- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania,
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania,
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia,
Aaron S. Dumont
Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania,
DOI:10.4103/2152-7806.105099Copyright: © 2012 Amenta PS This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Amenta PS, Starke RM, Jabbour PM, Tjoumakaris SI, Gonzalez LF, Rosenwasser RH, Pribitkin EA, Dumont AS. Successful treatment of a traumatic carotid pseudoaneurysm with the Pipeline stent: Case report and review of the literature. Surg Neurol Int 26-Dec-2012;3:160
How to cite this URL: Amenta PS, Starke RM, Jabbour PM, Tjoumakaris SI, Gonzalez LF, Rosenwasser RH, Pribitkin EA, Dumont AS. Successful treatment of a traumatic carotid pseudoaneurysm with the Pipeline stent: Case report and review of the literature. Surg Neurol Int 26-Dec-2012;3:160. Available from: http://sni.wpengine.com/surgicalint_articles/successful-treatment-of-a-traumatic-carotid-pseudoaneurysm-with-the-pipeline-stent-case-report-and-review-of-the-literature/
Background:Traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to treat. In the case of traumatic pseudoaneurysms that may not be treated with parent vessel sacrifice, some flow diversion strategy such as stent-assistance or use of a flow diversion device is usually necessary.
Case Description:In this study we describe endovascular parent vessel wall-remodeling/endoluminal reconstruction and traumatic pseudoaneurysm thrombosis through the use of the Pipeline stent and review recent reports concerning indications, safety, and efficacy for alternative pathology.
Conclusion:Although currently not routinely employed in the treatment of traumatic pseudoaneurysms, the Pipeline stent may represent a safe and effective treatment alternative achieving complete endoluminal reconstruction of the damaged vessel wall.
Keywords: Aneurysm, endoscopic, flow diversion, hemorrhage, pipeline, pseudoaneurysm, sinusitis, sphenoidostomy, subarachnoid, trauma
Accounting for less than 1% of all aneurysms, traumatic intracranial pseudoaneurysms represent a class of relatively rare lesions.[
The patient is a 64-year-old female initially admitted with left-sided chronic maxillary, ethmoidal, and sphenoidal sinusitis. She underwent endoscopic left ethmoidectomy, maxillary antrostomy, and sphenoidostomy. During dissection of the sphenoid mucosa, pulsatile bleeding was observed through a punctate hole in the carotid canal, raising concern for injury to the internal carotid artery. Hemostasis was achieved with an Afrin-soaked pledget and pressure. The patient awoke neurologically intact and an immediate postoperative computed tomography angiogram (CTA) showed no evidence of contrast extravasation or pseudoaneurysm [
A CTA repeated one week later, revealed a 2 × 1.4 mm pseudoaneurysm arising from the left internal carotid artery at the level of the carotid canal dehiscence [
(a) At the time of treatment, the pseudoaneurysm had enlarged to 2.8 mm. (b) A 4×16 mm Pipeline stent was deployed across the pseudoaneurysm and the control angiogram demonstrated contrast stasis within the aneurysmal dome. (c) A 4×14 mm Pipeline stent was placed within the first stent to reinforce the construct and the final control angiogram revealed further stasis
By definition, intracranial pseudoaneurysms lack a true wall due to the transmural nature of the preceding injury and thus, are only contained by a friable layer of connective tissue.[
Recently, parent vessel preservation through endovascular intervention has gained increasing popularity, as coil, stent, and liquid embolic agent technology continue to evolve. The majority of existing literature regarding endovascular vessel preservation of traumatic pseudoaneurysms is comprised of case reports and series, each of which state various rates of success and aneurysm recurrence. Yuen et al. reported coil compaction and regrowth of a traumatic pericallosal pseudoaneurysm that required clip ligation.[
The Pipeline stent is a flow diversion and vessel remodeling device composed of cobalt chromium and platinum tungsten arranged in a 48-strand braided design. The stent reduces blood flow into the aneurysm, thus promoting thrombosis, while also providing a scaffold for endothelialization and reconstruction of the vessel wall. Due to these properties, the Pipeline stent has developed into a treatment option for aneurysms difficult to treat via clipping or coiling, such as, giant and fusiform aneurysms and those located at the skull base.
Chitale et al. reported the treatment of 42 aneurysms with the pipeline embolization device (PED) (41 anterior circulation, 1 vertebrobasilar junction) and experienced a symptomatic complication rate of 13.9%.[
Flow-diversion devices have also been utilized in the treatment of spontaneous dissecting aneurysms. Yeung et al. reported successful obliteration of four dissecting vertebral artery aneurysms with flow diversion.[
Traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to treat by either open or endovascular techniques. Although the PED has been shown to successfully obliterate complex aneurysms, there is a lack of literature regarding the use of this device in the treatment of traumatic pseudoaneurysms. Our case reports the novel use of the PED for successful obliteration of a traumatic pseudoaneurysm resulting from intraoperative injury during endoscopic sinus surgery. Complete exclusion of the pseudoaneurysm at 4-month follow up angiogram supports the possible durability of PED repair achieving endoluminal reconstruction of the damaged vessel. A limitation of the PED is that decreased flow into aneurysms may not provide immediate thrombosis, and it may take a number of weeks for complete occlusion. This may leave a patient at risk for rupture during this interim. Future investigations into the utility of the PED in the treatment of traumatic pseudoaneurysms are necessary in order to define the feasibility, durability, and complications associated with this treatment option.
Traumatic pseudoaneurysms remain rare, but challenging lesions treated via the open or endovascular route traditionally with parent vessel deconstruction. The PED has been shown to be effective in the treatment of simple and complex aneurysms. Although currently not routinely employed in the treatment of traumatic pseudoaneurysms, the PED may represent a safe and effective treatment alternative achieving complete endoluminal reconstruction of the damaged vessel wall.
1. Benoit BG, Wortzman G. Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry. 1973. 36: 127-38
2. Briganti F, Napoli M, Tortora F, Solari D, Bergui M, Boccardi E. Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications-a retrospective data analysis. Neuroradiology. 2012. 54: 1145-52
3. Chitale R, Gonzalez LF, Randazzo C, Dumont AS, Tjoumakaris S, Rosenwasser R. Single center experience with pipeline stent: Feasibility, technique and complications. Neurosurgery. 2012. 71: 679-91
4. Cohen JE, Gomori JM, Segal R, Spivak A, Margolin E, Sviri G. Results of endovascular treatment of traumatic intracranial aneurysms. Neurosurgery. 2008. 63: 476-85
5. Colby GP, Lin LM, Gomez JF, Paul AR, Huang J, Tamargo RJ. Immediate procedural outcomes in 35 consecutive pipeline embolization cases: A single-center, single-user experience. J Neurointerv Surg. 2012. p.
6. de Barros Faria M, Castro RN, Lundquist J, Scrivano E, Ceratto R, Ferrario A. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol. 2011. 32: 2192-5
7. Deutschmann HA, Wehrschuetz M, Augustin M, Niederkorn K, Klein GE. Long-term follow-up after treatment of intracranial aneurysms with the Pipeline embolization device: Results from a single center. AJNR Am J Neuroradiol. 2011. 33: 481-6
8. Ducruet AF, Crowley RW, Albuquerque FC, McDougall CG. Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the Pipeline embolization device. J Neurointerv Surg. 2012. p.
9. Fischer S, Vajda Z, Aguilar Perez M, Schmid E, Hopf N, Bazner H. Pipeline embolization device (PED) for neurovascular reconstruction: Initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2011. 54: 369-82
10. Fulkerson DH, Voorhies JM, McCanna SP, Payner TD, Leipzig TJ, Scott JA. Endovascular treatment and radiographic follow-up of proximal traumatic intracranial aneurysms in adolescents: Case series and review of the literature. Childs Nerv Syst. 2010. 26: 613-20
11. Hemphill JC, Gress DR, Halbach VV. Endovascular therapy of traumatic injuries of the intracranial cerebral arteries. Crit Care Clin. 1999. 15: 811-29
12. Holmes B, Harbaugh RE. Traumatic intracranial aneurysms: A contemporary review. J Trauma. 1993. 35: 855-60
13. Larson PS, Reisner A, Morassutti DJ, Abdulhadi B, Harpring JE. Traumatic intracranial aneurysms. Neurosurg Focus. 2000. 8: e4-
14. Lempert TE, Halbach VV, Higashida RT, Dowd CF, Urwin RW, Balousek PA. Endovascular treatment of pseudoaneurysms with electrolytically detachable coils. AJNR Am J Neuroradiol. 1998. 19: 907-11
15. Lim YC, Kang JK, Chung J. Reconstructive stent-buttressed coil embolization of a traumatic pseudoaneurysm of the supraclinoid internal carotid artery. Acta Neurochir (Wien). 2012. 154: 477-80
16. Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: The Buenos Aires experience. Neurosurgery. 2009. 64: 632-42
17. Medel R, Crowley RW, Hamilton DK, Dumont AS. Endovascular obliteration of an intracranial pseudoaneurysm: The utility of Onyx. J Neurosurg Pediatr. 2009. 4: 445-8
18. Naggara ON, Lecler A, Oppenheim C, Meder JF, Raymond J. Endovascular treatment of intracranial unruptured aneurysms: A systematic review of the literature on safety with emphasis on subgroup analyses. Radiology. 2012. 263: 828-35
19. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2010. 32: 34-40
20. Phillips TJ, Wenderoth JD, Phatouros CC, Rice H, Singh TP, Devilliers L. Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol. 2012. 33: 1225-31
21. Sim SY, Shin YS, Yoon SH. Endovascular internal trapping of traumatic pericallosal pseudoaneurysm with hydrogel-coated self-expandable coil in a child: A case report. Surg Neurol. 2008. 69: 418-22
22. Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W. Treatment of intracranial aneurysms by functional reconstruction of the parent artery: The Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol. 2010. 31: 1139-47
23. Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC. Traumatic intracranial carotid tree aneurysms. Neurosurgery. 1998. 43: 1314-20
24. Voelker JL, Ortiz O. Delayed deterioration after head trauma due to traumatic aneurysm. W V Med J. 1997. 93: 317-9
25. Yeung TW, Lai V, Lau HY, Poon WL, Tan CB, Wong YC. Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery. J Neurosurg. 2012. 116: 882-7
26. Yuen CM, Kuo YL, Ho JT, Liao JJ. Rapid regrowth of a successfully coiled traumatic pericallosal aneurysm. J Clin Neurosci. 2007. 14: 1215-9