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Early angiography, endovascular therapy effective for traumatic intracranial brain aneurysms

Monday, September 29 2008 | Comments

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What's This? Early angiographic diagnosis and endovascular treatment of traumatic intracranial aneurysms (TICAs) appears to be a valuable alternative to surgery, based on the results of a small prospective series with a variety of patient ages, mechanisms of injury, and treatment techniques.

TICAs are frequently associated with a poor prognosis and should be diagnosed as soon as possible to prevent delayed intracranial traumatic hemorrhage and high rates of morbidity and mortality related to bleeding, according to the authors of the study. Until recently, the researchers added, TICAs were typically treated with open surgery or were managed conservatively. Although surgery appears to provide better results than those obtained through conservative treatment, the mortality rate following surgery can be as high as 29%, they noted.

Although there are still few reports of endovascular treatment for TICAs, the authors remarked that recent reports of endovascular exclusion have shown promising results. The investigators examined data from a series of early angiographic diagnoses and various endovascular treatments, including glue, coils, and stents.

From June 2002 to December 2006, diagnostic angiography was performed on 34 patients with moderate to severe traumatic brain injury (TBI) that involved a cranial base fracture or a penetrating brain injury with a tract from the penetrating agent that entered at the pterional area, went through the middle cerebral artery candelabra, and crossed the midline. Angiography confirmed 25 penetrating brain injuries (PBIs) and 9 blunt injuries. A total of 13 TICAs were diagnosed (10 from PBIs and 3 from blunt trauma).

The patients had a mean age of 18.4 years (range, 6 months to 31 years), and 10 were male. Their Glasgow Coma Scale scores at angiography ranged from 5 to 15, and their injuries were derived from terrorist bombings (3 patients), combat explosions (4 patients), gunshot wounds (2 patients), motor vehicle accidents (2), a fall from a height (1 patient), and a stabbing (1 patient).

Angiography was performed for screening in 8 of the patients and for clinical indications in the other 5 patients. The TICAs were diagnosed before symptoms appeared in 8 cases and before rupture in 11 cases. Seven of the aneurysms were located on branches of the middle cerebral artery, 2 were on pericallosal branches of the anterior cerebral artery, and 4 were on the internal carotid artery.

Six of the 13 patients refused angiographic follow-up, but 5 of these patients were followed by periodic computed tomographic angiography (CTA). No recanalization was detected in 12 of the patients. The remaining patient, who had been treated with a bare stent and coils, underwent internal carotid artery coil occlusion and extracranial-intracranial microvascular bypass after a growing intracavernous pseudoaneurysm was detected at follow-up CTA.

There were no procedure-related morbidities or mortalities, and, at a mean clinical follow-up of 2.6 years, none of the patients had experienced delayed bleeding.

"We find that the endovascular approach may have advantages over open surgery," the authors concluded, including being able to perform treatment in the same session as the diagnostic procedure. (Cohen JE, et al. Neurosurgery 2008;63:476-486.)

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