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

• Sim KB
• Park SQ
• Choi HA
• Kim DH

• KMID: 2191153
• DOI: http://doi.org/10.3340/jkns.2014.56.6.531

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.

Reference

1. Baskaya MK, Coscarella E, Gomez F, Morcos JJ. Surgical and angiographic anatomy of the posterior communicating and anterior choroidal arteries. Neuroanatomy. 2004; 3:38–42.

2. Bunai Y, Nagai A, Nakamura I, Ohya I. Traumatic rupture of the basilar artery : report of two cases and review of the literature. Am J Forensic Med Pathol. 2000; 21:343–348. PMID: 11111794.

3. Çakmak YÖ, Özdoğmuş Ö, Gürdal E, Uzun İ, Çavdar S. Origins and diameter of the anterior choroidal artery. Marmara Med J. 2009; 22:123–126.

4. Filter ER, Fernandes JR. Fatal traumatic subarachnoid hemorrhage due to assault-related tear of the basilar artery. J Forensic Leg Med. 2009; 16:414–416. PMID: 19733334.

5. Fung C, Z'Graggen WJ, Beck J, Gralla J, Jakob SM, Schucht P, et al. Trau-matic subarachnoid hemorrhage, basal ganglia hematoma and ischemic stroke caused by a torn lenticulostriate artery. Acta Neurochir (Wien). 2012; 154:59–62. PMID: 21976234.

6. Gross A. Traumatic basal subarachnoid hemorrhages : autopsy material analysis. Forensic Sci Int. 1990; 45:53–61. PMID: 2335336.

7. Harland WA, Pitts JF, Watson AA. Subarachnoid haemorrhage due to upper cervical trauma. J Clin Pathol. 1983; 36:1335–1341. PMID: 6655067.

8. Mosberg WH, Lindenberg R. Traumatic hemorrhage from the anterior choroidal artery. J Neurosurg. 1959; 16:209–221. PMID: 13642112.

9. Pollanen MS, Deck JH, Blenkinsop B. Injury of the tunica media in fatal rupture of the vertebral artery. Am J Forensic Med Pathol. 1996; 17:197–201. PMID: 8870868.

10. Simonsen J. Fatal subarachnoid haemorrhages in relation to minor injuries in Denmark from 1967 to 1981. Forensic Sci Int. 1984; 24:57–63. PMID: 6698453.