J Korean Neurosurg Soc.  2014 Dec;56(6):531-533. 10.3340/jkns.2014.56.6.531.

Demonstration of Traumatic Subarachnoid Hemorrhage from the Anterior Choroidal Artery

Affiliations
  • 1Department of Neurosurgery, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea.
  • 2Department of Neurosurgery, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea. drcolor@schmc.ac.kr
  • 3Department of Neurosurgery and Neurology, University of Texas Medical School at Houston, Houston, TX, USA.
  • 4Department of Neurosurgery, University of Texas Medical School at Houston, Houston, TX, USA.

Abstract

We present a case of angiographically confirmed transection of the cisternal segment of the anterior choroidal artery (AChA) associated with a severe head trauma in a 15-year old boy. The initial brain computed tomography scan revealed a diffuse subarachnoid hemorrhage (SAH) and pneumocephalus with multiple skull fractures. Subsequent cerebral angiography clearly demonstrated a complete transection of the AChA at its origin with a massive extravasation of contrast medium as a jet trajectory creating a plume. We speculate that severe blunt traumatic force stretched and tore the left AChA between the internal carotid artery and the optic tract. In a simulation of the patient's brain using a fresh-frozen male cadaver, the AChA is shown to be vulnerable to stretching injury as the ipsilateral optic tract is retracted. We conclude that the arterial injury like an AChA rupture should be considered in the differential diagnosis of severe traumatic SAH.

Keyword

Traumatic subarachnoid hemorrhage; Anterior choroidal artery; Transection; Angiography; Cadaver

MeSH Terms

Angiography
Arteries*
Brain
Cadaver
Carotid Artery, Internal
Cerebral Angiography
Choroid*
Craniocerebral Trauma
Diagnosis, Differential
Humans
Male
Pneumocephalus
Rupture
Skull Fractures
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage, Traumatic*
Visual Pathways

Figure

  • Fig. 1 Cranial CT scan at admission revealed severe tSAH in the basal cistern and pneumocephalus predominantly in the right Sylvian fissure (A and B) and an extensive basal skull fracture extending from the left temporal bone to the right side of the sphenoid sinus and sella turcica (C) and a diastatic fracture through the coronary suture and communicated fracture of the left parietal bone (D). CT : computed tomography, tSAH : traumatic subarachnoid hemorrhage.

  • Fig. 2 Digital subtraction cerebral angiography revealed massive contrast media extravasation from the ICA distal to posterior communicating artery (arrowheads) (A), and the extravasation from the origin of the AChA showed a jet trajectory of the contrast medium (arrow) (B). The coil passing through the AChA origin did not prevent the leaking of the contrast media. ICA : internal carotid artery, AChA : anterior choroidal artery.

  • Fig. 3 A simulation of the patient's situation in the brain using a fresh-frozen male cadaver (A) and computer graphics (B). The right anterior cerebral arteries (*) were removed to expose the AChAs and the frontal lobes are retracted posteriorly with the head fully extended. The optico-carotid cisterns are widened by the effect of gravity and retraction of the frontal lobes with the stretch of the AChA. When the optic tract is dragged backward with a retractor, the AChA is more stretched to be thinner and tensor. A schematic drawing shows typically the anatomic change in the AChA according to those situations (B). AChA : anterior choroidal artery.


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