Intracranial Pseudoaneurysms: Evaluation and Management

Abstract

Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.

Keywords: endovascular treatment; iatrogenic; intracranial pseudoaneurysms; management; trauma.

Figure 1

Brain trauma leads to rupture of the intima, media, and adventitia of the blood vessel (A,B), forming an organized hematoma cavity (C). When the hematoma forms outside the arterial wall, it continues to communicate with the injured vessel, thus predisposing it to re-bleeding (D).

Figure 2

(A) Angiography demonstrated the intracavernous iatrogenic pseudoaneurysm of the left internal carotid artery (ICA). (B) The pseudoaneurysm was treated by endovascular coiling. (C) Angiogram at 4-month follow-up showed no evidence of aneurysmal filling [adapted from Lin et al. (72)].

Figure 3

(A) An axial CT scan showed skull bone fracture and traumatic subarachonoid hemorrhage. (B) Two weeks later, the patient suffered rehemorrhage. A lateral cerebral angiogram of the right ICA demonstrated a large pseudoaneurysm at the C6 segment and a dissection of the C1 segment. Angiogram after balloon occlusion test (C) showed good compensation from the anterior communicating artery (D) and posterior communicating artery (E,F) The pseudoaneurysm and parent artery were trapped with six detachable coils. Postoperative right (G) and left (H) carotid angiograms showed exclusion of the pseudoaneurysm from the circulation [adapted from Lin et al. (72)].

Figure 4

(A) Oblique cerebral angiogram showed a pseudoaneurysm in the cavernous segment of righ ICA following endoscopic transsphenoid surgery. (B) A 4*13 mm Willis covered stent was deployed across the pseudoaneurysm. (C) The control angiogram demonstrated complete obliteration of the pseudoaneurysm with preservation of carotid artery patency. (D) A follow-up angiogram showed no recanalization of the aneurysm and patentcy of the parent artery.