J Neurosurg 49:100-102, 1978
Traumatic intracranial internal carotid aneurysm due to gunshot wound Case report GIUSEPPE SALAR, M . D . , AND SALVATORE MINGRINO, M . D .
Department of Neurosurgery, University of Padua, Padua, Italy v' This patient developed an intracranial carotid artery aneurysm after a bullet wound. A review of the related literature, and the pathogenesis of traumatic false and true aneurysms are presented. KEY Wol~oS 9 traumatic aneurysm false aneurysm 9 true aneurysm
F
ORMATION of intracranial arterial aneurysms after intracranial penetrating missile wounds is unusual. Meirowsky9 found no aneurysms in a series of 879 patients with craniocerebral missile wounds reported during the Korean War. Hammon 7 analyzed 2187 cases of craniocerebral wounds due to bullet or shell fragments seen in military hospitals during the Vietnam conflict, and observed only two cases of "pseudoaneurysm." In our series of 665 cases of intracranial aneurysms diagnosed angiographically, only one followed injury from an intracranial gunshot wound. Case Report
A 26-year-old man attempted suicide by three successive shots from a Flobert-type (22-caliber rim fire) gun in the right temporal region. Upon admission the patient was awake and presented no neurological deficit. In the right temporal region there was a small circular penetrating wound, about 5 mm in diameter. X-ray examination showed three intracranial foreign bodies, one of which lay immediately adjacent to the right sellar region. After 3 days the patient manifested paralysis of the right abducens and 100
9 gunshot wound
9
oculomotor nerves. The same day right brachial angiography (Fig. 1) showed an aneurysm of the intracavernous portion of the carotid artery just adjacent to the parasellar bullet. Fifteen days later, the abducens paralysis became worse and ptosis appeared. Right carotid angiography (Fig. 2) showed marked enlargement of the aneurysm. The patient has never demonstrated any signs of subarachnoid hemorrhage (SAH). In view of the rapid progression of symptoms and enlargement of the aneurysmal sac the right common carotid artery was ligated following the technique of Smith. TM The postoperative course was uneventful. The deficit of the third and fifth cranial nerves remained unchanged. The patient slowly recovered from his severe depression and was discharged after about 2 months. Follow-up examination after 4 years showed that the ptosis was improved, while the paralysis of the abducens nerve was unchanged. Discussion
Among the possible vascular complications of head injuries the most frequent are carotidcavernous fistula, internal carotid artery thrombosis, and aneurysms of the extra-
J. Neurosurg. / Volume 49 / July, 1978
Intracranial internal carotid traumatic aneurysm
FIG. 1. Right brachial angiography, anteroposterior (left) and lateral (right) views, 3 days after intracranial penetration of the bullets. The numbers indicate the three bullets, the last of which is adjacent to the syphon and caused the arterial dilatation (arrows).
FIG. 2. Right carotid angiography, anteroposterior (left) and lateral (right) views, 15 days after intracranial penetration of the bullets. The aneurysm (arrows) has greatly enlarged since the first angiogram.
J. Neurosurg. / Volume 49 / July, 1978
]01
G. S a l a r a n d S. M i n g r i n o cranial internal carotid artery. It is also recognized that trauma may contribute to rupture of pre-existing arterial aneurysms; Locksley8 reported that 2.8% of cases of SAH result from rupture of an aneurysm after craniocerebral trauma. Fleischer, et al., e and Asari, et al., 2 collected from the literature 41 and 60 cases of traumatic aneurysms, respectively. The vascular lesions were associated with different pathogenetic factors: closed head injury, intracranial surgery, penetrating foreign body, and gunshot wound. Several authors a,5'11'12differentiate between "true" and "false" traumatic aneurysms. The true aneurysm results from an incomplete alteration of the arterial wall, probably of the media and elastic layer, with successive aneurysmal dilatation. The false aneurysm follows complete laceration of the arterial wall with a perivascular hematoma which develops into an aneurysmal sac by cavitation and organization of the hematoma. 1,4'5,1~ Considering the clinical picture and the angiographic findings in our patient, this is considered to be a case of true aneurysm. Although the existence of a congenital aneurysm of the carotid syphon cannot be ruled out, it is unquestionable that the foreign body resulted in damage to the arterial wall with its consequent localized enlargement.
References
4. 5.
6. 7. 8.
9.
10. l l. 12.
Review and case report. J Neurosurg 28:468--474, 1968 Chadduck WM: Traumatic cerebral aneurysm due to speargun injury. Case report. J Neurosurg 31:77-79, 1969 Ferry DJ Jr, Kempe LG: False aneurysm secondary to penetration of the brain through orbitofacial wounds. Report of two cases. J Neurosurg 36:503-506, 1972 Fleischer AS, Patton JM, Tindall GT! Cerebral aneurysms of traumatic origin. Surg Neurol 4:233-239, 1975 Hammon WM: Analysis of 2187 consecutive penetrating wounds to the brain from Vietnam. J Neurosurg 34:127-131, 1971 Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V, Part 1. Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 25:219-239, 1966 Meirowsky AM: Penetrating wounds of the brain, in Coates JB Jr (ed): Neurological Surgery of Trauma. Washington, DC: US Government Printing Office, 1965, pp 103-130 Menezes AH, Graf CJ: True traumatic aneurysm of anterior cerebral artery. Case report. J Neurosurg 40:544-548, 1974 Sedzimir CB, Occleshaw JV, Buxton PH: False cerebral aneurysm. Case report. J Neurosurg 29:636-639, 1968 Smith DR, Kempe LG: Cerebral false aneurysm formation in closed head trauma. Case report. J Neurosurg 32:357-359, 1970 Smith FP: Differential carotid ligation for supraclinoidal arterial cerebral aneurysms. J Neurosurg 19:787-792, 1962
13. 1. Acosta C, Williams PE Jr, Clark K: Traumatic aneurysms of the cerebral vessels. J Neurosurg 36:531-536, 1972 2. Asari S, Nakamura S, Yamada O, et al: Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg Address reprint requests to: Giuseppe Salar, 46:795-803, 1977 3. Burton C, Velasco FC, Dorman J: Traumatic M.D., Department of Neurosurgery, University of aneurysm of a peripheral cerebral artery. Padua, Padua 35100, Italy.
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J. Neurosurg. / Volume 49 / July, 1978
Traumatic intracranial internal carotid aneurysm due to gunshot wound Case report GIUSEPPE SALAR, M . D . , AND SALVATORE MINGRINO, M . D .
Department of Neurosurgery, University of Padua, Padua, Italy v' This patient developed an intracranial carotid artery aneurysm after a bullet wound. A review of the related literature, and the pathogenesis of traumatic false and true aneurysms are presented. KEY Wol~oS 9 traumatic aneurysm false aneurysm 9 true aneurysm
F
ORMATION of intracranial arterial aneurysms after intracranial penetrating missile wounds is unusual. Meirowsky9 found no aneurysms in a series of 879 patients with craniocerebral missile wounds reported during the Korean War. Hammon 7 analyzed 2187 cases of craniocerebral wounds due to bullet or shell fragments seen in military hospitals during the Vietnam conflict, and observed only two cases of "pseudoaneurysm." In our series of 665 cases of intracranial aneurysms diagnosed angiographically, only one followed injury from an intracranial gunshot wound. Case Report
A 26-year-old man attempted suicide by three successive shots from a Flobert-type (22-caliber rim fire) gun in the right temporal region. Upon admission the patient was awake and presented no neurological deficit. In the right temporal region there was a small circular penetrating wound, about 5 mm in diameter. X-ray examination showed three intracranial foreign bodies, one of which lay immediately adjacent to the right sellar region. After 3 days the patient manifested paralysis of the right abducens and 100
9 gunshot wound
9
oculomotor nerves. The same day right brachial angiography (Fig. 1) showed an aneurysm of the intracavernous portion of the carotid artery just adjacent to the parasellar bullet. Fifteen days later, the abducens paralysis became worse and ptosis appeared. Right carotid angiography (Fig. 2) showed marked enlargement of the aneurysm. The patient has never demonstrated any signs of subarachnoid hemorrhage (SAH). In view of the rapid progression of symptoms and enlargement of the aneurysmal sac the right common carotid artery was ligated following the technique of Smith. TM The postoperative course was uneventful. The deficit of the third and fifth cranial nerves remained unchanged. The patient slowly recovered from his severe depression and was discharged after about 2 months. Follow-up examination after 4 years showed that the ptosis was improved, while the paralysis of the abducens nerve was unchanged. Discussion
Among the possible vascular complications of head injuries the most frequent are carotidcavernous fistula, internal carotid artery thrombosis, and aneurysms of the extra-
J. Neurosurg. / Volume 49 / July, 1978
Intracranial internal carotid traumatic aneurysm
FIG. 1. Right brachial angiography, anteroposterior (left) and lateral (right) views, 3 days after intracranial penetration of the bullets. The numbers indicate the three bullets, the last of which is adjacent to the syphon and caused the arterial dilatation (arrows).
FIG. 2. Right carotid angiography, anteroposterior (left) and lateral (right) views, 15 days after intracranial penetration of the bullets. The aneurysm (arrows) has greatly enlarged since the first angiogram.
J. Neurosurg. / Volume 49 / July, 1978
]01
G. S a l a r a n d S. M i n g r i n o cranial internal carotid artery. It is also recognized that trauma may contribute to rupture of pre-existing arterial aneurysms; Locksley8 reported that 2.8% of cases of SAH result from rupture of an aneurysm after craniocerebral trauma. Fleischer, et al., e and Asari, et al., 2 collected from the literature 41 and 60 cases of traumatic aneurysms, respectively. The vascular lesions were associated with different pathogenetic factors: closed head injury, intracranial surgery, penetrating foreign body, and gunshot wound. Several authors a,5'11'12differentiate between "true" and "false" traumatic aneurysms. The true aneurysm results from an incomplete alteration of the arterial wall, probably of the media and elastic layer, with successive aneurysmal dilatation. The false aneurysm follows complete laceration of the arterial wall with a perivascular hematoma which develops into an aneurysmal sac by cavitation and organization of the hematoma. 1,4'5,1~ Considering the clinical picture and the angiographic findings in our patient, this is considered to be a case of true aneurysm. Although the existence of a congenital aneurysm of the carotid syphon cannot be ruled out, it is unquestionable that the foreign body resulted in damage to the arterial wall with its consequent localized enlargement.
References
4. 5.
6. 7. 8.
9.
10. l l. 12.
Review and case report. J Neurosurg 28:468--474, 1968 Chadduck WM: Traumatic cerebral aneurysm due to speargun injury. Case report. J Neurosurg 31:77-79, 1969 Ferry DJ Jr, Kempe LG: False aneurysm secondary to penetration of the brain through orbitofacial wounds. Report of two cases. J Neurosurg 36:503-506, 1972 Fleischer AS, Patton JM, Tindall GT! Cerebral aneurysms of traumatic origin. Surg Neurol 4:233-239, 1975 Hammon WM: Analysis of 2187 consecutive penetrating wounds to the brain from Vietnam. J Neurosurg 34:127-131, 1971 Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V, Part 1. Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 25:219-239, 1966 Meirowsky AM: Penetrating wounds of the brain, in Coates JB Jr (ed): Neurological Surgery of Trauma. Washington, DC: US Government Printing Office, 1965, pp 103-130 Menezes AH, Graf CJ: True traumatic aneurysm of anterior cerebral artery. Case report. J Neurosurg 40:544-548, 1974 Sedzimir CB, Occleshaw JV, Buxton PH: False cerebral aneurysm. Case report. J Neurosurg 29:636-639, 1968 Smith DR, Kempe LG: Cerebral false aneurysm formation in closed head trauma. Case report. J Neurosurg 32:357-359, 1970 Smith FP: Differential carotid ligation for supraclinoidal arterial cerebral aneurysms. J Neurosurg 19:787-792, 1962
13. 1. Acosta C, Williams PE Jr, Clark K: Traumatic aneurysms of the cerebral vessels. J Neurosurg 36:531-536, 1972 2. Asari S, Nakamura S, Yamada O, et al: Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg Address reprint requests to: Giuseppe Salar, 46:795-803, 1977 3. Burton C, Velasco FC, Dorman J: Traumatic M.D., Department of Neurosurgery, University of aneurysm of a peripheral cerebral artery. Padua, Padua 35100, Italy.
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