Traumatic intracranial aneurysms

Tania Rebeiz MD (Dr. Rebeiz of the University of Chicago has no relevant financial relationships to disclose.)
James R Brorson MD (Dr. Brorson of the University of Chicago received consultation fees from CVS-Caremark, National Peer Review Corporation, and Medico-legal Consulting.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released October 28, 1997; last updated January 9, 2017; expires January 9, 2020

This article includes discussion of traumatic intracranial aneurysms, traumatic true aneurysms, traumatic false aneurysms, and traumatic mixed aneurysms. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Traumatic intracranial aneurysms result from either penetrating head trauma causing direct injury to the vascular wall or from severe closed head injury producing torsion or stretching of an intracranial vessel against the hard edge of dural membranes, bony protrusions, or fractured bones. As traumatic intracranial aneurysms have a high rate of growth and rupture, they need to be detected early and treated aggressively. Recent experience from the military conflict in the Iraq war has provided the most extensive descriptions of traumatic aneurysms. The authors highlight this broadened experience and the growing role for endovascular approaches in the treatment of these aneurysms.

Key points

 

• Traumatic intracranial aneurysms result from severe penetrating head trauma or closed head injuries, causing direct mural injury or indirect stretching injury to arterial walls.

 

• Although traumatic aneurysms constitute a small fraction of all aneurysms in adults, they are not uncommon following penetrating head injury or severe closed head trauma with skull fracture.

 

• Traumatic aneurysms carry a high risk of progressive growth and rupture and, therefore, are important to detect.

 

• Surgical risks of treatment of traumatic aneurysms are high, often requiring sacrifice of the parent vessel for effective exclusion of the aneurysm from the circulation.

 

• Endovascular approaches can be effective in obliterating traumatic aneurysms with preservation of the parent artery.

Historical note and terminology

An autopsy-proven case of a middle meningeal artery aneurysm after head injury was first recorded in 1829 (Smith 1829). Later, in 1891, Bollinger postulated that some instances of "delayed apoplexy" after head injury were due to the rupture of a traumatic aneurysm. Guibert reported a case involving the infraclinoid internal carotid artery, but Birley and Trotter were the first to describe a case of an intracranial aneurysm after severe head injury (Guibert 1895; Birley and Trotter 1928). Tonnis demonstrated the first case proven by angiography and Cairns provided a comprehensive description of these aneurysms (Tonnis 1934; Cairns 1942). Aneurysm formation after a depressed skull fracture was described by Krauland in 1949, and angiographically demonstrated after a closed head injury in 1962 (Hirsch et al 1962).

The frequency of diagnosis has decreased from the 1970s to the present due to the application of computerized tomography (rather than traditional angiography) as the modality of choice for evaluation of head-injured patients, with traumatic aneurysms sometimes overlooked. Conventional cerebral angiography remains the reference standard for the diagnostic work-up of intracranial aneurysms (Dubey et al 2008).

Traumatic aneurysms have been traditionally divided into "true," "false," and "mixed," depending on whether the arterial wall is partially lacerated and ballooned ("true") or completely ruptured with organized clot or brain tissue forming the outer membrane ("false"). When a true aneurysm ruptures and forms a false aneurysm outside the true one, the aneurysm is "mixed." This histologic classification of aneurysms has little practical usefulness.

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.