- Email: [email protected]
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device
Journal Pre-proof Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device. Zaid Aljuboori, MD, Kimberley Meyer, APRN, Dale Ding, MD, Robert James, MD. PII:
S1878-8750(19)32623-3
DOI:
https://doi.org/10.1016/j.wneu.2019.10.008
Reference:
WNEU 13479
To appear in:
World Neurosurgery
Received Date: 31 August 2019 Revised Date:
30 September 2019
Accepted Date: 1 October 2019
Please cite this article as: Aljuboori Z, Meyer K, Ding D, James R, Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device., World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.008. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Zaid Aljuboori, MD, Kimberley Meyer, APRN, Dale Ding, MD, Robert James, MD.
Department of Neurological surgery, University of Louisville, KY, USA.
Corresponding Author Zaid Aljuboori, MD, 220 Abraham Flexner way, Ste.1500 Louisville, KY 40202, USA. Tel: (502) 588-0492 Fax: (502) 407- 3256 Email: [email protected]
Keywords Subarachnoid hemorrhage, trauma, flow diversion, pseudoaneurysm.
Acknowledgments None Funding source None
Abstract Objective Traumatic pseudoaneurysms of the proximal middle cerebral artery (MCA) segments are challenging to treat. We describe the management of traumatic internal carotid artery (ICA) and MCA pseudoaneurysms with flow diversion. Methods A 19-year-old male sustained a gunshot wound to the head. Delayed digital subtraction angiography (DSA) showed de novo formation of left ICA ophthalmic segment and left MCA M2 segment pseudoaneurysms. We initially performed coil embolization of the left MCA pseudoaneurysm, but it recurred two weeks later. We treated both pseudoaneurysms with flow diversion using the Pipeline Flex Embolization Device. The patient was maintained on dual antiplatelet therapy (DAPT) of aspirin and ticagrelor. Results Follow-up DSA at 6 months showed complete obliteration of both pseudoaneurysms with patent parent vessels. The patient remained neurologically intact. Conclusion Flow diversion can be an efficacious treatment for traumatic MCA pseudoaneurysms in appropriately selected cases. The risks versus benefits of DAPT must be weighed in trauma settings.
Introduction Middle cerebral artery (MCA) dissections are rare, and they can present with ischemia or hemorrhage 1,2 The ischemic subset of MCA dissections commonly presents with focal neurological deficits or altered mental status, whereas the hemorrhagic subtype usually presents as subarachnoid hemorrhage (SAH).1 The natural history of MCA dissections is poorly defined. Pseudoaneurysms, a type of arterial dissections, are especially challenging to successfully manage due to their high risk of rupture and intracranial haemorrhage.1-4 Multiple treatment options, including endovascular stenting with or without coiling, extracranial-intracranial bypass, and clip wrapping, have been described with varying results.4-9 Recently, endovascular flow diversion has been proven to be effective for the treatment of saccular, fusiform, and blister aneurysms, but evidence supporting its role in the management of intracranial pseudoaneurysms caused by penetrating injuries is lacking. 10-14 The aim of this case report is to describe a case of traumatic intracranial internal carotid artery (ICA) and MCA pseudoaneurysms that were treated with flow diversion.
Case presentation History A 19-year-old male sustained a gunshot wound to the face wherein the bullet entered the right side of the face, traversed the cranial cavity, and exited through the left temporal bone. On admission, the patient’s Glasgow Coma Scale (GCS) was 10T. The patient underwent brain computed tomography (CT) during the initial evaluation, which showed a small left temporal subdural hematoma, bony fragments around the proximal sylvian fissure, and traumatic SAH [Fig.1]. Brain CTA only showed mild vasospasm of the left ICA and MCA [Fig.2]. Initially, the patient was managed conservatively with broad-spectrum antibiotics, external ventricular drain (EVD) placement, and medical therapies to maintain a normal intracranial pressure. On day 7 post injury a follow-up diagnostic cerebral angiogram (DSA) showed two left-sided pseudoaneurysms of the ICA and MCA superior division [Fig. 3A, 3B].
2
On post-injury day 9, we completely occluded the left MCA pseudoaneurysm utilizing coil embolization [Fig. 4], with a plan to observe the left ICA pseudoaneurysm due to its small size. Follow-up DSA two weeks later showed recurrence of the initially coiled MCA pseudoaneurysm and unchanged appearance of the ICA pseudoaneurysm [Fig. 5A, 5B]. We treated both the left MCA and ICA pseudoaneurysms with flow diversion using two telescoping Pipeline Flex Embolization Devices (Medtronic Neurovascular, Irvine, CA) [Fig. 6A, 6B]. The patient was administered dual antiplatelet therapy (DAPT) comprising aspirin 81 mg daily and ticagrelor 90 mg twice daily. The flow diversion procedure was uncomplicated, and the patient’s post-embolization neurological exam improved to a GCS of 15. He was subsequently discharged 4 weeks after the initial presentation to a rehabilitation facility. Post-embolization DSA at 6 months follow-up showed complete obliteration of both the left ICA and MCA pseudoaneurysms with preserved patency of the parent vessels [Fig. 7A, 7B]. The patient was neurologically intact at follow-up with a modified Rankin Scale of 1.
Discussion Traumatic dissections of the MCA remain challenging to manage despite significant advances in cerebrovascular techniques and technology. Traumatic extracranial cerebrovascular injuries are classified by the Biffl grading system, but the classification of intracranial cerebrovascular injuries is not as firmly established.15 Unlike systemic arteries, cerebral arteries have no external elastic lamina, but instead have a well-developed internal elastic lamina. Furthermore, cerebral arteries have paucity of elastic fibers in the medial layer and a very thin adventitia.16 These structural differences lead to increased risk of SAH in intracranial dissections. Intracranial dissections manifesting as intimal flaps can be treated with stenting. However, stenting monotherapy for traumatic intracranial pseudoaneurysms may not sufficiently reduce the elevated risk of rupture and SAH.1- 4 In a cohort of 23 MCA dissections, Lin et al. reported presentations of ischemia and hemorrhage in 88% and 12%, respectively.1 The available treatment options for intracranial pseudoaneurysms include coiling alone, stent-assisted coiling, EC-IC bypass, and
3
clip wrapping.4-9 However, the optimal therapy remains controversial, and management decisions are subject to each physician’s personal and institutional biases. We present a unique and challenging case of a proximal MCA pseudoaneurysm caused by a penetrating head injury which recurred after initial treatment with coil embolization. We decided to treat the MCA pseudoaneurysm due to its high risk of rupture and SAH, which can cause substantial neurological morbidity and mortality. We decided against surgical clipping due to the lack of a true vessel wall to secure a clip. We were also concerned that surgical exploration would incur the risk of parent vessel sacrifice, which could result in an infarct of the dominant hemisphere. Surgical bypass could preserve perfusion to the at-risk brain region, but it is technically challenging and also carries the potential for ischemia, due to the need for temporary occlusion and postoperative bypass occlusion. We initially decided to coil the MCA pseudoaneurysm in order to avoid the necessity of DAPT in the setting of subacute neurotrauma and intracranial surgery. Despite complete occlusion after the initial coiling procedure, the pseudoaneurysm recurred 2 weeks later. We successfully treated both the recurrent MCA pseudoaneurysm and the initially untreated ICA pseudoaneurysm with flow diversion using the Pipeline Flex Embolization Device. Colby et al. reported a similar case in an infant, except the etiology of the injury was iatrogenic rather than traumatic.17 The literature supporting the use of flow diversion for unruptured aneurysms is robust, and the risk for SAH from DAPT is extremely low as true aneurysms have all the component of the vessel wall.10-14 The major limiting factors for the use of flow diversion in setting of acute or subacute intracranial or multisystem trauma the necessity for DAPT, which incurs the risk of significant hemorrhagic complications. We decided to perform flow diversion in the present case due to the lack of more favorable treatment options. We identified reports of stenting monotherapy, stent-assisted coiling, and flow diversion for the treatment of MCA dissections.9,17-19 However, the etiology of the MCA pseudoaneurysm in our case, which arose after a penetrating head injury from a gunshot wound, is unique.
4
We administered a DAPT regimen of aspirin and ticagrelor, since ticagrelor is a reversible platelet inhibitor with mean terminal half-life of 7-8 hours.20 We believed that the relatively shorter half-life of ticagrelor compared to other antiplatelet agents could potentially curb the severity of any hemorrhagic complications. The emergence of the Pipeline Embolization Device with Shield technology, a surface modification which reduces the thrombogenicity of the device, could curtail the necessity of DAPT to antiplatelet monotherapy for flow diversion.21
Conclusion In conclusion, flow diversion is an effective treatment of traumatic MCA pseudoaneurysms in appropriately selected cases. DAPT is necessary to minimize the thromboembolic complications associated with flow diversion, and it should be used judiciously in the setting of acute or subacute trauma. DAPT can be safely administered to patients with recent penetrating head injuries, but the treating physician must weigh its risks versus benefits on a case-by-case basis. Future studies are warranted to clarify the role of flow diversion in the management of MCA dissections and pseudoaneurysms.
Acknowledgements None Disclosures None References 1. Lin CH, Jeng JS, Yip PK. Middle cerebral artery dissections: differences between isolated and extended dissections of internal carotid artery. J Neurol Sci. 2005;235(1-2):37-44. 2. Asaithambi G, Saravanapavan P, Rastogi V, Khan S, Bidari S, Khanna AY, et al. Isolated middle cerebral artery dissection: a systematic review. Int J Emerg Med. 2014;7(1):44.
5
3. Fukuma K, Ihara M, Tanaka T, Morita Y, Toyoda K, Nagatsuka K. Intracranial Cerebral Artery Dissection of Anterior Circulation as a Cause of Convexity Subarachnoid Hemorrhage. Cerebrovasc Dis. 2015;40(1-2):45-51. 4. Puri AS, Gounis MJ, Massari F, Howk M, Weaver J, Wakhloo AK. Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection. J Neurointerv Surg. 2016;8(4): e13. 5. Cikla U, Li Y, Hernandez-Duran S, Kozan A, Baskaya MK. Treatment of Supraclinoid Internal Carotid Artery Iatrogenic Pseudoaneurym with Extracranial-to- Intracranial Bypass and Trapping: Demonstration of Technique with Video Presentation. Turk Neurosurg. 2015;25(2):305-9. 6. O'Shaughnessy BA, Getch CC, Bowman RM, Batjer HH. Ruptured traumatic vertebral artery pseudoaneurysm in a child treated with trapping and posterior inferior cerebellar artery reimplantation. Case report and review of the literature. J Neurosurg. 2005;102(2 Suppl):231-7. 7. Ali MJ, Bendok BR, Tawk RG, Getch CC, Batjer HH. Trapping and revascularization for a dissecting aneurysm of the proximal posteroinferior cerebellar artery: technical case report and review of the literature. Neurosurgery. 2002;51(1):258-62; discussion 62-3. 8. Nishizawa S, Yokoyama T, Sugiyama K, Yokota N. Intracerebral hemorrhage from a ruptured pseudoaneurysm after STA-MCA anastomosis--case report. Neurol Med Chir (Tokyo). 2000;40(8):40812. 9. Nam DH, Park SK. Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity. J Cerebrovasc Endovasc Neurosurg. 2015;17(2):108-12. 10. Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus. 2017;42(6): E14. 11. Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, et al. Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid
6
Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery. 2017;80(1):40-8. 12. Becske T, Potts MB, Shapiro M, Kallmes DF, Brinjikji W, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg. 2017;127(1):81-8. 13. Bhogal P, AlMatter M, Bazner H, Ganslandt O, Henkes H, Aguilar Perez M. Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience. Front Neurol. 2017; 8:20. 14. Colby GP, Bender MT, Lin LM, Beaty N, Caplan JM, Jiang B, et al. Declining complication rates with flow diversion of anterior circulation aneurysms after introduction of the Pipeline Flex: analysis of a single-institution series of 568 cases. J Neurosurg. 2018:1-7. 15. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999;47(5):845-53. 16. Lee, R. M. (1995). Morphology of cerebral arteries. Pharmacol Ther, 66(1), 149-173. doi:10.1016/01637258(94)00071-a 17. Colby GP, Jiang B, Bender MT, Beaty NB, Westbroek EM, Xu R, et al. Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case. J Neurosurg Pediatr. 2018:1-9. 18. Al-Mufti F, Cohen E, R, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach N, S, Meyers P, M: Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. Interevent Neurol 2019; 8:38-54. doi: 10.1159/000489016 19. de Barros Faria M, Castro RN, Lundquist J, Scrivano E, Ceratto R, Ferrario A, et al. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol. 2011;32(11):2192-5.
7
20. Appelboom G, Kadri K, Hassan F, Leclerc X. Infectious aneurysm of the cavernous carotid artery in a child treated with a new-generation of flow-diverting stent graft: case report. Neurosurgery. 2010;66(3): E623-4; discussion E4. 21. Manning, N. W., Cheung, A., Phillips, T. J., & Wenderoth, J. D. (2019). Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid hemorrhage: multicenter experience. J Neurointerv Surg, 11(7), 694-698. doi:10.1136/neurintsurg-2018-014363
Figure Legends Figure 1 CT scan brain axial section shows bullet fragments near sylvian fissure with subarachnoid hemorrhage in the sylvian fissure. Figure 2 CT Angiogram of the brain, coronal section shows the Left MCA M2 trunks with vasospasm but no pseudoaneurysm. Figure 3 [A] Left sided ICA angiogram A/P view shows the MCA inferior division pseudoaneurysm (arrow). [B] Left sided ICA angiogram lateral view shows the ICA ophthalmic segment pseudoaneurysm (arrow) with stenosis of the ICA supraclinoid segment. Figure 4 Left sided ICA DSA A/P view post coiling shows complete obliteration of the MCA inferior division pseudoaneurysm. Figure 5 [A] Left sided ICA DSA A/P view post coiling shows recurrence of the MCA inferior division pseudoaneurysm. [B] Left sided ICA DSA lateral view shows stable ICA ophthalmic segment pseudoaneurysm.
8
Figure 6 [A] Left sided ICA DSA A/P view post Pipeline Flex stent deployment with the stent spanning both pseudoaneurysms. [B] Left sided ICA DSA native A/P view shows the location of the Pipeline Flex stent (yellow dotted line). Figure 7 [A] 6 months follow up left sided ICA DSA A/P shows complete obliteration of both pseudoaneurysms. [B] 6 months follow up left sided ICA DSA lateral view shows obliteration of both pseudoaneurysms.
9
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Abbreviations MCA; middle cerebral artery, ICA; internal carotid artery, DSA; digital subtraction angiography, CT; computed tomography, A/P; anteroposterior view, DAPT; dual antiplatelet therapy, SAH; subarachnoid hemorrhage, GCS; Glasgow coma scale, EVD; external ventricular drain.
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Zaid Aljuboori, MD, Kimberley Meyer, APRN, Dale Ding, MD, Robert James, MD.
Disclosures None Conflict of interest None
S1878-8750(19)32623-3
DOI:
https://doi.org/10.1016/j.wneu.2019.10.008
Reference:
WNEU 13479
To appear in:
World Neurosurgery
Received Date: 31 August 2019 Revised Date:
30 September 2019
Accepted Date: 1 October 2019
Please cite this article as: Aljuboori Z, Meyer K, Ding D, James R, Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device., World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.008. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Zaid Aljuboori, MD, Kimberley Meyer, APRN, Dale Ding, MD, Robert James, MD.
Department of Neurological surgery, University of Louisville, KY, USA.
Corresponding Author Zaid Aljuboori, MD, 220 Abraham Flexner way, Ste.1500 Louisville, KY 40202, USA. Tel: (502) 588-0492 Fax: (502) 407- 3256 Email: [email protected]
Keywords Subarachnoid hemorrhage, trauma, flow diversion, pseudoaneurysm.
Acknowledgments None Funding source None
Abstract Objective Traumatic pseudoaneurysms of the proximal middle cerebral artery (MCA) segments are challenging to treat. We describe the management of traumatic internal carotid artery (ICA) and MCA pseudoaneurysms with flow diversion. Methods A 19-year-old male sustained a gunshot wound to the head. Delayed digital subtraction angiography (DSA) showed de novo formation of left ICA ophthalmic segment and left MCA M2 segment pseudoaneurysms. We initially performed coil embolization of the left MCA pseudoaneurysm, but it recurred two weeks later. We treated both pseudoaneurysms with flow diversion using the Pipeline Flex Embolization Device. The patient was maintained on dual antiplatelet therapy (DAPT) of aspirin and ticagrelor. Results Follow-up DSA at 6 months showed complete obliteration of both pseudoaneurysms with patent parent vessels. The patient remained neurologically intact. Conclusion Flow diversion can be an efficacious treatment for traumatic MCA pseudoaneurysms in appropriately selected cases. The risks versus benefits of DAPT must be weighed in trauma settings.
Introduction Middle cerebral artery (MCA) dissections are rare, and they can present with ischemia or hemorrhage 1,2 The ischemic subset of MCA dissections commonly presents with focal neurological deficits or altered mental status, whereas the hemorrhagic subtype usually presents as subarachnoid hemorrhage (SAH).1 The natural history of MCA dissections is poorly defined. Pseudoaneurysms, a type of arterial dissections, are especially challenging to successfully manage due to their high risk of rupture and intracranial haemorrhage.1-4 Multiple treatment options, including endovascular stenting with or without coiling, extracranial-intracranial bypass, and clip wrapping, have been described with varying results.4-9 Recently, endovascular flow diversion has been proven to be effective for the treatment of saccular, fusiform, and blister aneurysms, but evidence supporting its role in the management of intracranial pseudoaneurysms caused by penetrating injuries is lacking. 10-14 The aim of this case report is to describe a case of traumatic intracranial internal carotid artery (ICA) and MCA pseudoaneurysms that were treated with flow diversion.
Case presentation History A 19-year-old male sustained a gunshot wound to the face wherein the bullet entered the right side of the face, traversed the cranial cavity, and exited through the left temporal bone. On admission, the patient’s Glasgow Coma Scale (GCS) was 10T. The patient underwent brain computed tomography (CT) during the initial evaluation, which showed a small left temporal subdural hematoma, bony fragments around the proximal sylvian fissure, and traumatic SAH [Fig.1]. Brain CTA only showed mild vasospasm of the left ICA and MCA [Fig.2]. Initially, the patient was managed conservatively with broad-spectrum antibiotics, external ventricular drain (EVD) placement, and medical therapies to maintain a normal intracranial pressure. On day 7 post injury a follow-up diagnostic cerebral angiogram (DSA) showed two left-sided pseudoaneurysms of the ICA and MCA superior division [Fig. 3A, 3B].
2
On post-injury day 9, we completely occluded the left MCA pseudoaneurysm utilizing coil embolization [Fig. 4], with a plan to observe the left ICA pseudoaneurysm due to its small size. Follow-up DSA two weeks later showed recurrence of the initially coiled MCA pseudoaneurysm and unchanged appearance of the ICA pseudoaneurysm [Fig. 5A, 5B]. We treated both the left MCA and ICA pseudoaneurysms with flow diversion using two telescoping Pipeline Flex Embolization Devices (Medtronic Neurovascular, Irvine, CA) [Fig. 6A, 6B]. The patient was administered dual antiplatelet therapy (DAPT) comprising aspirin 81 mg daily and ticagrelor 90 mg twice daily. The flow diversion procedure was uncomplicated, and the patient’s post-embolization neurological exam improved to a GCS of 15. He was subsequently discharged 4 weeks after the initial presentation to a rehabilitation facility. Post-embolization DSA at 6 months follow-up showed complete obliteration of both the left ICA and MCA pseudoaneurysms with preserved patency of the parent vessels [Fig. 7A, 7B]. The patient was neurologically intact at follow-up with a modified Rankin Scale of 1.
Discussion Traumatic dissections of the MCA remain challenging to manage despite significant advances in cerebrovascular techniques and technology. Traumatic extracranial cerebrovascular injuries are classified by the Biffl grading system, but the classification of intracranial cerebrovascular injuries is not as firmly established.15 Unlike systemic arteries, cerebral arteries have no external elastic lamina, but instead have a well-developed internal elastic lamina. Furthermore, cerebral arteries have paucity of elastic fibers in the medial layer and a very thin adventitia.16 These structural differences lead to increased risk of SAH in intracranial dissections. Intracranial dissections manifesting as intimal flaps can be treated with stenting. However, stenting monotherapy for traumatic intracranial pseudoaneurysms may not sufficiently reduce the elevated risk of rupture and SAH.1- 4 In a cohort of 23 MCA dissections, Lin et al. reported presentations of ischemia and hemorrhage in 88% and 12%, respectively.1 The available treatment options for intracranial pseudoaneurysms include coiling alone, stent-assisted coiling, EC-IC bypass, and
3
clip wrapping.4-9 However, the optimal therapy remains controversial, and management decisions are subject to each physician’s personal and institutional biases. We present a unique and challenging case of a proximal MCA pseudoaneurysm caused by a penetrating head injury which recurred after initial treatment with coil embolization. We decided to treat the MCA pseudoaneurysm due to its high risk of rupture and SAH, which can cause substantial neurological morbidity and mortality. We decided against surgical clipping due to the lack of a true vessel wall to secure a clip. We were also concerned that surgical exploration would incur the risk of parent vessel sacrifice, which could result in an infarct of the dominant hemisphere. Surgical bypass could preserve perfusion to the at-risk brain region, but it is technically challenging and also carries the potential for ischemia, due to the need for temporary occlusion and postoperative bypass occlusion. We initially decided to coil the MCA pseudoaneurysm in order to avoid the necessity of DAPT in the setting of subacute neurotrauma and intracranial surgery. Despite complete occlusion after the initial coiling procedure, the pseudoaneurysm recurred 2 weeks later. We successfully treated both the recurrent MCA pseudoaneurysm and the initially untreated ICA pseudoaneurysm with flow diversion using the Pipeline Flex Embolization Device. Colby et al. reported a similar case in an infant, except the etiology of the injury was iatrogenic rather than traumatic.17 The literature supporting the use of flow diversion for unruptured aneurysms is robust, and the risk for SAH from DAPT is extremely low as true aneurysms have all the component of the vessel wall.10-14 The major limiting factors for the use of flow diversion in setting of acute or subacute intracranial or multisystem trauma the necessity for DAPT, which incurs the risk of significant hemorrhagic complications. We decided to perform flow diversion in the present case due to the lack of more favorable treatment options. We identified reports of stenting monotherapy, stent-assisted coiling, and flow diversion for the treatment of MCA dissections.9,17-19 However, the etiology of the MCA pseudoaneurysm in our case, which arose after a penetrating head injury from a gunshot wound, is unique.
4
We administered a DAPT regimen of aspirin and ticagrelor, since ticagrelor is a reversible platelet inhibitor with mean terminal half-life of 7-8 hours.20 We believed that the relatively shorter half-life of ticagrelor compared to other antiplatelet agents could potentially curb the severity of any hemorrhagic complications. The emergence of the Pipeline Embolization Device with Shield technology, a surface modification which reduces the thrombogenicity of the device, could curtail the necessity of DAPT to antiplatelet monotherapy for flow diversion.21
Conclusion In conclusion, flow diversion is an effective treatment of traumatic MCA pseudoaneurysms in appropriately selected cases. DAPT is necessary to minimize the thromboembolic complications associated with flow diversion, and it should be used judiciously in the setting of acute or subacute trauma. DAPT can be safely administered to patients with recent penetrating head injuries, but the treating physician must weigh its risks versus benefits on a case-by-case basis. Future studies are warranted to clarify the role of flow diversion in the management of MCA dissections and pseudoaneurysms.
Acknowledgements None Disclosures None References 1. Lin CH, Jeng JS, Yip PK. Middle cerebral artery dissections: differences between isolated and extended dissections of internal carotid artery. J Neurol Sci. 2005;235(1-2):37-44. 2. Asaithambi G, Saravanapavan P, Rastogi V, Khan S, Bidari S, Khanna AY, et al. Isolated middle cerebral artery dissection: a systematic review. Int J Emerg Med. 2014;7(1):44.
5
3. Fukuma K, Ihara M, Tanaka T, Morita Y, Toyoda K, Nagatsuka K. Intracranial Cerebral Artery Dissection of Anterior Circulation as a Cause of Convexity Subarachnoid Hemorrhage. Cerebrovasc Dis. 2015;40(1-2):45-51. 4. Puri AS, Gounis MJ, Massari F, Howk M, Weaver J, Wakhloo AK. Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection. J Neurointerv Surg. 2016;8(4): e13. 5. Cikla U, Li Y, Hernandez-Duran S, Kozan A, Baskaya MK. Treatment of Supraclinoid Internal Carotid Artery Iatrogenic Pseudoaneurym with Extracranial-to- Intracranial Bypass and Trapping: Demonstration of Technique with Video Presentation. Turk Neurosurg. 2015;25(2):305-9. 6. O'Shaughnessy BA, Getch CC, Bowman RM, Batjer HH. Ruptured traumatic vertebral artery pseudoaneurysm in a child treated with trapping and posterior inferior cerebellar artery reimplantation. Case report and review of the literature. J Neurosurg. 2005;102(2 Suppl):231-7. 7. Ali MJ, Bendok BR, Tawk RG, Getch CC, Batjer HH. Trapping and revascularization for a dissecting aneurysm of the proximal posteroinferior cerebellar artery: technical case report and review of the literature. Neurosurgery. 2002;51(1):258-62; discussion 62-3. 8. Nishizawa S, Yokoyama T, Sugiyama K, Yokota N. Intracerebral hemorrhage from a ruptured pseudoaneurysm after STA-MCA anastomosis--case report. Neurol Med Chir (Tokyo). 2000;40(8):40812. 9. Nam DH, Park SK. Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity. J Cerebrovasc Endovasc Neurosurg. 2015;17(2):108-12. 10. Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J. Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus. 2017;42(6): E14. 11. Becske T, Brinjikji W, Potts MB, Kallmes DF, Shapiro M, Moran CJ, et al. Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid
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Figure Legends Figure 1 CT scan brain axial section shows bullet fragments near sylvian fissure with subarachnoid hemorrhage in the sylvian fissure. Figure 2 CT Angiogram of the brain, coronal section shows the Left MCA M2 trunks with vasospasm but no pseudoaneurysm. Figure 3 [A] Left sided ICA angiogram A/P view shows the MCA inferior division pseudoaneurysm (arrow). [B] Left sided ICA angiogram lateral view shows the ICA ophthalmic segment pseudoaneurysm (arrow) with stenosis of the ICA supraclinoid segment. Figure 4 Left sided ICA DSA A/P view post coiling shows complete obliteration of the MCA inferior division pseudoaneurysm. Figure 5 [A] Left sided ICA DSA A/P view post coiling shows recurrence of the MCA inferior division pseudoaneurysm. [B] Left sided ICA DSA lateral view shows stable ICA ophthalmic segment pseudoaneurysm.
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Figure 6 [A] Left sided ICA DSA A/P view post Pipeline Flex stent deployment with the stent spanning both pseudoaneurysms. [B] Left sided ICA DSA native A/P view shows the location of the Pipeline Flex stent (yellow dotted line). Figure 7 [A] 6 months follow up left sided ICA DSA A/P shows complete obliteration of both pseudoaneurysms. [B] 6 months follow up left sided ICA DSA lateral view shows obliteration of both pseudoaneurysms.
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Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Abbreviations MCA; middle cerebral artery, ICA; internal carotid artery, DSA; digital subtraction angiography, CT; computed tomography, A/P; anteroposterior view, DAPT; dual antiplatelet therapy, SAH; subarachnoid hemorrhage, GCS; Glasgow coma scale, EVD; external ventricular drain.
Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device.
Zaid Aljuboori, MD, Kimberley Meyer, APRN, Dale Ding, MD, Robert James, MD.
Disclosures None Conflict of interest None