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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 663-665

Endovascular N-Butyl cyanoacrylate glue embolization of traumatic anterior cerebral artery pseudo-aneurysm


1 Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, India
2 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, India

Date of Submission05-Sep-2012
Date of Decision10-Sep-2012
Date of Acceptance23-Oct-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Ajay Kumar
Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105216

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How to cite this article:
Kumar A, Ahuja CK, Khandelwal N, Mathuriya SN. Endovascular N-Butyl cyanoacrylate glue embolization of traumatic anterior cerebral artery pseudo-aneurysm . Neurol India 2012;60:663-5

How to cite this URL:
Kumar A, Ahuja CK, Khandelwal N, Mathuriya SN. Endovascular N-Butyl cyanoacrylate glue embolization of traumatic anterior cerebral artery pseudo-aneurysm . Neurol India [serial online] 2012 [cited 2020 Dec 3];60:663-5. Available from: https://www.neurologyindia.com/text.asp?2012/60/6/663/105216


Sir,

Traumatic intracranial aneurysms are rare entities comprising less than 1% of all intracranial aneurysms [1] and arise as a result of closed head trauma (62%), penetrating wounds (27%), and iatrogenic trauma (11%). [2] We present a rare case of traumatic pseudo-aneurysm of the frontopolar branch of anterior cerebral artery (ACA) successfully managed by intra-arterial embolization using cyanoacrylate glue.

A 19-year-old male patient presented in altered mental state with profuse bleeding from the forehead following an assault. On examination, he was delirious, having eye opening to pain stimulus and localized motor response [Glasgow coma scale 10/15 (E2 V3 M5)] with, pulse rate of 84/min, and BP of 110/70 mmHg. Noncontrast computed tomography (CT) head showed frontal bone displaced depressed fracture with left frontal lobe hematoma extending into the ventricular system [Figure 1]. CT angiography demonstrated a 5 × 4 × 8 mm sized pseudoaneurysm arising from the bifurcation of fronto-polar branch of left ACA [Figure 2]. With conservative management, he gradually improved over the next 8 days. The treatment options were discussed in the inter-specialty meeting and with the family; a consensus decision was made to do endovascular embolization of the aneurysm. Digital subtraction angiography (DSA) performed prior to the procedure confirmed pseudoaneurysm with a narrow neck and significant parent artery spasm. Left internal carotid access was secured by placing a 6F guiding catheter (Envoy, Cordis) in its distal segment. A microcatheter (Echelon 10 -eV3) was then advanced into the left ACA. Multiple attempts were made to reach the aneurysm neck. However, small arterial calibre and significant persistent vasospasm during catheter manipulation made us to stay proximal to the pseudoaneurysm neck, or else we were likely to retrogradely slip into the main trunk or cause a dissection. The pseudoaneurysm was embolized from this position with 30% mixture of cyanoacrylate glue and iodophendylate oil (Lipiodol, Guerbet, Aulnay-Sous-Bois, France). Post-embolization control angiograms revealed complete occlusion of distal parent vessel, pseudoaneurysm, and the cortical arteries supplying the contused brain parenchyma [Figure 3]a-e. The patient regained full consciousness, orientation, and motor power over a period of 10 days following the procedure. He was discharged in a neurologically intact condition and had no fresh complaints at 1 year follow-up.
Figure 1: Post-trauma initial non-contrast computed tomography showing left frontal large acute hematoma with obliquely placed bony fragment (arrow) in anterior hemispheric fissure, hematoma mass effect is evident by chinking of frontal horn of ipsilateral lateral ventricle and mild midline shift

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Figure 2: Computed tomography angiography – Axial base images (a-c) show the pseudoaneurysm (straight arrows), both anterior cerebral artery (elbow arrows) and the bony fragment (curved arrows); sagittal
Multi Planar Reformats reconstruction image precisely showing the relation of these structures. Note the amount of hemorrhage has increased with intraventricular extension in comparison to previous non contrast computed tomography [Figure 1]


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Figure 3: Digital subtraction angiography – Selective left internal carotid artery, early (a) and delayed (b) angiographic images showing saccular pseudoaneurysm arising from frontopolar bifurcation branch of left anterior cerebral artery; note the narrow neck of pseudoaneurysm with spasm. Image (c) reveals the supra-selective microcathater angiographic run showing the portion of feeder artery, pseudoanerysm, and distal small cortical branch arising near the neck of aneurysm; image (d) is showing the glue cast. Post-mbolization control angiogram (e) showing non-opacification of pseudoanerysm and feeder

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Traumatic intracranial aneurysms are rare [1] and may develop as a consequence of direct vessel injury or secondary to an impact against the bony edge. [2],[3] Mortality rates after aneurysm rupture are high ranging from 31 to 54%. [2] Traumatic aneurysms or pseudoaneurysms essentially contain hematomas with disruption of all three vessel wall layers. Spontaneous thrombosis of these aneurysms has been reported [4] though rarely. Because the incidence of rupture is high, a conservative approach is not recommended and an active management strategy is preferred. These aneurysms are difficult to treat either by direct clipping [5] or by endovascular coil embolization, because of a weak wall with absent true collagenous layer. Moreover, the hematoma and gliosis prevent an accurate open surgery. Endovascular approach has been considered a reasonable option with stent reconstruction, embolization with coils/liquid embolics, and parent vessel occlusion being successfully attempted by various authors. [6],[7] These interventional techniques have gained ground over the last decade due to improvisation in the expertise and available hardware.

Parent artery occlusion involves the irreversible elimination of blood flow into the pseudoaneurysm. The only major concern with this procedure is the risk of distal brain parenchymal ischemia, reported to be between 0% and 4.6%. [5] Our case illustrates the difficulty of surgical option due to the adverse adjacent environment. From the various endovascular methods available with us, the option of coil embolization and stent reconstruction was thought of but not considered due to the significant caliber gradient of the parent artery proximal and distal to the pseudoaneurysm and the extremely narrow neck. Our initial plan was to reach as close to the aneurysm neck as possible and use a liquid embolic agent. However, we realized during the procedure that distal catheter placement was extremely demanding and the catheter was recoiling into the main ACA. Also there was recurrent spasm of the feeding artery with a significant risk of arterial dissection and loss of access. Lower concentration (about 30-40%) of N-BCA glue was chosen so that it reaches uptil the pseudoaneurysm, or else the pseudoaneurysm was likely to fill retrogradely by collateral flow. Although we do not intend to propagate its routine use in all such patients, N-BCA glue can be a handy embolic agent in such an anatomy when the operator is unable to reach very close to the pseudoaneurysm.

 
  References Top

1.Benoit BG, Wortzman G. Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 1973;36:127-38.  Back to cited text no. 1
[PUBMED]    
2.Asari S, Nakamura S, Yamada O, Beck H, Sugatani H. Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg 1977;46:795-803.  Back to cited text no. 2
[PUBMED]    
3.Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC, et al. Traumatic intracranial carotid tree aneurysms. Neurosurgery 1998;43:1314-20.  Back to cited text no. 3
[PUBMED]    
4.Morón F, Benndorf G, Akpek S, Dempsy R, Strother CM. Spontaneous thrombosis of a traumatic posterior cerebral artery aneurysm in a child. AJNR Am J Neuroradiol 2005;26:58-60.  Back to cited text no. 4
    
5.Charbel FT, Gonzales-Portillo G, Hoffman W, Cochran E. Distal internal carotid artery pseudoaneurysms: Technique and pitfalls of surgical management: Two technical case reports. Neurosurgery 1999;45:643-8.  Back to cited text no. 5
    
6.Fiorella D, Albuquerque FC, Deshmukh VR, Woo HH, Rasmussen PA, Masaryk TJ, et al. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery 2006;59:291-300.  Back to cited text no. 6
    
7.Medel R, Crowley RW, Hamilton DK, Dumont AS. Endovascular obliteration of an intracranial pseudoaneurysm: The utility of Onyx. J Neurosurg Pediatr 2009;4:445-8.  Back to cited text no. 7
    


    Figures

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