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Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report
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Surgical Neurology 71 (2009) 701 – 704 www.surgicalneurology-online.com
Trauma
Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report Hyoung-Joon Chun, MD, Hyeong-Joong Yi, MD⁎ Department of Neurosurgery, Hanyang University Medical Center, Seoul 133-792, South Korea Received 27 September 2007; accepted 17 November 2007
Abstract
Background: Extracranial pseudoaneurysm is barely noticed after head injury, and therefore, recognizing such sequels is amenable when there is severe initial injury, unexplained intracranial bleeding, or neurologic sequelae. We report such an unexpected case of intraorbital pseudoaneurysm presenting as delayed intraparenchymal hemorrhage. Case Description: A 71-year-old man with traumatic brain injury sustained delayed intraparenchymal hemorrhage after unremarkable surgical evacuation. Suspicious intraorbital mass was shown adjacent to the fracture line of medial orbital wall. Catheter angiogram revealed peripheral, extracranial ophthalmic artery pseudoaneurysm, and endovascular occlusion was attempted. The patient made gradual recovery with radiographic evidence of disappeared pseudosac and resolved intracranial hematoma. Conclusion: Traumatic aneurysm of peripheral ophthalmic artery should be strongly suspected when there is skull fracture at the orbital wall or persistent or delayed intraparenchymal hemorrhage despite proper surgical hematoma evacuation, and in such case, swift endovascular occlusion can be done safely. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Delayed intraparenchymal hemorrhage; Peripheral ophthalmic artery; Pseudoaneurysm; Skull fracture; Traumatic brain injury
1. Introduction
2. Case report
The presence of traumatic aneurysm is seldom suspected in the cranium unless there is bony disruption along the course of responsible artery, severe brain contusion, otherwise unexplained neurologic deficits, or intracranial bleeding [9]. Even if there is strong evidence of the above features, extracranial pseudoaneurysm still provokes diagnostic perplexity because of rare incidence, variegated clinical manifestations, and unexpected natural course. We herein briefly describe a very infrequent case of traumatic pseudoaneurysm arising at peripheral ophthalmic artery within the orbit. Some important diagnostic clues and appropriate management are also presented.
A 71-year-old man complained of headache and difficult breathing after a car accident and then was referred to our institute. Although he was alert and free of any neurologic deficits, he had multiple traumatic lesions including chest contusion, multiple rib fractures, and periorbital contusion, as well as fractures on the medial orbital wall, zygoma, frontal sinus, and nasoethmoidal ridge. Admission head CT scan showed thin subdural and intraparenchymal hematoma on the left frontal lobe. At fourth hospital day during careful critical care, he became unresponsive, and immediate CT scan revealed increased intracranial bleeding (Fig. 1A). By craniotomy, hematoma was successfully evacuated, but any culprit evidence of vault fracture or cortical contusion was discovered all through the operative procedure (Fig. 1B). Postoperatively, he regained consciousness with residual headache and mild right arm weakness (grade IV). Head CT
Abbreviations: CT, computed tomography; POD, postoperative day. ⁎ Corresponding author. Tel.: +82 2 2290 8499; fax: +82 2 2281 0954. E-mail address: [email protected] (H.-J. Yi). 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.11.018
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H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
Fig. 1. A: Computed tomographic scan reveals increased frontal subdural and intraparenchymal hematoma compared to the initial scan. B: Immediate postevacuation scan shows significant reduction of hematoma. C: Follow-up scan on POD 3 reveals increasing frontal intraparenchymal hematoma. D: Orbital CT scan shows semilunar mass lesion in the orbital space adjacent to the fracture in the medial orbital wall and ethmoid.
scan on third POD showed further increased intraparenchymal hematoma when compared with immediate postoperative scan (Fig. 1C). Interim orbital CT scan showed a semilunar mass within the orbit abutting fracture line of the left ethmoid and medial orbital wall (Fig. 1D). Transfemoral catheter angiography was performed to identify suspicious vascular lesion that was responsible for such delayed bleeding, and pseudoaneurysm was found at peripheral
ophthalmic artery locating within the medial orbital canal adjacent to the fracture (Fig. 2A). Endovascular occlusion was attempted accordingly. A microcatheter (Prowler 14, Cordis, J&J, Miami, Fla) was navigated into the peripheral ophthalmic artery. However, because of acute angle at transition into the peripheral segment and fear for inadvertent occlusion of the central retinal artery, scrupulous handling had to be done several times. All of a sudden, vasospasm
H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
703
appeared along the distal arterial course of pseudosac instead of the central retinal artery, and the pseudosac did not show up any further (Fig. 2B). After the procedure, he did not complain of any visual symptoms. At 14th POD, repeated angiography failed to reveal any residual pseudosac, and head CT scan also showed resolved hematoma (Fig. 3). He was transferred to the pulmonary
Fig. 3. Head CT scan on POD 14 shows resolved hematoma.
department for chest care and still has been free of any neurologic deficit up to the last follow-up visit. 3. Discussion
Fig. 2. A: Transfemoral catheter angiogram of the left carotid shows irregular, peripherally located pseudoaneurysm on the ethmoidal branch of the ophthalmic artery. B: Sudden vasospasm develops along the pathway of microcatheter, and pseudosac does not show up any further.
The ophthalmic artery, the first large branch of the internal carotid artery after its exit from the cavernous sinus, enters the orbit and then courses lateral to the optic nerve. Within the orbital cavity, several branches including central retinal, lacrimal, recurrent meningeal, and posterior ciliary arteries arise sequentially. And then, it gives rise to the anterior and posterior ethmoidal arteries, which pass through the anterior and posterior ethmoidal canals [5]. Because of this relatively fixed structure at narrow space of the ethmoidal arteries takeoff, fracture crossing this point consequently seemed to bring about pseudoaneurysm by partial vessel wall tearing. Through the crack that was enlarged by arterial pulsation, pseudoaneurysm leaked clots and subsequent intracranial bleeding occurred. Traumatic aneurysm results from either a direct injury to the arterial wall by skull fracture or from accelerationinduced shear by different velocity between brain and skull. It is generally believed that pseudoaneurysm is caused by a minor tear in arterial wall after blunt or penetrating injury, which is sealed off by a clot, recanalizing later and forming a false lumen [10]. These pseudoaneurysms gradually enlarge and rupture anytime, and thus, prognosis is generally poor. A mortality rate of 20% has been quoted in the literature [2]. It is difficult to identify traumatic aneurysm at first hand. Because traumatic aneurysms can occur after mild head injury,
704
H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
decision to when and why the cerebral angiography should be performed is not easy. However, high index of suspicion should be placed when such a delayed or persistent intraparenchymal hemorrhage is present despite proper surgical management. Because of very few detailed reports on peripheral ophthalmic artery aneurysms, their clinical features are not fully understood. Most common neurological symptom of intracranial ophthalmic artery aneurysms is progressive visual disturbance, whereas symptoms associated with extracranial intraorbital counterpart are exophthalmos and visual loss. All these symptoms result from mass effect of the aneurysm [3,7,12]. In the current case, CT scan revealed intraorbital mass adjacent to fracture line of the medial orbital wall and ethmoid, and we thought the ethmoidal branch of ophthalmic artery was responsible for arterial segment of pseudosac. Although the pseudoaneurysm did not manifest as compressive lesion, ceaseless leakage through the fracture line ultimately results in significant clinical attention. Occurrence of traumatic extracranial pseudoaneurysm has been reported in most cases at the middle meningeal artery [1,2,11], albeit infrequently. Traumatic pseudoaneurysm of the ophthalmic artery has been exclusively reported on the intracranial portion [6,8], and in such instance, acceleration-shear injury appears as a main pathophysiologic process. In the present case, direct insult such as bony disruption and sudden impact on the arterial wall is an apparent cause. As for the treatment of ophthalmic artery pseudoaneurysm involved, identification of sufficient collateral circulation of the orbital contents is most crucial. If these collaterals are sufficient, defective treatment can be obtained with occlusion of the proximal vessel segment, avoiding the risk of retrograde filling [1]. The decision on whether to conduct microsurgical trapping and resection or endovascular occlusion relies on patient's symptoms and location of the responsible aneurysm [4]. Endovascular occlusion with glue or other embolic material provides promising results, and once the ruptured aneurysm totally disappears, recanalization seemed to be quite less likely to occur.
4. Conclusion It is important to be aware of possible ophthalmic pseudoaneurysms in cases of head injury on the frontal and orbitofacial areas, particularly if the fracture crosses the anticipated location of the peripheral ophthalmic artery and unexplained delayed intracranial bleeding persists postoperatively. Once such lesion is identified, prompt endovascular occlusion can prevent unexpected sequelae. References [1] Bozzetto-Ambrosi P, Andrade G, Azevedo-Filho H. Traumatic pseudoaneurysm of the middle meningeal artery and cerebral intraparenchymal hematoma: case report. Surg Neurol 2006;66(S): S29-S31. [2] Bruneau M, Gustin T, Zekhnini K, et al. Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage: case report and literature review. Surg Neurol 2002;57:174-8. [3] Dehdashti AR, Safran AB, Martin JB, et al. Intraorbital ophthalmic artery aneurysm associated with basilar tip saccular aneurysm. Neuroradiology 2002;44:600-3. [4] Johnson HC, Walker AE. Angiographic diagnosis of spontaneous thrombosis of the internal and common carotid artery. J Neurosurg 1951;8:631-59. [5] Lasjaunias P, Berenstein A, ter Brugge JG. Surgical neuroangiography. Clinical vascular anatomy and variations, vol 1. 2nd ed. Berlin Springer; 2001. p. 435-55. [6] Ogawa A, Tominaga T, Yoshimoto T, et al. Intraorbital ophthalmic artery aneurysm. Neurosurgery 1992;31:1102-4. [7] Piché SL, Haw CS, Redekop GJ, et al. Rare intracanalicular ophthalmic aneurysm: endovascular treatment and review of the literature. AJNR Am J Neuroradiol 2005;26:1929-31. [8] Rahmat H, Abbassioun K, Amirjamshidi A. Pulsating unilateral exophthalmos due to traumatic aneurysm of the intraorbital ophthalmic artery: case report. J Neurosurg 1984;60:630-2. [9] Singh M, Ahmad FU, Mahapatra AK. Traumatic middle meningeal artery aneurysm causing intracerebral hematoma: a case report and review of literature. Surg Neurol 2006;66:321-3. [10] Srinivasan A, Lesiuk H, Goyal M. Spontaneous resolution of posttraumatic middle meningeal artery pseudoaneurysm. AJNR Am J Neuroradiol 2006;27:882-3. [11] Tsutsumi M, Kazekawa K, Tanaka A, et al. Traumatic middle meningeal artery pseudoaneurysm and subsequent fistular formation with the cavernous sinus. Surg Neurol 2002;58:325-8. [12] Yanaka K, Matsumaru Y, Kamezaki T, et al. Ruptured aneurysm of the ophthalmic artery trunk demonstrated by three-dimensional rotational angiography: case report. Neurosurgery 2002;51:1066-70.
Surgical Neurology 71 (2009) 701 – 704 www.surgicalneurology-online.com
Trauma
Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report Hyoung-Joon Chun, MD, Hyeong-Joong Yi, MD⁎ Department of Neurosurgery, Hanyang University Medical Center, Seoul 133-792, South Korea Received 27 September 2007; accepted 17 November 2007
Abstract
Background: Extracranial pseudoaneurysm is barely noticed after head injury, and therefore, recognizing such sequels is amenable when there is severe initial injury, unexplained intracranial bleeding, or neurologic sequelae. We report such an unexpected case of intraorbital pseudoaneurysm presenting as delayed intraparenchymal hemorrhage. Case Description: A 71-year-old man with traumatic brain injury sustained delayed intraparenchymal hemorrhage after unremarkable surgical evacuation. Suspicious intraorbital mass was shown adjacent to the fracture line of medial orbital wall. Catheter angiogram revealed peripheral, extracranial ophthalmic artery pseudoaneurysm, and endovascular occlusion was attempted. The patient made gradual recovery with radiographic evidence of disappeared pseudosac and resolved intracranial hematoma. Conclusion: Traumatic aneurysm of peripheral ophthalmic artery should be strongly suspected when there is skull fracture at the orbital wall or persistent or delayed intraparenchymal hemorrhage despite proper surgical hematoma evacuation, and in such case, swift endovascular occlusion can be done safely. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Delayed intraparenchymal hemorrhage; Peripheral ophthalmic artery; Pseudoaneurysm; Skull fracture; Traumatic brain injury
1. Introduction
2. Case report
The presence of traumatic aneurysm is seldom suspected in the cranium unless there is bony disruption along the course of responsible artery, severe brain contusion, otherwise unexplained neurologic deficits, or intracranial bleeding [9]. Even if there is strong evidence of the above features, extracranial pseudoaneurysm still provokes diagnostic perplexity because of rare incidence, variegated clinical manifestations, and unexpected natural course. We herein briefly describe a very infrequent case of traumatic pseudoaneurysm arising at peripheral ophthalmic artery within the orbit. Some important diagnostic clues and appropriate management are also presented.
A 71-year-old man complained of headache and difficult breathing after a car accident and then was referred to our institute. Although he was alert and free of any neurologic deficits, he had multiple traumatic lesions including chest contusion, multiple rib fractures, and periorbital contusion, as well as fractures on the medial orbital wall, zygoma, frontal sinus, and nasoethmoidal ridge. Admission head CT scan showed thin subdural and intraparenchymal hematoma on the left frontal lobe. At fourth hospital day during careful critical care, he became unresponsive, and immediate CT scan revealed increased intracranial bleeding (Fig. 1A). By craniotomy, hematoma was successfully evacuated, but any culprit evidence of vault fracture or cortical contusion was discovered all through the operative procedure (Fig. 1B). Postoperatively, he regained consciousness with residual headache and mild right arm weakness (grade IV). Head CT
Abbreviations: CT, computed tomography; POD, postoperative day. ⁎ Corresponding author. Tel.: +82 2 2290 8499; fax: +82 2 2281 0954. E-mail address: [email protected] (H.-J. Yi). 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2007.11.018
702
H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
Fig. 1. A: Computed tomographic scan reveals increased frontal subdural and intraparenchymal hematoma compared to the initial scan. B: Immediate postevacuation scan shows significant reduction of hematoma. C: Follow-up scan on POD 3 reveals increasing frontal intraparenchymal hematoma. D: Orbital CT scan shows semilunar mass lesion in the orbital space adjacent to the fracture in the medial orbital wall and ethmoid.
scan on third POD showed further increased intraparenchymal hematoma when compared with immediate postoperative scan (Fig. 1C). Interim orbital CT scan showed a semilunar mass within the orbit abutting fracture line of the left ethmoid and medial orbital wall (Fig. 1D). Transfemoral catheter angiography was performed to identify suspicious vascular lesion that was responsible for such delayed bleeding, and pseudoaneurysm was found at peripheral
ophthalmic artery locating within the medial orbital canal adjacent to the fracture (Fig. 2A). Endovascular occlusion was attempted accordingly. A microcatheter (Prowler 14, Cordis, J&J, Miami, Fla) was navigated into the peripheral ophthalmic artery. However, because of acute angle at transition into the peripheral segment and fear for inadvertent occlusion of the central retinal artery, scrupulous handling had to be done several times. All of a sudden, vasospasm
H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
703
appeared along the distal arterial course of pseudosac instead of the central retinal artery, and the pseudosac did not show up any further (Fig. 2B). After the procedure, he did not complain of any visual symptoms. At 14th POD, repeated angiography failed to reveal any residual pseudosac, and head CT scan also showed resolved hematoma (Fig. 3). He was transferred to the pulmonary
Fig. 3. Head CT scan on POD 14 shows resolved hematoma.
department for chest care and still has been free of any neurologic deficit up to the last follow-up visit. 3. Discussion
Fig. 2. A: Transfemoral catheter angiogram of the left carotid shows irregular, peripherally located pseudoaneurysm on the ethmoidal branch of the ophthalmic artery. B: Sudden vasospasm develops along the pathway of microcatheter, and pseudosac does not show up any further.
The ophthalmic artery, the first large branch of the internal carotid artery after its exit from the cavernous sinus, enters the orbit and then courses lateral to the optic nerve. Within the orbital cavity, several branches including central retinal, lacrimal, recurrent meningeal, and posterior ciliary arteries arise sequentially. And then, it gives rise to the anterior and posterior ethmoidal arteries, which pass through the anterior and posterior ethmoidal canals [5]. Because of this relatively fixed structure at narrow space of the ethmoidal arteries takeoff, fracture crossing this point consequently seemed to bring about pseudoaneurysm by partial vessel wall tearing. Through the crack that was enlarged by arterial pulsation, pseudoaneurysm leaked clots and subsequent intracranial bleeding occurred. Traumatic aneurysm results from either a direct injury to the arterial wall by skull fracture or from accelerationinduced shear by different velocity between brain and skull. It is generally believed that pseudoaneurysm is caused by a minor tear in arterial wall after blunt or penetrating injury, which is sealed off by a clot, recanalizing later and forming a false lumen [10]. These pseudoaneurysms gradually enlarge and rupture anytime, and thus, prognosis is generally poor. A mortality rate of 20% has been quoted in the literature [2]. It is difficult to identify traumatic aneurysm at first hand. Because traumatic aneurysms can occur after mild head injury,
704
H.-J. Chun, H.-J. Yi / Surgical Neurology 71 (2009) 701–704
decision to when and why the cerebral angiography should be performed is not easy. However, high index of suspicion should be placed when such a delayed or persistent intraparenchymal hemorrhage is present despite proper surgical management. Because of very few detailed reports on peripheral ophthalmic artery aneurysms, their clinical features are not fully understood. Most common neurological symptom of intracranial ophthalmic artery aneurysms is progressive visual disturbance, whereas symptoms associated with extracranial intraorbital counterpart are exophthalmos and visual loss. All these symptoms result from mass effect of the aneurysm [3,7,12]. In the current case, CT scan revealed intraorbital mass adjacent to fracture line of the medial orbital wall and ethmoid, and we thought the ethmoidal branch of ophthalmic artery was responsible for arterial segment of pseudosac. Although the pseudoaneurysm did not manifest as compressive lesion, ceaseless leakage through the fracture line ultimately results in significant clinical attention. Occurrence of traumatic extracranial pseudoaneurysm has been reported in most cases at the middle meningeal artery [1,2,11], albeit infrequently. Traumatic pseudoaneurysm of the ophthalmic artery has been exclusively reported on the intracranial portion [6,8], and in such instance, acceleration-shear injury appears as a main pathophysiologic process. In the present case, direct insult such as bony disruption and sudden impact on the arterial wall is an apparent cause. As for the treatment of ophthalmic artery pseudoaneurysm involved, identification of sufficient collateral circulation of the orbital contents is most crucial. If these collaterals are sufficient, defective treatment can be obtained with occlusion of the proximal vessel segment, avoiding the risk of retrograde filling [1]. The decision on whether to conduct microsurgical trapping and resection or endovascular occlusion relies on patient's symptoms and location of the responsible aneurysm [4]. Endovascular occlusion with glue or other embolic material provides promising results, and once the ruptured aneurysm totally disappears, recanalization seemed to be quite less likely to occur.
4. Conclusion It is important to be aware of possible ophthalmic pseudoaneurysms in cases of head injury on the frontal and orbitofacial areas, particularly if the fracture crosses the anticipated location of the peripheral ophthalmic artery and unexplained delayed intracranial bleeding persists postoperatively. Once such lesion is identified, prompt endovascular occlusion can prevent unexpected sequelae. References [1] Bozzetto-Ambrosi P, Andrade G, Azevedo-Filho H. Traumatic pseudoaneurysm of the middle meningeal artery and cerebral intraparenchymal hematoma: case report. Surg Neurol 2006;66(S): S29-S31. [2] Bruneau M, Gustin T, Zekhnini K, et al. Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage: case report and literature review. Surg Neurol 2002;57:174-8. [3] Dehdashti AR, Safran AB, Martin JB, et al. Intraorbital ophthalmic artery aneurysm associated with basilar tip saccular aneurysm. Neuroradiology 2002;44:600-3. [4] Johnson HC, Walker AE. Angiographic diagnosis of spontaneous thrombosis of the internal and common carotid artery. J Neurosurg 1951;8:631-59. [5] Lasjaunias P, Berenstein A, ter Brugge JG. Surgical neuroangiography. Clinical vascular anatomy and variations, vol 1. 2nd ed. Berlin Springer; 2001. p. 435-55. [6] Ogawa A, Tominaga T, Yoshimoto T, et al. Intraorbital ophthalmic artery aneurysm. Neurosurgery 1992;31:1102-4. [7] Piché SL, Haw CS, Redekop GJ, et al. Rare intracanalicular ophthalmic aneurysm: endovascular treatment and review of the literature. AJNR Am J Neuroradiol 2005;26:1929-31. [8] Rahmat H, Abbassioun K, Amirjamshidi A. Pulsating unilateral exophthalmos due to traumatic aneurysm of the intraorbital ophthalmic artery: case report. J Neurosurg 1984;60:630-2. [9] Singh M, Ahmad FU, Mahapatra AK. Traumatic middle meningeal artery aneurysm causing intracerebral hematoma: a case report and review of literature. Surg Neurol 2006;66:321-3. [10] Srinivasan A, Lesiuk H, Goyal M. Spontaneous resolution of posttraumatic middle meningeal artery pseudoaneurysm. AJNR Am J Neuroradiol 2006;27:882-3. [11] Tsutsumi M, Kazekawa K, Tanaka A, et al. Traumatic middle meningeal artery pseudoaneurysm and subsequent fistular formation with the cavernous sinus. Surg Neurol 2002;58:325-8. [12] Yanaka K, Matsumaru Y, Kamezaki T, et al. Ruptured aneurysm of the ophthalmic artery trunk demonstrated by three-dimensional rotational angiography: case report. Neurosurgery 2002;51:1066-70.