision of the A3- segment harboring the aneurysm and flow replacement intra-to-intracranial (IC-IC) bypass via reimplantation of the right remaining PericA on the contralateral PericA (end-to-side anastomosis) was performed (in situ bypass). TICA of the dACA are exceptionally rare. Mechanical vessel wall injury and aneurysm formation of the dACA in blunt head trauma is very likely due to the proximity of the dACA with the rigid free edge of the falx. Given their nature as dissecting (complex) aneurysm, trapping and revascularization is a very important strategy. The interhemispheric cistern offers multiple revascularization options with its numerous donor vessels. The IC-IC bypass is often the simplest revascularization construct.

Fatal subarachnoid hemorrhage caused by rupture of variant anterior communicating artery: a case report and literature review.

Fatal subarachnoid hemorrhage (SAH) caused by anterior communicating artery (ACoA) rupture is a rare event in medicolegal practice. Anatomical variations of the ACoA tend to make its anatomical structure, and as a result, blood flow through it, more complicated, which may increase hemodynamic stress and cause weak spots in the affected blood vessels. Variant ACoAs are prone to rupture in the event of a blunt-force trauma. Here, we report a fatal case of SAH caused by the rupture of a variant ACoA when the victim's head was struck from behind, causing the head to rotate and the victim to fall forward onto the ground. A medicolegal autopsy revealed diffuse basal SAH and ACoA duplication. The smaller of the two variant ACoA branches had ruptured near its junction with the right anterior cerebral artery. No basal aneurysms or other fatal diseases or injuries were found. This case highlights the significance of anatomical variation in forensic pathology.

[Traumatic intracranial aneurysm secondary to a bullet wound. Clinical case and a review of the literature]. / Aneurisma intracraneal traumático secundario a un trauma balístico. Caso clínico y revisión de la literatura.

Traumatic intracranial aneurysms (AICT) are rare and are associated with high morbidity and mortality. AICT are the result of head injuries caused by accidents, explosions, and gunfire. The case is reported here of a 28 year old man who was admitted to our hospital after suffering a penetrating head injury caused by a bullet. Radiographic studies showed interhemispheric subarachnoid haemorrhage and a likely AICT image that initially went unnoticed. One week later he underwent a cerebral angiography which showed a bilateral vasospasm of the terminal portion of the internal carotid and the appearance of a 2mm fusiform AICT at the orbit-frontal branch of the anterior cerebral artery. This was surgically treated after an aneurismal growth of 3.4mm and failure of the endovascular treatment. The patient showed a favourable outcome after surgery.

Traumatic rupture of the circle of Willis with closed head injury: Its pathology and possible pathogenesis.

Massive and fatal subarachnoid hemorrhage (SAH) with an injury on the circle of Willis may be caused by blunt force to the head; however, it is extremely rare, and the precise mechanism of arterial rupture remains unclear. We investigated the clinicopathologic appearance of four rare autopsy cases of massive SAH associated with the rupture of the circle of Willis. All four cases were men aged 17-75 years who presented with a loss of consciousness within a short interval after the injury. Autopsy revealed that the rupture site was located in the vertebral artery in two cases and in the anterior cerebral artery (ACA) in two cases. During our literature review, we found no previous report on traumatic ACA rupture. Based on the correlation of the autopsy findings and the circumstance of injury, we determined that the accidental excessive stretching of the selected artery by neck anteflexion or rotation after a blunt trauma to the posterior head might have caused this rare lethal injury. These cases demonstrated the diversity of the traumatic rupture site of the circle of Willis after a blunt head and/or neck injury. The topographical features of the circle of Willis, particularly in correlation with the surrounding tissue, might account for the occurrence and site of these rare injuries.

Rescue balloon-assisted remodeling technique for protrusion of coil loop: A case report.

RATIONALE: Among the possible complications during endovascular embolization of intracranial aneurysms, coil protrusion into the parent artery is associated with parent artery occlusion or thromboembolic of the distal arteries. There is no clearly established management strategy for coil protrusion. This report demonstrates our experience with balloon-assisted remodeling to reposition a protruded coil loop. PATIENT CONCERNS: A 53-year-old man was admitted to our hospital with severe bursting headache, nausea, and vomiting. Computed tomography showed subarachnoid hemorrhage and digital subtraction angiography revealed an anterior communicating artery aneurysm. We decided to obliterate the aneurysm with endovascular embolization using detachable coils. DIAGNOSIS: A small loop protruded into the parent artery during the removal of the microcatheter. INTERVENTIONS: We performed successful repositioning of the protruded coil loop using balloon inflation. CONCLUSION: The rescue balloon-assisted remodeling technique was useful in the management of protrusion of a small coil loop into the parent artery during endovascular coil embolization of an intracranial aneurysm. The procedure was associated with minimal complications.

Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience.

BACKGROUND: Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns. METHODS: Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up. RESULTS: Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours. CONCLUSIONS: CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

Treatment of traumatic intracranial aneurysm: Experiences at a single center.

OBJECTIVE: To report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China. PATIENTS AND METHODS: All patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998. RESULTS: A total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture. CONCLUSION: Although the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.

An atypical case of head trauma with late onset of contrecoup epidural hematoma, cerebellar contusion, and cerebral infarction in the territory of the recurrent artery of Heubner.

We encountered a case of head trauma with very unusual delayed events. A 68-year-old woman was admitted to our hospital after receiving a direct impact to her occiput in a traffic accident. Head CT scans showed a thin acute epidural hematoma in the posterior fossa corresponding to a linear fracture, followed by late onset of contrecoup left frontal epidural hematoma and subsequent cerebellar contusion in the right cerebellar hemisphere. Fifteen days after the trauma, the patient developed mild motor weakness of right upper extremity. MRIs demonstrated an infarct in the territory of the left recurrent artery of Heubner. Although rare, atypical late events in patients with head trauma as reported here should be taken into consideration during subacute follow-up periods.

Anterior Cerebral Artery Rupture During Extended Endoscopic Endonasal Transsphenoidal Approach for Severely Calcified Craniopharyngioma.

BACKGROUND: This report discusses the risks and complications of using the extended endoscopic endonasal transsphenoidal approach (EEETA) in a special craniopharyngioma case to caution neurosurgeons. CASE DESCRIPTION: A 38-year-old woman with craniopharyngioma underwent EEETA surgery. Her anterior cerebral artery was punctured intraoperatively and clipped using an aneurysm clip through the nose in an emergency procedure. CONCLUSIONS: The coexistence of severe calcified craniopharyngiomas, especially with sharp calcified spurs, a narrow distance between the anterior communicating artery and the planum sphenoidale, and a narrow distance between the bilateral internal carotid arteries is a significant warning signal during EEETA for craniopharyngiomas. In this circumstance, it may be preferable to use open microsurgical approaches. If the anterior communicating artery or anterior cerebral artery is punctured during EEETA, another method is available to fix the problem using an aneurysm clip through the nose, and not only endovascular embolization.

Death related to nasal surgery: case report with review of therapy-related deaths.

The investigation of deaths that are suspected to be related to medical therapy present several challenges for the forensic pathologist. In all such cases, it is important for the pathologist to understand the therapy/procedure that may have played a role in death. As such, review of medical records and possible consultation with various medical specialists before autopsy can provide valuable information to ensure proper evaluation in any given case.Herein, we describe a rare death occurring as a complication of septoplasty, nasal polypectomy, and intranasal endoscopic ethmoidectomy, which are common surgical procedures performed by otolaryngology/head and neck surgeons. An otherwise healthy 58-year-old woman underwent the elective surgical procedures for a deviated nasal septum, multiple nasal polyps, and chronic ethmoid sinusitis. Following surgery, the patient never awoke from general anesthesia, and further evaluation before death revealed a basilar subarachnoid hemorrhage. Autopsy disclosed basilar subarachnoid hemorrhage, a traumatic defect of the right cribiform plate, and associated anterior cerebral artery injury with frontal lobe damage. No vascular anomalies were present. The cause of death was attributed to complications related to nasal surgery, and the manner of death was ruled "accident."Following the presentation of this case, the authors discuss these common nasal surgical procedures, including a summary of their known complications. In addition, the authors address and review the topic of deaths related to medical therapy.

In vitro testing of current spread during ventricular catheter coagulation using diathermy. Technical note.

The authors report on the development of an anterior cerebral artery pseudoaneurysm that hemorrhaged after monopolar coagulation for a ventricular catheter lodged in the interhemispheric fissure. After observing this complication, the authors developed a simple bench test that can be performed by any neurosurgeon to determine the safest coagulation parameters for any given diathermy unit. A modified grounding pad was placed in a beaker of a protein solution consisting of egg whites. Ventricular catheters were then placed in the solution, and a monopolar diathermy current was applied to a metal stylet at various wattages and for different durations of time. Inducing coagulation at 40 W with a diathermy unit produced flames emanating from around the pores of the catheter tip. Flash flames were also observed at 35 W, forming a coagulum of egg white for a distance of up to 1 cm from the catheter tip. All heat was dissipated through the holes of the first 16 mm of the catheter. At 20 W the flame was minimal and coagulation appeared adequate, whereas at 15 W only bubbles were seen around the tip together with suboptimal coagulum formation. This technique is a simple and effective means of determining the optimal setting for monopolar diathermy and can be used to figure the optimal catheter coagulation wattage for a given diathermy unit. Considering the results of this study, the authors have lowered the current for coagulation in ventricular catheters to 20 W.

Flow-diverter stenting of post-traumatic bilateral anterior cerebral artery pseudoaneurysm: A case report.

The use of flow-diverter (FD) stents in recent years has positively changed the therapeutic approach to some vascular diseases, especially of certain types of aneurysms. This paper describes the case of a young patient after a major head trauma causing multiple skull fractures. The trauma occasioned two pseudoaneurysms from the A1 segment of the right anterior cerebral artery and from the A2 segment of the left anterior cerebral artery. Both lesions were treated with two Pipeline devices (ev3, Irvine, CA, USA) in two different sessions. The CT study and angiographic investigations performed in the following month showed a complete resolution of the post-traumatic pseudoaneurysmal lesions. Although the use of FD stents is described in the literature, particularly in the treatment of selected aneurysms, this paper shows good technical results in the use of these stents in cases of intracranial post-traumatic pseudoaneurysms with clinical improvement.

Traumatic aneurysm of the callosomarginal artery.

Intracranial aneurysms are rare complications of head injury. The primary goals in the management of patients harbouring these lesions are early identification and intervention to prevent bleeding or rebleeding. The authors present a case of traumatic false aneurysm of the callosomarginal artery which was diagnosed following head injury and managed successfully with a good outcome.

Coil embolization of a traumatic intracranial aneurysm of the distal part of the azygos anterior cerebral artery followed up for 4 years.

Traumatic intracranial aneurysms are rare, usually occur as a result of traffic accidents, and are associated with high rates of morbidity and mortality. A 12-year-old boy was admitted for treatment of cerebral hemorrhage in the left frontal lobe, 3 months after a traffic accident. Angiography revealed an intracranial aneurysm of the distal part of the azygos anterior cerebral artery (ACA). The maximum size of this aneurysm was 9.5 mm. Coil embolization was successfully performed with preservation of the parent arteries. Angiography performed at the 4-year follow-up examination revealed no abnormalities. The present case showed that primary coiling may allow aneurysm occlusion along with parent vessel preservation in selected cases of traumatic intracranial aneurysm of the distal part of the azygos ACA.

Tratamiento endovascular plurimodal de aneurismas múltiples de la circulación anterior. Reporte de un caso / Multimodalities endovascular treatment of multiple aneurysms of the anterior circulation. Case report

Aneurismas cerebrales son una enfermedad grave, a pesar del alto grado de conocimiento respecto su fisiopatología y patogenia. La letalidad de ruptura de un aneurisma cerebral es todavía alrededor de 50%, allá de altas tasas de morbilidad. El tratamiento endovascular ha evolucionado en las últimas décadas para mejorar los resultados. Se presenta el caso de un paciente con síntomas neurológicos graves secundarios a la hemorragia subaracnoidea, cuya investigación mostró múltiples aneurismas. Varios dispositivos fueron utilizados en modalidades terapéuticas endovasculares consecutivas, incluyendo la embolización con remodelación, colocación de stents y desviador de flujo, con buen resultado clínico y angiográfico.

Cerebral aneurysms are a serious illness, despite the high degree of knowledge about its pathophysiology and pathogenesis. The lethality of cerebral aneurysm´s rupture is still about 50% beyond high morbidity. Endovascular treatment has evolved in recent decades to improve outcomes. It is reported the case of a patient with severe neurological symptoms secondary to subarachnoid hemorrhage, whose examination showed multiple aneurysms. Several devices were used on consecutive endovascular therapeutic modalities, including remodeling embolization, stenting and flow diverter, with good clinical and angiographic outcome.

Comparison of experimental rat models of early brain injury after subarachnoid hemorrhage.

OBJECTIVE: To investigate acute pathophysiological changes after subarachnoid hemorrhage (SAH) in rats and compare endovascular perforation and double blood injection models for studies of early brain injury after SAH. METHODS: Rat SAH was induced by endovascular perforation of the internal carotid artery (n = 41) or double injection of autologous blood into the cisterna magna (n = 23). Effects of SAH on arterial blood pressure, intracranial pressure, cerebral artery dimensions, and cerebral blood flow were measured. Neuronal death was assessed 24 hours after SAH. RESULTS: SAH was more severe in the endovascular perforation model (4-fold greater hemoglobin content on the basal brain surface), and mortality was greater (47%) than in the blood injection model (0%). Intracranial pressure increases were faster and greater in the perforation model. Correspondingly, cerebral blood flow reductions were greater after perforation than in the blood injection model, particularly in middle cerebral artery-supplied regions (32 +/- 16 versus 65 +/- 18 mL/100 g/min, P < 0.01). Diffuse neuronal death occurred in all rats in the perforation model but more seldom after blood injection. Anterior cerebral artery diameter and cross sectional area were significantly decreased on day 1 after SAH induction (52 +/- 21% and 22 +/- 16% of control values; P < 0.001) in the perforation model but not after blood injection. CONCLUSION: The perforation model produced more severe pathophysiological changes than the double blood injection, and it mimics human SAH in having an injured blood vessel and direct hemorrhagic brain lesion under arterial blood pressure. Therefore, endovascular perforation seems more suitable for study of acute SAH sequelae. However, further model refinement is required to reduce the high mortality rate.