Treatment of a Traumatic Pseudoaneurysm with a Pipeline Embolization Device: Case Report and Review of the Literature

A 66-year-old male experienced the acute onset of headache in 2012 and subsequently developed diplopia within hours. Neuro-ophthalmology diagnosed a right CN VI palsy and an MRI demonstrated a small enhancing mass at the orbital apex. Lumbar puncture was negative and biopsy via a right pterional craniotomy was nondiagnostic at an outside institution. Suspecting an inflammatory etiology, the patient was placed on steroids and Cellcept. The lesion grew and the patient developed severe systemic and central nervous system histoplasmosis. Repeat craniotomy (2015) and biopsy demonstrated spindle cells suggestive of meningioma. He was radiated at that time, however, the lesion continued to grow, he lost all vision in the right eye, and developed significant retro-orbital pain.

The patient sought treatment with ophthalmology and a right lateral orbitotomy and biopsy were planned. During the procedure, brisk arterial hemorrhage was encountered as biopsies were taken from the bony defect near the right orbital apex. Bleeding was controlled with packing and the procedure was aborted. The patient awakened from anesthesia with a dense left hemiparesis and dysarthria, which prompted a neurosurgery consultation. The hemiparesis and dysarthria nearly completely resolved within the hour.

CT of the head demonstrated subarachnoid hemorrhage located predominately in the right basal cisterns and Sylvian fissure. CTA of the head showed a possible mild dilatation of the proximal right M1. The patient was taken for an emergent angiogram, which demonstrated a 2 × 2 mm pseudoaneurysm arising from the ventral surface of the proximal right M1 segment. The patient was loaded with 600 mg Plavix and 650 mg aspirin. A 3.25 × 14 Pipeline Embolization Device (PED) was deployed within the M1 across the neck of the pseudoaneurysm. A follow-up run demonstrated immediate stasis of contrast within the pseudoaneurysm. Angiography on postoperative day 6 demonstrated complete occlusion of the pseudoaneurysm and restoration of the normal caliber and contour of the right M1 segment. The patient was maintained on daily aspirin and Plavix and was discharged to rehab neurologically intact. Angiography at 6 weeks, showed no evidence of pseudoaneurysm and a widely patent stent.

Traumatic pseudoaneurysms are particularly challenging lesions to treat and are associated with a high incidence of rupture, re-rupture, and life-threatening intracerebral hemorrhage. Prompt recognition of the lesion and obliteration are key to ensuring the best possible outcome. In cases of revision cranial base surgery and when operating in a radiated and scarred field, the risk of vascular injury increases. Traditionally, open surgical management of traumatic pseudoaneurysms includes trapping the lesion or deconstructing the vessel with or without bypass.

Intracranial flow diverters, such as the PED, now offer a minimally invasive means by which to obliterate intracranial pseudoaneurysms, while also preserving vessel patency. Extracranial-intracranial bypass would have been particularly difficult in this instance due to the heavily scarred twice operated and radiated field. The risk of dual antiplatelet therapy in the setting of acute intracerebral hemorrhage must be considered and longer follow-up is necessary to determine the durability of flow diverters.