- Department of Neurosurgery, Nara City Hospital, , Nara, Japan
- Department of Neurosurgery, Nara Prefecture General Medical Center, Nara, Japan.
Correspondence Address:
Takayuki Morimoto, Department of Neurosurgery, Nara City Hospital, Nara, Japan.
DOI:10.25259/SNI_752_2023
Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Kengo Yamada1, Takayuki Morimoto1, Kenta Fujimoto2, Toshikazu Nishioka1, Hidemori Tokunaga1. Traumatic intracranial aneurysm in a distal posterior cerebral artery: A case report and literature review. 15-Dec-2023;14:428
How to cite this URL: Kengo Yamada1, Takayuki Morimoto1, Kenta Fujimoto2, Toshikazu Nishioka1, Hidemori Tokunaga1. Traumatic intracranial aneurysm in a distal posterior cerebral artery: A case report and literature review. 15-Dec-2023;14:428. Available from: https://surgicalneurologyint.com/surgicalint-articles/12672/
Abstract
Background: Traumatic intracranial aneurysms (TICAs) are rare and known to rupture easily and have a high mortality rate.
Case Description: An 87-year-old male patient with no neurological deficits presented to our hospital after head trauma. Computed tomography (CT) revealed a tentorial acute subdural hematoma (ASDH). The patient was managed conservatively and discharged home six days after hospitalization. Two days later, the patient returned with a severe headache. CT showed that the ASDH had enlarged and extended from the tentorium to the convexity. CT angiography and digital subtraction angiography revealed a pseudoaneurysm in a branch of the left posterior inferior temporal artery. The patient was diagnosed with an enlarged ASDH due to a ruptured TICA that arose from the P3 segment. We performed endovascular intervention with parent artery occlusion (PAO) using n-butyl-2-cyanoacrylate (NBCA). The parent artery was accessed through the left posterior communicating artery because left vertebral angiography revealed an aplastic left P1 segment. After navigating the microcatheter near the aneurysm, we injected 33% NBCA into the parent artery. The pseudoaneurysm disappeared after injection. The patient was discharged on hospital day 25 despite persistent delirium.
Conclusion: This is the first report of a TICA arising from the P3 segment that was treated with PAO using NBCA. TICAs are rare; however, a TICA must be considered when an enlarged hematoma caused by head injury is detected.
Keywords: Acute subdural hematoma, N-butyl-2-cyanoacrylate, Parent artery occlusion, Traumatic intracranial aneurysm
INTRODUCTION
Traumatic intracranial aneurysms (TICAs) are very rare, accounting for <1% of all aneurysms. It is known to rupture easily and has a high mortality rate.[
CASE REPORT
An 87-year-old healthy male patient presented to the emergency department with head trauma after a fall. The patient’s Glasgow coma scale (GCS) score was 14 (E4V4M6), indicating a mild disturbance of consciousness. The patient had no neurological deficits. A head computed tomography (CT) scan showed a subcutaneous hematoma in the right parietal region and ASDH extending from a subarachnoid cyst in the left middle cranial fossa to the left tentorium and falx [
Figure 1:
(a and b) Initial computed tomography (CT) scan showing left tentorial acute subdural hemorrhage (ASDH). (c and d) A CT scan during the second admission showed enlarged ASDH. (e and f) CT angiography showing left pseudoaneurysm in the P3 segment of the posterior cerebral artery (arrowhead) (arrow).
Two days after discharge, the patient presented to the emergency department with a headache and disorientation. The assessment indicated mild disturbance of consciousness, a GCS score of 14 (E4V4M6), and no focal signs. Head CT imaging revealed ASDH extending from the left tentorium to the left convexity, with effacement of the sulci and a midline shift [
Endovascular treatment was performed under general anesthesia. We approached through the left posterior communicating artery as the left P1 segment was hypoplastic. A 6 Fr FUBUKI catheter (Asahi Intec, Aichi, Japan) was guided into the origin of the left internal carotid artery using a 4-Fr JB2 catheter and a 0.035-inch guiding wire. An intermediate catheter (Guidepost; Tokai Medical Products, Aichi, Japan) was, then, advanced into the left internal carotid artery. A microcatheter (DeFrictor BULL; Medicos Hirata, Tokyo, Japan) was inserted proximal to the aneurysm in the left PITA using a microwire (TENROU 1014; Kaneka Medix, Osaka, Japan; [
Head magnetic resonance imaging on the following day showed a partial acute infarction at the base of the left temporal lobe. However, the patient experienced no symptoms such as visual apraxia or loss [
DISCUSSION
TICA are rare, accounting for under 1% of all intracranial aneurysms. Approximately 30% of TICAs occur in patients younger than 20 years old and are often associated with blunt head trauma.[
Direct vascular injury or stretching was reported to cause TICA.[
The mechanisms of forming an ASDH without cerebral contusion include (1) disruption to the adhesion between the cortical artery and the dura mater, (2) disruption to the dural branch of the cortical artery, and (3) spontaneous rupture of a cortical artery at the small arterial branch origin, particularly at points of potential weakness, such as right-angled branches.[
The treatment strategies for common aneurysms in the PCA includes direct surgery and endovascular treatment. Direct surgery, such as aneurysm trapping, is a high-risk procedure with a complication rate of 13% and a mortality rate of 19%.[
CONCLUSION
We reported a rare case of ruptured TICA in the PITA branching from the P3 segment and presenting only with ASDH. Cerebrovascular assessment should be performed for patients with head trauma presenting with ASDH and an atypical hematoma location or with an atypical clinical course. When an enlarged hematoma caused by head injury is detected, the possibility of TICA must be considered.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Ethical approval
Not applicable.
Declaration of patient consent
Patient’s consent not required as patient’s identity is not disclosed or compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
References
1. Borzone M, Altomonte M, Baldini M, Rivano C. Pure subdural haematomas of arteriolar origin. Acta Neurochir (Wien). 1993. 121: 109-12
2. Buckingham MJ, Crone KR, Ball WS, Tomsick TA, Berger TS, Tew JM. Traumatic intracranial aneurysms in childhood: Two cases and a review of the literature. Neurosurgery. 1988. 22: 398-408
3. Ciceri EF, Klucznik RP, Grossman RG, Rose JE, Mawad ME. Aneurysms of the posterior cerebral artery: Classification and endovascular treatment. AJNR Am J Neuroradiol. 2001. 22: 27-34
4. Ciochon UM, Steuble Brandt EG, Stavngaard T. Acute tentorial subdural hematoma caused by rupture of the posterior cerebral artery after minor trauma-a case report. Diagnostics (Basel). 2020. 10: 175
5. Fuga M, Tanaka T, Nogami R, Tachi R, Teshigawara A, Ishibashi T. Delayed tentorial subdural hematoma caused by traumatic posterior cerebral artery aneurysm: A case report and literature review. Am J Case Rep. 2021. 22: e933771
6. Holmes B, Harbaugh RE. Traumatic intracranial aneurysms: A contemporary review. J Trauma. 1993. 35: 855-60
7. Komiyama M, Morikawa T, Nakajima H, Yasui T, Kan M. “Early” apoplexy due to traumatic intracranial aneurysm--case report. Neurol Med Chir (Tokyo). 2001. 41: 264-70
8. Larson PS, Reisner A, Morassutti DJ, Abdulhadi B, Harpring JE. Traumatic intracranial aneurysms. Neurosurg Focus. 2000. 8: e4
9. Li XY, Li CH, Wang JW, Liu JF, Li H, Gao BL. Endovascular management of cerebral aneurysms of the posterior cerebral artery. Front Neurol. 2021. 12: 700516
10. Loevner LA, Ting TY, Hurst RW, Goldberg HI, Schut L. Spontaneous thrombosis of a basilar artery traumatic aneurysm in a child. AJNR Am J Neuroradiol. 1998. 19: 386-8
11. Meyer FB, Sundt TM, Fode NC, Morgan MK, Forbes GS, Mellinger JF. Cerebral aneurysms in childhood and adolescence. J Neurosurg. 1989. 70: 420-5
12. Terasaka S, Sawamura Y, Kamiyama H, Fukushima T. Surgical approaches for the treatment of aneurysms on the P2 segment of the posterior cerebral artery. Neurosurgery. 2000. 47: 359-64
13. Zeal AA, Rhoton AL. Microsurgical anatomy of the posterior cerebral artery. J Neurosurg. 1978. 48: 534-59