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|Year : 2018 | Volume
| Issue : 1 | Page : 115-117
Pseudoaneurysms of the craniocervical region
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Web Publication||11-Jan-2018|
Dr. Mathew Abraham
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abraham M. Pseudoaneurysms of the craniocervical region. Neurol India 2018;66:115-7
Few will dispute that the elegance of aneurysm surgery is in a properly executed arachnoidal dissection. Delicate and skillfully methodic, it isolates the aneurysm with the least disruption of endothelial integrity, maintaining safety thoroughout, with control of all involved vasculature. Pseudoaneurysms without an organized vessel wall lined by fibrous tissue, evolving from a hematoma, and supported by surrounding tissues with little capability to handle pulsatile arterial flow, do not offer any scope for such an artistic dissection. They have been recognized since long and considered as challenging lesions by neurosurgeons.
Most lesions of the craniocervical region would be traumatic in nature although infection, malignant deposits and invasive therapeutic maneuvers could be the cause in a few.,,, It is also possible that a pseudoaneurysm may piggy back on a ruptured true aneurysm. Blunt trauma from road traffic accidents or penetrating injuries are the main aetiologic factors responsible for traumatic aneurysms.,, This type of trauma may be dominated by other injuries including craniofacial fractures, hematomas or parenchymal contusions. The understanding of the early natural history of intracranial pseudoaneurysms would remain significantly blurred by the outcome of such grave injuries. As imaging in the acute time frame may not be very much focused on the vascular anatomy, their diagnosis would be a product of magnetic resonance imaging (MRI) or contrast computed tomographic (CT) studies done subsequently during which the dominating acute changes may start to resolve. However, symptoms like a pulsatile neck mass, proptosis, tinnitus or a bruit may be highly suggestive. Penetrating trauma would more readily prompt investigation of the integrity of the vascular anatomy. Gross irregularity of the aneurysmal wall, and/or changes in its morphology over short periods of time with the background history of trauma readily suggests the diagnosis.,
The conventional therapeutic option for pseudoaneurysms in the body was repairing the vessel wall with or without a patch or circumferential grafting.,, However, this option remains severely limited within the cranial cavity due to the ergonomic difficulties and ischemic complications. Bypass and trapping was an alternative in skilled hands. Endovascular route has increasingly gained popularity in the management of this condition. Uncovered stents have been effective in the management of arterial dissection with an intimal flap, with a high degree of success. Lesions with a more extensive neck would demand coil embolization also. Compared to stenting, placement of coils would increase the risk of disruption of the poorly formed wall with all its consequences. However, covered stents would be an ideal option for eliminating the pseudo- aneurysm from the lumen of a vessel. Several stent options have been used for this indication., The option of stent placement with the patient undergoing an awake craniotomy would also help in the continuous neurological monitoring of the patient.
The placement of endovascular stents mandates the prompt institution of antithrombotic medication. Thrombotic and embolic complications of stents are best prevented with double anti- platelet agents. The time frame of presentation or diagnosis of pseudoaneurysms after trauma has varied from a few hours to several years. The priority in acute trauma involving the cranial cavity would naturally swing in favor of reducing the mass effect and in reducing the progress of any ongoing or impending haemorragic complications. Endovascular management of acute pseudoaneurysms would be limited by this priority and requirement. However, occluding the vessel involved or placement of a stent across a well-demarcated portion of the involved neck vessel are useful options.
A definitive role of surgery in the management of pseudoaneurysms in the current scenario with highly maneuverable stents being freely available, would be mostly associated with the management of acute hematomas with mass effect. However, more distal pseudoaneurysms can be managed through an endovascular route, only with vessel occlusion. Skilled surgery can possibly avoid this with direct repair or reconstruction. Bypass surgery would become the necessity when pseudoaneurysms are difficult to manage and there is evidence of possible ischemia if the offending vessel is occluded. A balloon occlusion test with hypotensive haemodynamic maneuvers may be considered the gold standard before undertaking bypass procedures.
Numerous case reports related to the innovative management of pseudoaneurysms from various causes are seen in literature. However, published series are relatively rare and numbers few. Most are retrospective, descriptive studies spanning periods of several years. The overall outcomes of documented pseudoaneurysms of the cervicocranial region managed through the endovascular route or through open surgery appear to be good. Most elective interventions for proximal pseudoaneurysms have been endovascular in most series. The published series have not attempted to classify management strategies, outcome or complications on the basis of the temporal profile of symptoms or signs of the disease. They are more focused on the procedural and technical outcomes. The natural history and the essential time frame of management cannot be understood with clarity from most published series. The trend is to manage smaller and proximal lesions with covered stents and the overall success rates appear excellent. The larger lesions are more often subjected to coiling to control the flow across the neck; they are then stented, again a highly effective strategy.
Patients with superficial or subcutaneous pseudoaneurysms, such as those seen on the scalp or superficial temporal artery, are not good candidates for endovascular embolization or stent placement. Surgical excision is an ideal option for these lesions and ischemic complications are unlikely. Being an amorphous category of vascular lesions, management may have to be tailored taking into consideration the whole clinical picture and open surgery would have a significant role to play in appropriate cases. Presentation with raised intracranial pressure, the presence of a hematoma, or encountering a patient with a deteriorating sensorium, are situations that usually warrant an operative management and decompression, keeping in mind the necessity to normalize the general cerebral perfusion at the earliest. The more frequent use of endovascular interventional approach would also create an increasing subset of patients in whom the procedure has failed or has resulted in complications. Open surgery would be needed for this group and these are likely to be even more challenging than the conventional surgeries done earlier. Lesions with a suspected focus of infection or mycotic aneurysms merge imperceptibly with the clinical picture of pseudoaneurysms. Surgical excision including removal of the involved vessels wall as far as possible till a healthy zone is visualized, leaving behind little foreign tissue would be appropriate, combined with any essential reconstruction or revascularization. Endovascular intervention would still have a strong role in selected patients in this group with appropriate modification of technique and materials used.,
The current series described by Cai et al., has been recorded in a time frame of 5 years and is one of the largest single centre series seen in literature. The documented duration of lesions vary vastly (4 days to 8 years) and these have diverse traumatic etiologies. The main strategy has been to use covered stents with addition of coil placements, whenever felt necessary. The outcomes have been excellent with very few recurrences and complications. The study will help to achieve an overall favorable outcome in the management of these difficult lesions. It would serve to be a technical road map for centers with evolving experience in the management of similar lesions. Greater focus on the vascular anatomy during emergency imaging for trauma is likely to reveal many more pseudoaneurysms than we normally perceive. Prospective investigations into the genesis and evolution of these lesions and an assessment of their detailed management may then give us a more vivid understanding of their natural history in craniocervical trauma.
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