intracranial_pseudoaneurysm [Operative Neurosurgery]

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====== Intracranial pseudoaneurysm ======

[[False aneurysm]]s, also known as a [[pseudoaneurysm]], requires all three [[layer]]s of the [[arterial wall]] wall to be disrupted, and integrity of the [[vessel]] is only maintained by associated [[hematoma]] or surrounding connective tissue
((McElroy KM, Malone RJ, Freitag WB, Keller I, Shepard S, Roychowdhury S. Traumatic pseudoaneurysm of the basilar artery. Am J Phys Med Rehabil. 2008;87:690–691. doi: 10.1097/PHM.0b013e31817fbaea.)).

In true [[aneurysm]]s, the [[adventitia]] is preserved.

Direct communication of [[blood flow]] exists between the vessel lumen and the [[aneurysm]] lumen through the hole in the [[arterial wall]]. The risk of rupture is higher than that of a true aneurysm of comparable size due to poor support of the aneurysm wall and thus false aneurysms generally require treatment.
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The extracranial [[vertebral artery]] are traditionally believed to be more vulnerable to trauma than intracranial vessels owing to their relatively exposed location within the cervical vertebrae. However, a review demonstrates [[PICA]] to be the most common vessel involved, in 54 % of cases 
((Krings T, Geibprasert S, terBrugge KG. Pathomechanisms and treatment of pediatric aneurysms. Childs Nerv Syst. 2010;26:1309–1318. doi: 10.1007/s00381-009-1054-9.)).

Almost one third of cases were in patients aged under 16. The higher proportion of traumatic aneurysms in children may be due to the paediatric cervical spine and craniocervical junction being relatively mobile, exposing vessels to stretching and shearing forces. The overall young age of presentation across this review (mean age 24) and the male preponderance (75 %) 
((Quattrocchi KB, Nielsen SL, Poirier V, Wagner FC., Jr Traumatic aneurysm of the superior cerebellar artery: case report and review of the literature. Neurosurgery. 1990;27:476–479. doi: 10.1227/00006123-199009000-00025. ))
also reflects the higher incidence of trauma in young males.

===== Etiology =====
trauma (dissection or laceration):

In a [[brachial plexus injury]]: Progressive deficit is usually due to vascular injuries (pseudoaneurysm, A-V fistula, or expansile clot); these should be explored immediately.

Stroke risk due to [[carotid artery blunt injury]] 44 %.

It is an indication for neurosurgical intervention in [[gunshot wound]] to the [[brachial plexus]].
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iatrogenic (dissection, laceration or puncture), e.g. [[arterial catheterization]] (accounts for most cases in this category).

see [[Internal carotid artery injury after transsphenoidal approach]].
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biopsy, surgery

spontaneous dissection

fibromuscular dysplasia (dissection)

mycotic aneurysm (inflammatory digestion of the vessel wall)

myocardial infarction (left ventricular false aneurysm)

regional inflammatory process

acute pancreatitis

chronic pancreatitis

vessel injury/erosion due to a tumour: relatively uncommon

vasculitides 

Behcet syndrome

giant cell arteritis

Takayasu arteritis

systemic lupus erythematosus

polyarteritis nodosa

penetrating atherosclerotic ulcer


They can involve any arterial segment or even a cardiac chamber. Examples include

aortic pseudoaneurysm: traumatic aortic pseudoaneurysm

femoral artery pseudoaneurysm: relatively common site due to femoral punctures

carotid artery pseudoaneurysm

visceral arterial pseudoaneurysm

hepatic arterial pseudoaneurysm

gastroduodenal arterial pseudoaneurysm

splenic arterial pseudoaneurysm

renal arterial pseudoaneurysm

peripheral arterial (limb) pseudoaneurysm

left ventricular pseudoaneurysm

brachiocephalic artery pseudoaneurysm


Some of the imaging features may be dependent on location.

Ultrasound

Due to the turbulent forward and backward flow, a characteristic yin-yang sign may be seen on colour flow while a "to and fro" pattern may be seen with pulsed Doppler.

CT

hypodense (non-contrated) or hyperdense (contrast-enhanced) smooth walled sac adjacent to an artery, usually with a communication.
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In view of the aggressive natural history of posterior circulation traumatic intracranial aneurysm TICA, deSouza et al., recommend that [[CTA]] of the head and neck vessels be performed for cases presenting with post-traumatic disproportionate cisternal and or third or fourth ventricular SAH. In the event of initial CTA being negative, repeat CTA and if negative DSA should be performed between 5 to 7 days, with a low threshold for further repeat at 10 days if a traumatic dissection is still suspected. Close monitoring for hydrocephalus and vasospasm is required during hospital admission and significant therapy input is likely to be required post discharge from acute care
((deSouza RM, Shah M, Koumellis P, Foroughi M. Subarachnoid haemorrhage
secondary to traumatic intracranial aneurysm of the posterior cerebral
circulation: case series and literature review. Acta Neurochir (Wien). 2016
Sep;158(9):1731-40. doi: 10.1007/s00701-016-2865-6. Epub 2016 Jun 30. Review.
PubMed PMID: 27364895; PubMed Central PMCID: PMC4980416.
)).
===== Common carotid artery pseudoaneurysm =====
 
[[Common carotid artery pseudoaneurysm]].
 

===== Internal carotid artery pseudoaneurysm =====

see [[Internal carotid artery pseudoaneurysm]].

===== Superficial temporal artery pseudoaneurysm =====

see [[Superficial temporal artery pseudoaneurysm]].

===== Traumatic pseudoaneurysm =====

[[Traumatic pseudoaneurysm]].

==== Case reports ====

Full-endoscopic [[Transforaminal lumbar endoscopic discectomy]] is based on a [[puncture]] [[technique]] using a guide [[needle]] to reach the target area of the [[foramen]] via a percutaneous posterolateral/lateral approach. It may correlate with specific approach-related complications, as exiting [[nerve root injury]]. 

Panagiotopoulos et al., report the first case of [[pseudoaneurysm]] of the [[lumbar segmental artery]] secondary to a transforaminal full-endoscopic surgery in the treatment of a [[lumbar disc herniation]]. A 39-year-old man underwent left L4-L5 full-endoscopic transforaminal lumbar discectomy for a herniated disc. Three hours after surgery, he experienced acute progressive [[abdominal pain]]. An abdomen CT scan showed contrast extravasation in the left paraspinal compartment at L4 vertebral body level. The selective left lumbar [[angiogram]] revealed a pseudoaneurysm of a side branch of the left lumbar segmental artery, which was treated by endovascular [[coiling]]. The patient made a rapid postoperative recovery without further complications and was discharged 4 days later. This report identifies a rare complication of transforaminal full-endoscopic surgery in the treatment of a herniated lumbar disc. This is the first case of pseudoaneurysm formation of the lumbar artery following a full-endoscopic transforaminal lumbar discectomy
((Panagiotopoulos K, Gazzeri R, Bruni A, Agrillo U. Pseudoaneurysm of a
segmental lumbar artery following a full-endoscopic transforaminal lumbar
discectomy: a rare approach-related complication. Acta Neurochir (Wien). 2019 Mar
16. doi: 10.1007/s00701-019-03876-7. [Epub ahead of print] PubMed PMID: 30879131.
)).

===== Posterior communicating artery pseudoaneurysm =====

see [[Posterior communicating artery pseudoaneurysm]].

===== Treatment =====
With the advances in techniques and materials, endovascular treatment has been an alternative to surgery for the treatment of intracranial pseudoaneurysms. Endovascular procedures include coiling, stent-assisted coiling, occlusion of the parent artery with or without aneurysm, and flow diversion.