Korean J Neurotrauma.  2015 Oct;11(2):170-174. 10.13004/kjnt.2015.11.2.170.

Perfusion Study for Internal Carotid Artery Trapping of a Traumatic Pseudoaneurysm in an Unconscious Patient

Affiliations
  • 1Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea. sunchulh@schmc.ac.kr
  • 2Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.

Abstract

Perfusion study should be preoperatively required for the trapping of an internal carotid artery (ICA) in the traumatic pseudoaneurysm in the petrous ICA. A 23-year-old man was admitted with a semicomatose consciousness after a passenger traffic accident. A fracture on the right petrous apex and a pseudoaneurysm in the right petrous ICA was found in the brain computed tomography (CT) angiogram. The size of aneurysm grew in the catheter angiogram at the 3rd day of trauma. One-day protocol of brain single photon emission CT (SPECT), which the first scan with 20 mCi of technetium-99m-ethyl cysteinate diethylester ((99m)Tc-ECD) and the second scan with 40 mCi in double dose at 15 minutes during the balloon test occlusion (BTO) at the same day, was done for the perfusion evaluation before trapping the right ICA. Perfusion asymmetry was aggravated of 21% at the post-occlusion scan in the right frontal cortex. So, he got a superficial temporal artery-middle cerebral artery anastomosis and then ICA trapping. After the surgery, he recovered consciousness and went back to his normal life. He has not developed new neurologic symptom for 8 years. Brain SPECT with double-dose injection of (99m)Tc-ECD may be a useful tool to be performed with BTO.

Keyword

Aneurysm, false; Carotid artery injuries; Tomography, emission-computed, single-photon; Carotid artery, internal

MeSH Terms

Accidents, Traffic
Aneurysm
Aneurysm, False*
Brain
Carotid Artery Injuries
Carotid Artery, Internal*
Catheters
Cerebral Arteries
Consciousness
Humans
Neurologic Manifestations
Perfusion*
Tomography, Emission-Computed, Single-Photon
Young Adult

Figure

  • FIGURE 1 Initial brain computed tomography (CT) and CT angiogram. A: Subarachnoid hemorrhage and pneumocephalus on the interpeduncular cistern was seen. B: Multiple facial bone fractures and fracture on the right petrous apex (arrow) nearby the carotid canal were found. C: Multiple hypodense lesions were seen on the right frontal at the 2nd day of trauma. D: Abnormal dye filling sac (arrowhead) at the petrous internal carotid artery was found in the CT angiogram. The pseudoaneurysm was located in the posterior part of cavernous sinus.

  • FIGURE 2 Catheter angiogram for the further evaluation of vascular injury. The catheter angiogram was taken the day after the computed tomography angiogram. The pseudoaneurysm (arrowhead) was grown in size. Arterial dissection (arrow) was also found at the entrance of petrous bone and around the anterior part of cavernous sinus (A, B). This vascular injury might be caused by the immobilization of the artery to the petrous bone and the dural ring. The right middle cerebral artery (MCA) was clearly visualized on the right internal carotid artery (ICA) angiogram (C). The pseudoaneurysm size grew markedly in the intraoperative angiogram during the endovascular coiling on the cavernous ICA distal to the pseudoaneurysm (D, E). Intraoperative angiogram after the ICA trapping and the revascularization showed that the distal branches of the right MCA was visualized from the superficial temporal artery (F).

  • FIGURE 3 Perfusion study of single photon emission computed tomography (CT) before and after balloon occlusion test for the right internal carotid artery (ICA) in the same day. The baseline scan (A) was taken by injecting 20 mCi of technetium-99m-ethyl cysteinate diethylester (99mTc-ECD) before the angiogram and 40 mCi of 99mTc-ECD was given at 15 minutes in the balloon occlusion of the right ICA (B). At the post-occlusion scan, aggravation of perfusion asymmetry on the right frontal cortex was seen, especially in the middle and posterior frontal cortex (arrows) and about 21% of perfusion reduction was measured. The hypoperfusion area in the right frontal was matched with the infarct zone in the brain CT.


Reference

1. Cohen JE, Gomori JM, Segal R, Spivak A, Margolin E, Sviri G, et al. Results of endovascular treatment of traumatic intracranial aneurysms. Neurosurgery. 2008; 63:476–485. discussion 485-486PMID: 18812959.
Article
2. Eckard DA, Purdy PD, Bonte FJ. Temporary balloon occlusion of the carotid artery combined with brain blood flow imaging as a test to predict tolerance prior to permanent carotid sacrifice. AJNR Am J Neuroradiol. 1992; 13:1565–1569. PMID: 1442432.
3. Hattori N, Yonekura Y, Tanaka F, Fujita T, Wang J, Ishizu K, et al. One-day protocol for cerebral perfusion reserve with acetazolamide. J Nucl Med. 1996; 37:2057–2061. PMID: 8970534.
4. Kapucu OL, Nobili F, Varrone A, Booij J, Vander Borght T, Någren K, et al. EANM procedure guideline for brain perfusion SPECT using 99mTc-labelled radiopharmaceuticals, version 2. Eur J Nucl Med Mol Imaging. 2009; 36:2093–2102. PMID: 19838703.
Article
5. Larson PS, Reisner A, Morassutti DJ, Abdulhadi B, Harpring JE. Traumatic intracranial aneurysms. Neurosurg Focus. 2000; 8:e4. PMID: 16906700.
Article
6. Léveillé J, Demonceau G, De Roo M, Rigo P, Taillefer R, Morgan RA, et al. Characterization of technetium-99m-L,L-ECD for brain perfusion imaging, Part 2: Biodistribution and brain imaging in humans. J Nucl Med. 1989; 30:1902–1910. PMID: 2809757.
7. Malek AM, Halbach VV, Phatouros CC, Meyers PM, Dowd CF, Higashida RT. Endovascular treatment of a ruptured intracranial dissecting vertebral aneurysm in a kickboxer. J Trauma. 2000; 48:143–145. PMID: 10647582.
Article
8. Marshall RS, Lazar RM, Young WL, Solomon RA, Joshi S, Duong DH, et al. Clinical utility of quantitative cerebral blood flow measurements during internal carotid artery test occlusions. Neurosurgery. 2002; 50:996–1004. discussion 1004-1005PMID: 11950402.
Article
9. Mathis JM, Barr JD, Jungreis CA, Yonas H, Sekhar LN, Vincent D, et al. Temporary balloon test occlusion of the internal carotid artery: experience in 500 cases. AJNR Am J Neuroradiol. 1995; 16:749–754. PMID: 7611033.
10. Miley JT, Rodriguez GJ, Qureshi AI. Traumatic Intracranial Aneurysm Formation following Closed Head Injury. J Vasc Interv Neurol. 2008; 1:79–82. PMID: 22518228.
11. Schneweis S, Urbach H, Solymosi L, Ries F. Preoperative risk assessment for carotid occlusion by transcranial Doppler ultrasound. J Neurol Neurosurg Psychiatry. 1997; 62:485–489. PMID: 9153606.
Article
12. Walovitch RC, Hill TC, Garrity ST, Cheesman EH, Burgess BA, O'Leary DH, et al. Characterization of technetium-99m-L,L-ECD for brain perfusion imaging, Part 1: Pharmacology of technetium-99m ECD in nonhuman primates. J Nucl Med. 1989; 30:1892–1901. PMID: 2809756.
13. Zhong J, Ding M, Mao Q, Wang B, Fu H. Evaluating brain tolerability to carotid artery occlusion. Neurol Res. 2003; 25:99–103. PMID: 12564135.
Article
Full Text Links
  • KJN
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr