Brushing Against the Tentorium: Traumatic Pseudoaneurysm of the Posterior Cerebral Artery
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Brushing Against the Tentorium: Traumatic Pseudoaneurysm of the Posterior Cerebral Artery Charlotte E. Dujardin1, Harry Cloft2 and Eelco F. M. Wijdicks3* © 2019 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Both blunt and penetrating traumatic brain injury (TBI) may cause damage to the intracranial vasculature. Blunt force brings about sudden deceleration, and injury may develop in arteries that are in the anatomic vicinity of the falx, tentorium, or bone. Displacement of brain tissue and its vasculature allows arteries to brush against these hard surfaces. This injury causes a wall hematoma and rapidly creates ballooning of the outer layer of the artery, also known as a pseudoaneurysm. The aneurysm is unstable and may rupture, usually after some asymptomatic time interval. These intracranial pseudoaneurysms are at different sites (most commonly the pericallosal branches of the anterior cerebral artery, followed by branches of the middle cerebral artery and the posterior cerebral artery). These aneurysms remain an unusual complication of blunt TBI. In contract, penetrating injury (often from shrapnel) can damage any cerebral artery and in a series including penetrating injury traumatic aneurysms were also found in the cavernous portion of the carotid artery and presenting with epistaxis [1]. We present a case of a pseudoaneurysm of the posterior cerebral artery that was situated on a temporal branch and was detected while evaluating an unusual pattern of tentorial blood. This raises the important question of which patient with TBI may need a cerebral angiogram.
Case Description A 65-year-old woman, with major comorbidities of congestive heart failure, hypertension, and atrial fibrillation treated with aspirin, fell flat on her face while *Correspondence: [email protected] 3 Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, Rochester, MN 55905, USA Full list of author information is available at the end of the article
intoxicated. For 3 days, she developed massive facial ecchymoses and spent most of the day in bed until she developed a seizure. On admission, she opened her eyes to pain and localized to pain but with some evidence of a left hemiparesis. She required mechanical ventilation for airway protection. Her computed tomography (CT) scan showed subdural hematomas and a large collection of blood on the tentorium (Fig. 1 upper row). Her initial blood gas showed a lactic acidosis consistent with a recent seizure. Subsequently, she developed epilepsia partialis continua in the left arm and leg but was successfully treated with an escalating number of anti-seizure medications. Further CT imaging and a cerebral angiogram revealed a small pseudoaneurysm on the temporal branch of the posterior cerebral artery (Fig. 1 lower row). Two transthoracic echocardiograms showed no valvular vegetations, and blood cultures were repeatedly negative. A single 1 mm × 3 cm helical coil was placed just proximal to aneurysm (see supplemental figures). Sh
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