Surgical Neurolog

Aneurysm

Urgent treatment of severe subarachnoid hemorrhage caused by ruptured

traumatic aneurysm of the cavernous internal carotid artery using coil

embolization followed by superficial temporal artery-middle cerebral

artery anastomosis: A case report

Tomohiro Inoue, MDa, Kazuo Tsutsumi, MDa,T, Akira Iijima, MDc, Munehisa Shinozaki, MDa,

Junro Ishida, MDb, Kyoko Yako, MDa

aDepartment of Neurosurgery, bDepartment of Emergency Medicine, Showa General Hospital, Tokyo 187-8510, JapancDepartment of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan

Received 14 June 2004; accepted 29 December 2004

Abstract Background: Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into

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0090-3019/$ – see fro

doi:10.1016/j.surneu.2

Abbreviations: CC

artery; ICP, intracran

subarachnoid hemorrh

T Corresponding

E-mail address: k

the subarachnoid space is associated with increased risk of fatality especially when it is accompanied

by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and

who were treated in a delayed setting have been reported. There has been no successfully treated case

immediately after an injury.

Case Description: We encountered a 48-year-old man who presented with dense SAH immediately

after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm

of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the

subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum

coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery

anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and

drainage, was performed. The patient eventually made a good recovery.

Conclusion: Considering the extremely poor prognosis and unstable nature of a ruptured traumatic

aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding

in conjunction with proper revascularization would be warranted, such as in the present case.

D 2005 Elsevier Inc. All rights reserved.

Keywords: Traumatic aneurysm; Carotid cavernous fistula; Subarachnoid hemorrhage; Coil embolization; STA-MCA

anastomosis

1. Introduction

Although cases involving traumatic cavernous aneurysm

that presented with CCF in the chronic stage have been

cumulated, dealing with the acute cases that presented with

severe SAH caused by traumatic cavernous aneurysm

rupture beyond the sinus wall have not been well discussed.

nt matter D 2005 Elsevier Inc. All rights reserved.

004.12.023

F, carotid cavernous fistula; ICA, internal carotid

ial pressure; MCA, middle cerebral artery; SAH,

age; STA, superficial temporal artery.

author. Tel.: +81 424 61 0052; fax: +81 424 64 7912.

.tsutsumi-md@nifty.com (K. Tsutsumi).

Considering the extremely unstable nature of a ruptured

pseudoaneurysmal wall and anatomically difficult accessi-

bility, management would be very troublesome. We recently

encountered a 48-year-old man who presented with dense

SAH caused by ruptured traumatic cavernous aneurysm im-

mediately after a severe motor vehicle accident. Details

of the case and its management are presented and dis-

cussed herein.

2. Case report

A 48-year-old male patient was admitted to our hospital

emergently after he had a motor vehicle accident. Upon

y 64 (2005) 450–455

Fig. 1. Computed tomography scan performed upon admission showing

dense SAH with some intracranial air.

T. Inoue et al. / Surgical Neurology 64 (2005) 450–455 451

admission, the patient had a Glasgow Coma Scale score of

6 (E1 V1 M4), and his left dilated pupil had diminished

direct light reflex. He showed right hemiplegia and somewhat

spontaneous movement of the left extremities. There was a

5-cm-long scalp laceration in the right forehead. Mannitol

was infused emergently. Computed tomography scan of the

head revealed a dense SAH suggestive of arterial bleeding

and resultant acute hydrocephalus without any evidence of

Fig. 2. Upper left: Anteroposterior left ICA angiogram demonstrating traumatic c

the left anterior cerebral artery and MCA by steal phenomenon. The contralateral

left: Lateral left ICA angiogram revealing traumatic cavernous aneurysm extendin

the superior and inferior ophthalmic veins is also observed. Lower right: Matas’ te

most of the flow that should be directed toward the left MCA was stolen by CC

focal parenchymal hematoma or mass effect (Fig. 1). The

bone window images showed fracture of the right frontal

bone and the left lateral wall of the sphenoid sinus. Emergent

cerebral angiography demonstrated left cavernous traumatic

aneurysm beyond the normal cavernous sinus wall confines

into the subarachnoid space and concomitant high-flow CCF,

with resultant poor opacification of the left anterior cerebral

artery and the middle cerebral artery (MCA) areas. Matas’

test with the right carotid injection revealed cross-flow to the

left anterior cerebral artery area, although most of the flow

that should be directed toward the left MCA area was stolen

by the CCF (Fig. 2). Then, we proceeded to institute

ventricular drainage, and the outlet of the drainage was set

20 cm above the height of the external auditory canal to

obtain moderate ICP control and to prevent rerupture of

traumatic aneurysm by excessive drainage. The patient was

again transferred to the angiography suite. He was kept

deeply sedated with fentanyl and midazolam and was

mechanically ventilated. The systolic blood pressure was

kept below 130 mm Hg with a calcium-channel blocker

infusion. Given the thick SAH and traumatic cavernous

aneurysm of the ICA beyond the normal contour of the

cavernous sinus, we considered that any maneuver into the

cavernous sinus out of the ICA rent might cause a rerupture

avernous aneurysm and high-flow CCF with resultant poor opacification of

cavernous sinus is also filled through the coronary sinus. Upper right/lower

g beyond the normal confines of cavernous sinus. Venous drainage through

st with right carotid injection showing relatively good cross-filling, although

F.

T. Inoue et al. / Surgical Neurology 64 (2005) 450–455452

of traumatic aneurysm. We decided to proceed with

embolization of the cavernous ICA to segmentally isolate

the rent of the ICA, avoiding any irritation to traumatic

aneurysm. Because angiography demonstrated high-flow

CCF and because of the resultant steal phenomenon that was

causing poor opacification, especially in the left MCA area,

we expected better blood flow to the left MCA area by just

embolizing the cavernous ICA. The cavernous ICA across

the rent was embolized with detachable platinum coils

(COOK Inc, Bloomington, IN) through a microcatheter

placed through a transfemoral arterial route. The postem-

bolized common carotid injection on both sides demonstrat-

ed obliteration of the CCF, and the right carotid injection

demonstrated relatively good cross-flow. The left vertebral

angiogram also showed some collateral flow to the left MCA

area through the posterior communicating artery (Fig. 3).

The bruit audible over the left orbit had disappeared as soon

as embolization was accomplished. Subsequent CT scan of

the head did not show ischemic change or delayed contu-

sional change. Immediately after confirming that, he was

transferred to the operating room for superficial temporal

artery (STA)-MCA anastomosis. With scalp dissection

preserving the STA, left frontotemporal craniotomy was

Fig. 3. Upper left, Lateral left carotid injection demonstrating complete oblitera

injection showing relatively good cross-flow and obliteration of retrograde filling o

filling of the left MCA area through the posterior communicating artery.

carried out. One of the temporal branches of the MCA was

prepared, and the frontal branch of the STAwas anastomosed

with 10-0 nylon. The occlusion time was 20 minutes with

15 stitches. The cisternal drain was placed through the

prechiasmatic space. After operation, the systolic blood

pressure was kept below 150 mm Hg for 1 day to ensure

hemostasis and was allowed to rise as high as 200 mm Hg.

Ventriculocisternal irrigation and drainage were initiated with

a lactated Ringer solution and switched to a lactated Ringer

solution containing urokinase (120 IU/mL) from day 2 to

day 5 to enhance the washout of subarachnoid clot. The

solution dripped through the ventricular catheter at a rate of

20 mL/h, and the cisternal catheter was set at the height of

10 cm above the external auditory canal as an outlet.

Although the serial CT scan of the head continued to show

gradual washout of the SAH without any evidence of new

ischemic or hemorrhagic lesions other than small lacunar

strokes of the left anterior limb of the internal capsule, and a

slight contusional low-density area of the right frontal base,

both of which had appeared on day 1, the patient remained

semicomatose. The angiography performed on day 6 demon-

strated the filling of the entire leftMCA area by the STA in the

presence of diffuse vasospasm of both hemispheres (Fig. 4).

tion of the left ICA. Upper right/lower left, Anteroposterior right carotid

f CCF. Lower right, Lateral left vertebral injection revealing slight collateral

Fig. 4. Upper left/upper right: Lateral left carotid injection on day 6 demonstrating the filling of the entire left MCA area by the STA. Some spasms are also

observed through the M1 to C1 portions in delayed phase. Lower left, Anteroposterior right carotid injection on day 6 showing diffuse spasm especially in M1

and A1 compared with Fig. 3. Lower right, Lateral left vertebral injection on day 6 showing spasm especially in the basilar artery compared with Fig. 3.

T. Inoue et al. / Surgical Neurology 64 (2005) 450–455 453

From day 6 to day 14, the patient was maintained in a

mildly hypervolemic and hypertensive state, with the cisternal

catheter kept open at the height of 10 cm above the

external auditory canal to obtain adequate ICP control. He

gradually regained consciousness and then declined with the

development of normal pressure hydrocephalus. Placement of

ventriculoperitoneal shunt was performed on day 34. After

that, he demonstrated remarkable neurological recovery,

Fig. 5. Follow-up CT scan of the head performed 4 months after injury.

Ventriculoperitoneal shunt was placed through the right frontal horn.

progressing to walking independently, although he needed

some help to carry out usual daily activities when transferred

to a rehabilitation institute. Fourmonths after his initial injury,

the patient became independentwithmost daily activitieswith

only slight residual aphasia. Occupational therapywas used to

help him regain his job. The CT scan of the head revealed no

additional lesions (Fig. 5).

3. Discussion

Traumatic cavernous aneurysms and CCFs resulting

from a skull base fracture after a severe head injury are

very difficult lesions to manage. To exclude traumatic

aneurysm and concomitant CCF from circulation, versatile

therapeutic modalities including proximal occlusion and

direct surgical repair, mostly replaced by endovascular

techniques since the development of the detachable balloon

and stent in combination with coil embolization, are

discussed [2,3,9,12,13,15].

Most of the reported cases of successfully treated

traumatic cavernous aneurysm and CCF were managed in

delayed stages such as days, weeks, and sometimes up to

months after the initial trauma. The patients presented acutely

or subacutely with the development of typical cavernous

T. Inoue et al. / Surgical Neurology 64 (2005) 450–455454

sinus syndrome symptoms including increased ICP, rapidly

progressive proptosis, diminished visual acuity, and transient

ischemic attack by steal phenomenon [2,4-9,12,13]. Some

patients presented with abrupt SAH if the traumatic

aneurysm extended and ruptured beyond the sinus wall into

the subarachnoid space, and were associated with poorer

outcome [1,4,6].

The natural history and treatment of ruptured traumatic

cavernous aneurysms with high-flow CCF that presented

with dense SAH immediately after a head trauma, seem to

do not been well discussed have probably because this

situation is almost always fatal. Considering the fragile

hemostasis of ruptured traumatic aneurysm and the possible

steal phenomenon through high-flow CCF in the presence

of dense SAH, which can subsequently, cause increased ICP

by hydrocephalus and vasospasm both further compromis-

ing cerebral circulation, there will be no controversy on

extremely poor prognosis. If any chance for recovery exists,

rather than just conservative treatment, which is apparently

dismal, definitive and immediate hemostasis and proper

revascularization followed by aggressive therapy to SAH

would be warranted.

We chose coil embolization of the cavernous ICA rather

than trying to pack the fistula and traumatic aneurysm itself

with balloon or coils aiming at the preservation of ICA flow.

Any maneuver into the cavernous sinus and traumatic

aneurysm may resulted in catastrophic rebleeding into the

subarachnoid space, given preexisting massive SAH. This

means that the relatively wide dural rent of the superior wall

of the cavernous sinus and beyond it the aneurysmal wall

would be just composed of encapsulated hematomas. Even

experienced surgeons have suggested the difficulty of

detachable balloon or coil placements into the pseudoaneu-

rysm, because of the lack of tissue plane or wall except for

thrombus to keep the embolic material in place against the

fistula orifice [7]. Although Matas’ test after ICA emboli-

zation demonstrated good cross-flow through the anterior

communicating artery, we considered that if any spasm

happened to the anterior communicating artery, ischemic

damage of the left hemisphere would be devastating. STA-

MCA anastomosis would be necessary to overcome the

subsequent spasm period. In fact, a postoperative angiogram

performed on day 6 demonstrated filling of the entire left

MCA area by the STA in the presence of diffuse vasospasm

of both hemispheres. The definitive and immediate hemo-

stasis with cavernous ICA embolization also enabled us to

use ventriculocisternal irrigation with urokinase to wash out

dense SAH in the acute stage, which contributed to relieve

vasospasm [10,11,14].

In conclusion, cavernous ICA occlusion across the ICA

rent in conjunction with proper revascularization could be

more suitable compared with an endovascular maneuver

trying to pack the sinus or traumatic aneurysm with

preservation of ICA flow in cases of ruptured traumatic

cavernous aneurysm with severe SAH, especially consider-

ing the extreme instability of a ruptured traumatic aneurysm

in the acute stage. Immediate and definitive hemostasis could

also enable the aggressive treatment of SAH thereafter.

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Commentary

The authors made the right decision of permanently

occluding the ICA with coils. I would have chosen to use

retrievable coils, at least for the first coil, rather than

pushable coils that cannot be retrieved before being

detached, if for any reason the coil migrates into a nondesired

area. It should be noted that Matas’ test in a case of high-flow

CCF has no value to predict whether or not a patient will