trauma multidisciplinary approach to traumatic...

Trauma

Multidisciplinary Approach toTraumatic Intracranial AneurysmsSecondary to Shotgun andHandgun WoundsMichael B. Horowitz, M.D., Thomas A. Kopitnik, M.D., Fraser Landreneau, M.D.,Dharamdas M. Ramnani, M.D., Elisabeth J. Rushing, M.D., Eugene George, M.D.,Phillip P. Purdy, and Duke S. Samson, M.D.Department of Neurosurgery, University of Texas Southwestern Medical Center at Dallas,Dallas, Texas

Horowitz MB, Kopitnik TA, Landreneau F, Ramnani DM, RushingEJ, George E, Purdy PP, Samson DS. Multidisciplinary approachto traumatic intracranial aneurysms secondary to shotgun andhandgun wounds. Surg Neurol 1999;51:31–42.

BACKGROUNDTraumatic intracranial aneurysms (TICAs) may developfollowing gunshot injuries to the head. Management ofthese lesions often combines various aspects of micro-neurosurgical and endovascular techniques to safely re-pair or obliterate vessel defects.METHODSWe reviewed our experience over the last 18 years andidentified five cases of intracranial aneurysms followinggunshot and handgun wounds that were treated surgi-cally and/or endovascularly.RESULTSAll patients had successful obliteration of their lesionsusing a variety of therapeutic modalities aimed at pre-serving neurologic function while at the same time elim-inating the aneurysm from the circulation.CONCLUSIONBoth microneurosurgery and endovascular surgery haveimportant roles to play in the management of TICAs. Insome cases, both methods can be combined to eliminatelesions and maximize patient recovery in a safe, efficient,and effective fashion. © 1999 by Elsevier Science Inc.

KEY WORDSAneurysm, traumatic, shotgun, coils, bypass.

Traumatic intracranial aneurysms (TICAs) sec-ondary to missile injuries are rare occur-

rences. The majority of these lesions develop in theanterior and middle cerebral artery distributions.

We report five cases over an 18-year period. Allwere secondary to shotgun and handgun blastswith involvement of the cavernous carotid, middlecerebral, and posterior cerebral arteries. Review ofthe available literature reveals only 44 previouslyreported TICAs. None of these were located alongthe posterior cerebral artery and none were man-aged with excision and bypass. Only one other casewas treated using superficial temporal artery-middle cerebral artery bypass. This paper will re-port our management of five cases using a variety ofarterial bypass and trapping procedures. Pertinentliterature is reviewed.

Case ReportsCASE 1HISTORY A 35-year-old left-handed man presentedwith a shotgun blast to the head. The projectilestraveled from right to left across the patient’s face.His right eye was enucleated, and several metalfragments entered the head through the left orbit. Acomputed tomography (CT) head scan demon-strated intraparenchymal and intraventricular hem-orrhage along with a subdural hematoma (Figure 1).A cerebral arteriogram revealed a 2- to 3-mm non-branch point aneurysm involving the right poste-rior cerebral artery (PCA) along the P2 segment(Figure 2). The decision was made to repeat thearteriogram 1 week later to see whether the aneu-rysm resolved, remained the same, or enlarged.Because the patient had already lost the use of hisleft eye, we were cautious about prematurely per-forming any procedure that might infarct his right

Address reprint requests to: Dr. Michael B. Horowitz, Department ofNeurosurgery, University of Texas Southwestern Medical Center at Dallas,5323 Harry Hines Blvd, Dallas, TX 75235-8855.

Received June 12, 1997; accepted September 23, 1997.

© 1999 by Elsevier Science Inc. 0090-3019/99/$–see front matter655 Avenue of the Americas, New York, NY 10010 PII S0090-3019(98)00029-9

calcarine cortex and further compromise his re-maining vision. One week later, the arteriogram wasrepeated demonstrating enlargement of the aneu-rysm (Figure 3). This change made it imperative toobliterate the lesion for fear that it would rupture.

SURGICAL PROCEDURE A right coronal ventric-ulostomy was inserted to help provide brain relax-ation later in the case. The patient was then placedinto the lateral decubitus position with his rightside up. A cutaneous flap was elevated and a 6-cmsegment of superficial temporal artery was har-vested, flushed, and soaked in heparinized saline tobe used later for interposition grafting should an-eurysm resection become necessary. A temporalcraniotomy was then performed. The temporalbone was aggressively drilled until it was flat withthe floor of the middle fossa and petrous bone. Thedura was opened and a chronic subdural hematomacapsule was resected. The ventriculostomy wasopened and cerebrospinal fluid was evacuated. Byelevating the temporal lobe, the incisura and ambi-ent cistern arachnoid could be identified. Thearachnoid was opened, and cranial nerve 3 and thebasilar apex were visualized. The PCA was tracedcaudally along the P1 and P2 segments until a glioticarea with adhesions between brain and tentoriumwas identified. This region presumably harboredthe aneurysm. Sharp dissection along the PCA dis-tal to the adherent region provided distal control ofthe vessel. Sharp dissection and resection of brainpermitted visualization of the aneurysm, a 5-mm,

asymmetric, fusiform dilatation of the PCA. A right-angled Yasargil clip was placed across the aneu-rysm dome, but this only served to occlude thedistal PCA without completely obliterating theaneurysm.

After inducing etomidate burst suppression, tem-porary clips were placed across the PCA proximaland distal to the aneurysm. The aneurysmal seg-ment of vessel was resected and the superficialtemporal artery (STA) graft was inserted as an in-terposition graft with two end-to-end anastomoses

1 Non-contrast head CT demonstrating subarachnoidand intraparenchymal hemorrhage.

2 AP (A) and lateral (B) right vertebral artery arterio-gram demonstrating a PCA aneurysm (arrowhead).

32 Surg Neurol Horowitz et al1999;51:31–42

using 10-0 nylon suture. The patient was not hepa-rinized. After completing the anastomoses, the tem-porary clips were removed. The graft was noted tobe pulsatile and patent. A microdoppler ultrasoundprobe demonstrated excellent signal both distallyand proximally.

The patient awoke without deficit. Vision remainednormal. A repeat arteriogram the following day dem-onstrated a patent graft with excellent distal runoff(Figure 4). Follow-up CT revealed no infarcts.

CASE 2HISTORY A 17-year-old man presented with a shot-gun blast to the head with one pellet entering thehead through the right orbit. A head CT demon-strated a right subdural hematoma with mass effectand subarachnoid hemorrhage. The subdural he-matoma was evacuated. The following day, a cere-bral arteriogram revealed a small, presumably post-traumatic M1-segment middle cerebral artery(MCA) aneurysm (Figure 5). The patient remainedneurologically normal. One week later, the arterio-gram was repeated. This study demonstrated sig-nificant aneurysm enlargement (Figure 6). Surgerywas recommended in order to eliminate the lesionprior to rupture.

SURGICAL PROCEDURE A right frontotemporalcraniotomy was performed followed by a right STA-MCA bypass. The proximal Sylvian fissure was thenopened, and proximal and distal MCA control wasobtained. After 80 minutes of proximal and distalocclusion, the aneurysm was clip reconstructed.Postoperatively, the patient remained unchanged.A repeat arteriogram several days following surgerydemonstrated marked supraclinoid internal carotidartery vasospasm, no significant anterograde MCAfilling past the clip, and excellent retrograde MCAopacification from the bypass graft (Figure 7). Afinal arteriogram performed several weeks follow-ing surgery revealed a normal MCA, no residual

3 AP (A) and lateral (B) right vertebral artery arterio-gram demonstrating PCA aneurysm interval enlarge-

ment (arrowhead).

4 Vertebral arteriogram demonstrating interpositiongraft at site of previous PCA aneurysm (segment

located between arrowheads).

33Multidisciplinary Approach to Traumatic Intracranial Aneurysms Surg Neurol1999;51:31–42

aneurysm, and an occluded graft. The patient re-mained neurologically normal.

CASE 3HISTORY AND SURGICAL PROCEDURE A 25-year-old man presented following a shotgun woundto the face. A cerebral arteriogram revealed con-trast extravasation from a cavernous carotid trau-matic aneurysm into the sphenoid sinus and retro-pharynx (Figure 8). Upon inflation of a balloon inthe internal carotid artery (ICA) the patient imme-diately became hemiplegic. The balloon was de-flated and he was immediately brought to the op-erating room where a saphenous vein bypass graftwas sewn from the external carotid artery to theMCA (Figure 9). The ICA was then sacrificed justdistal to its origin in the neck and below the oph-thalmic artery in the head. Postoperatively, the pa-tient remained neurologically normal.

CASE 4HISTORY AND SURGICAL PROCEDURE A 27-year-old male victim of a drive-by shooting with ahandgun was admitted to the emergency room withbilateral traumatic orbital disruptions from a bulletthat crossed the anterior and middle fossae fromright to left. The patient’s best neurologic examina-tion consisted of following commands with his rightside. His left side was profoundly hemiparetic. A CTscan (Figure 10) and an arteriogram were then per-formed to search for vascular injuries. The latterstudy revealed a small false aneurysm involving aleft orbitofrontal artery branch and some irregular-

ity along the posterior wall of the right supraclinoidcarotid artery (Figure 11). The patient was trans-ferred to the intensive care unit and observed. Oneweek later, he underwent repair of his anteriorfossa floor defect. The following day, he experi-enced a worsening of his neurologic examination,and a CT scan demonstrated pancisternal sub-arachnoid hemorrhage. A repeat cerebral arterio-gram revealed absence of the orbitofrontal falseaneurysm and the presence of a large right supra-clinoid carotid aneurysm in the region of the previ-ously mentioned irregularity (Figure 12). The deci-sion was made to investigate the possibility ofvessel sacrifice.

Because of the patient’s condition, his neurologicexamination was not reliable. A 45-minute tempo-rary balloon occlusion of the ICA was conducted

5 Right internal carotid artery arteriogram demon-strating right MCA aneurysm (arrow).

6 Right internal carotid artery arteriogram demon-strating interval enlargement of right MCA trunk

aneurysm.


using continuous EEG monitoring. The EEG did notchange throughout the study. While the balloonwas inflated, 30 mCi of Te-99 and Bicisate dihydro-chloride (Neurolite, Dupont-Merck, Billerica, MA)was administered intravenously, so that single pho-ton emission CT (SPECT) images could be obtained.At the end of the balloon occlusion test, we fearedthat balloon deflation and the subsequent sudden

inflow of arterialized blood into the aneurysm of aheparinized patient would lead to aneurysm rup-ture. Therefore, the systolic blood pressure wasreduced to 90 mm Hg, and the balloon was deflatedgradually over 30 seconds. The subsequent SPECTimages demonstrated low flow in regions of theright hemisphere that were already hypodense onCT, thus leading us to surmise that these were areasof fixed deficits secondary to the gunshot wound.

The patient was returned to the angiographysuite. A temporary balloon catheter was then ad-vanced back into the ICA, and the balloon was in-flated to induce flow arrest. A microcatheter wasthen advanced coaxially to the level of the ophthal-mic artery, and the ICA was sacrificed using a vari-ety of Guglielmi detachable coils and Gianturcocoils. The balloon was then deflated, and no antero-grade flow was present. The patient continued to fillthe right MCA from the left ICA injection, which didnot show retrograde opacification of the aneurysm.The following day, the patient was taken to theoperating room where the ICA was clipped proximalto the posterior communicating artery, thus trap-ping the diseased segment.

Postoperatively, the patient was stable with noworsening of his neurologic examination until 5days later when he began to decerebrate. Repeatangiography revealed severe vertebral, basilar, leftICA, and left MCA vasospasm. Angioplasty of eachof these vessels was successfully completed, al-though the patient failed to improve. A final left ICAarteriogram following angioplasty demonstratedcoil and clip position and collateral filling of theright middle cerebral artery (Figure 13).

CASE 5HISTORY AND PROCEDURES A 33-year old manwas shot near the right mastoid with a handgun byhis wife. Admission GCS was 15. Multiple bone frag-ments protruded through the scalp. A head CT re-vealed a right posterior temporal/occipital hema-toma and contusion with right-to-left shift (Figure14). The patient was intubated, an intracranial pres-sure monitor was inserted, and he was transferredto the angiography suite to determine the presenceof any false aneurysms as well as a transverse/sigmoid sinus injury. While on the table, the pa-tient’s right pupil dilated. A right common carotidinjection was quickly performed, which was nor-mal, and he was taken directly to the operatingroom where a partial temporal and occipital lobec-tomy were performed.

Postoperatively the patient was following com-mands bilaterally. One week following admission,his arteriogram was repeated. This study demon-

7 Right common carotid artery arteriogram demon-strating aneurysm obliteration and MCA filling via

bypass graft.

8 Right internal carotid artery arteriogram demon-strating a cavernous carotid aneurysm (arrow) with

active contrast extravasation.


strated a distal right parieto-occipital PCA branchfalse aneurysm (Figure 15). This lesion was treatedby selectively catheterizing the feeding artery andsacrificing it just proximal to the aneurysm, usingseven 5-mm and 2-mm coils (Figure 16). Followingthe procedure, the aneurysm no longer opacified,and the patient’s examination remained unchanged.

HistologyThe resected aneurysm from Case 1 was sectionedand analyzed with H&E staining. The microscopicevaluation demonstrated fragmented intima, freshhemorrhage, and granulation tissue. Myofibro-blasts, inflammatory cells, and macrophages werefound around the area of vessel disruption (Figure17).

DiscussionMost information regarding TICAs secondary tomissile injuries comes from recent conflicts in Iranand Lebanon [1,6]. TICAs following missile injuriesare rare occurrences. Aarabi [1] identified 8 ante-rior circulation aneurysms in 225 consecutive pa-tients undergoing cerebral angiography followingmissile injuries to the head (3% incidence). Hadd-

9 Lateral (A) and AP (B) arteriograms following ICAocclusion, aneurysm trapping, and external carotid

to MCA vein bypass.

10 Head CT demonstrating intracranial shotgun pel-lets.


ad’s [6] review in 1991 revealed 30 previously re-ported patients [1–11,13–20]. Nineteen of thesewere secondary to gunshot wounds, and the re-mainder were due to shrapnel injuries. Only twolesions were located along posterior circulationvessels, one involving the basilar and the otherinvolving the superior cerebellar artery. The authoradded 14 additional cases from the Lebanese con-

flict, bringing the total number of reported cases to44 [6]. Thirteen of these cases were secondary toshrapnel injuries, and all were located along ante-rior circulation vessels. All cases were either ob-served, treated with proximal vessel sacrifice, ormanaged using primary aneurysm clipping or wrap-ping. No cases of PCA TICAs were reported, nocases were managed using aneurysm excision andinterposition grafting, and only one case was man-aged using a bypass [20].

Haddad [6] summarized his experience and thatof others at the conclusion of his article by makingthe following statements:

1. TICAs often remain undiagnosed.2. Because of their involvement in more violent

activities, men are more frequently affectedthan women. Peak incidence in the second de-cade is also a consequence of age relatedactivities.

3. TICAs may appear as early as 2 hours postin-jury. They may also appear in a delayed fashion(refer to Case 4).

4. Twenty percent of TICAs are multiple, and la-tency periods for appearance vary. This findingmakes it imperative to consider studying pa-tients at intervals in an attempt to identify TI-CAs that develop in a delayed fashion (refer toCase 4).

11 Left internal carotid artery arteriogram (A) dem-onstrating a traumatic orbitofrontal artery aneu-

rysm (arrowhead). Right internal carotid artery arterio-gram (B) demonstrates irregularity along the posteriorcarotid wall.

12 Right internal carotid artery arteriogram demon-strating development of a posterior carotid wall

aneurysm (arrow) at the site of the previously visualizedvessel wall irregularity.


5. TICAs may regress, resolve, or grow with time(refer to Case 1 and 2).

6. TICAs appear most frequently on peripheralbranches of the middle cerebral artery and lessoften on the pericallosal artery. Occurrencesare rare in the posterior circulation (refer toCase 1).

7. Bullets tend to completely transect vessels,whereas lower-velocity shrapnel fragmentstend to injure the vessel wall without disruptingits continuity. The latter are more likely to leadto TICA development.

8. TICAs are usually located in the distal part of amissile’s trajectory.

9. TICAs are associated with intracranial hemor-rhage in 80% of cases and subdural hematomasin 26% of cases (refer to Cases 1 and 2).

10. The wall of a TICA has minimal cellular ele-ments and may frequently be a false aneurysm.

11. Angiographic spasm is rare in such cases (referto Cases 2 and 4).

12. Whenever possible, TICAs should be trappedand excised.

Various treatment options were entertained forour five patients. These included proximal sacrificeof the afferent vessel, open surgical or endovasculartrapping of the involved segment, primary clip re-construction of the aneurysmal segment, aneurysmresection with interposition grafting using a seg-ment of superficial temporal artery, and externalcarotid artery-MCA bypass using superficial tempo-ral artery or saphenous vein.

In Case 1, vessel sacrifice either endovascularlywith proximal coils, or surgically with proximal anddistal trapping, was not considered ideal therapyfor this particular case. While Peerless and Drake[12] have noted that the PCA has the richest poten-tial for collateralization of all major cerebral vesselsand found no persistent visual field deficits in 27patients undergoing PCA occlusion, we did notwant to place the occipital cortex at risk in a patientwho already had visual loss from enucleation of thecontralateral eye. Although clip reconstruction wasa possibility, we were skeptical that we would beable to eliminate the aneurysm and its accompany-ing proximal and distal diseased segment of vesselwhile preserving a patent PCA lumen. The long-termeffectiveness of such primary reconstruction wasalso doubtful, especially knowing that previous his-tologic studies have demonstrated significant weak-ness in the involved vessel wall at the site of injury.Any primary clip reconstruction would put the pa-tient as risk for delayed aneurysm regrowth andrupture. The best option seemed to be aneurysmresection with interposition grafting.

13 Left internal carotid artery arteriogram demon-strating crossfill from right to left following right

internal carotid artery coil vessel sacrifice and left inter-nal carotid angioplasty for vasospasm.

14 Head CT demonstrating a right temporo-occipitalintraparenchymal hematoma and subarachnoid

hemorrhage.


We were fortunate that aneurysm resection andinterposition grafting was successful in this patient.The rich collateral flow to the occipital cortex nodoubt provided protection from ischemic injuryduring the 60 minutes that it took to perform thetwo anastomoses. The additional benefits of patientcooling, general anesthesia, and etomidate burstsuppression are indeterminate. Whether or not thepatient would have developed a visual deficit withvessel sacrifice alone is unknown, and some mightargue that tolerance to 60 minutes of occlusion isproof that interposition grafting was unnecessary.

Nevertheless, we are confident that successfulgrafting provided in both short- and long-term pro-tection against potential collateral failure andinfarction.

In Case 2, an initial STA-MCA bypass providedprotection from the prolonged MCA occlusion timeneeded to clip reconstruct the aneurysm and wouldhave permitted aneurysm trapping had this beennecessary. In additional to demonstrating the ben-efit of the bypass procedure, this case along withCase 4 showed that vasospasm, although rare fol-lowing subarachnoid hemorrhage from gunshots to

15 Left vertebral artery arteriogram demonstratinga small right parieto-occipital artery aneurysm. 16 Right vertebral artery anteriogram demonstrat-

ing distal vessel sacrifice proximal to the aneu-rysm using platinum coils (arrow).


the head, is not impossible. It also illustrated thefact that not all TICAs develop along distal aspectsof vessels.

In Case 3, the patient would not tolerate aneu-rysm trapping, as proven by immediate clinical failureduring ICA temporary balloon occlusion. STA-MCAbypass followed by aneurysm trapping provided thebest protection against fatal epistaxis. At the time thisaneurysm was treated, GDC coils were not yet devel-oped. Perhaps with the advent of this technology, thiscase could have been managed endovascularly.

In Case 4, open surgical trapping and STA-MCAbypass was considered; however, temporary bal-loon occlusion with EEG and SPECT information

provided us with the opportunity to treat the pa-tient with simple trapping. By sacrificing the ICAproximally, using endovascular techniques, we pro-vided protection against aneurysm rupture untildefinitive trapping could be carried out, providedearly proximal control for subsequent surgery, andleft the neck virgin so that a subsequent tracheos-tomy could be carried out without fear of contam-inating a cervical incision.

In Case 5, proximal vessel sacrifice using endo-vascularly placed coils provided a quick and easysolution for obliteration of this distal aneurysmwithout putting the patient through the stress of asecond craniotomy.

17 A, Higher magnificationview shows myofibro-

blastic proliferation close to thearea of disruption (upper left),scattered inflammatory cells,numerous hemosiderin-ladenmacrophages, and delicateblood vessels constituting gran-ulation tissue. The lumen (L) isat the lower left, and the aster-isk denotes the muscular wall(3100). B, Low-power view oftraumatic aneurysm. The mus-cular layer of the vessel is indi-cated by an asterisk and the ar-row shows the site ofdisruption. Fragmented rem-nants of the intima and a shaggyendothelial surface are seen onthe luminal aspect (L). Abun-dant granulation tissue (GT)surrounds and partly buries thevessel wall. Fresh hemorrhageand numerous hemosiderin-laden macrophages (insert) arealso seen (340).


ConclusionTICAs are rare finding. In order to detect them,surgeons must be suspicious whenever dealingwith missile injuries to the head and investigatesuch patients with cerebral angiography. Our cur-rent management scheme includes both early andrepeat angiography so that these dangerous lesionscan be treated before they have the opportunity torupture. While management can often simply in-volve Hunterian ligation or aneurysm trapping, ar-terial bypass or aneurysm resection with interposi-tion grafting may be deemed necessary. As thesefive cases demonstrate, management uses multiplemodalities with endovascular and surgical methodscomplimenting one another, so that the safest andmost effective therapy can be carried out rapidlyand efficiently.

REFERENCES1. Aarabi B. Traumatic aneurysms of brain due to high

velocity missile head wounds. Neurosurgery 1988;22:1056–63.

2. Acosta C, Williams PE Jr., Clark K. Traumatic aneu-rysms of the cerebral vessels. J Neurosurg 1972;36:531–6.

3. Bank WO, Nelson PB, Drayer BP. Traumatic aneu-rysms of the basilar artery. AJR 1978;130:975–7.

4. Courville CB. Traumatic aneurysm of an intracranialaartery. Description of a lesion incident to a shotgunwound of the skull and brain. Bull Neurol Soc 1960;25:48–54.

5. Ferry DJ Jr, Kempe LG. False aneurysm secondary topenetration of the brain through orbitofacial wounds:report of two cases. J Neurosurg 1972;36:503–6.

6. Haddad FS, Haddad GF, Taha J. Traumatic intracra-nial aneurysms caused by missiles: their presentationand management. Neurosurgery 1991;28:1–7.

7. Hirsch JF, David M, Sachs M. Les aneurismes arterielstraumatiques intracraniens. [Traumatic intracranialarterial aneurysms.] Neurochirurgie 1962;8:189–201.

8. Jackson FE, Augusta FA, Sazima HJ. Head injury anddelayed epistaxis. Report of a case of rupture of trau-matic aneurysm of internal carotid artery due to gre-nade fragment wound received in Vietnam conflict.J Trauma 1970;10:1158–67.

9. Kaufman HH, Sadhy VK, Clifton GL. Delayed intrace-rebral hematoma due to traumatic aneurysm causedby a shotgun wound: a problem in prophylaxis. Neu-rosurgery 1980;6:181–4.

10. Martin EM, Hummelgard AB. Traumatic aneurysms.J Neurosci Nursing 1986;18:89–93.

11. Moore D, Budde RB, Hunter CT. Massive epistaxisfrom aneurysm of the carotid artery. Surg Neurol1979;11:115–7.

12. Peerless SJ, Drake CG. Surgical techniques of poste-rior cerebral aneurysms. In: Schmidek HH and SweetWH, eds. Operative Neurosurgical Techniques. Indi-cations, Methods, and Results. Ed 2. Philadelphia: WBSaunders, 1988:pp. 973–89.

13. Petty JM. Epistaxis from aneurysm of the internal

carotid artery due to a gunshot wound: case report.J Neurosurg 1969;30:741–3.

14. Raimondi AJ, Yashom D, Reyer C. Intracranial falseaneurysms. Neurochirurgia (Stuttg) 1960;11:219–33.

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COMMENTARYThis is a very useful review of the topic of traumaticintracranial aneurysms secondary to missilewounds.

One of the important lessons from this paper isthe value of bypass grafting in the management ofthese lesions. Surgeons such as myself, who used toroutinely perform many EC-IC bypass proceduresevery year prior to the publication of the results ofthe EC-IC study, are finding it increasingly moredifficult to bring ourselves to plan a bypass proce-dure. Because we are losing our technical compe-tence in performing microvascular anastomosis, wetry, if at all possible, to avoid bypass grafting. Also,because of this lack of technical proficiency, it takesus increasingly longer times to perform this proce-dure. Yet there is still an unquestionable role forbypass grafting in neurosurgery, and this articleillustrates one of its undeniable indications. Trau-matic aneurysms in general cannot be clipped; theparent vessel must be sacrificed, and they fre-quently occur in an artery that simply cannot besacrificed without providing for distal perfusion inone way or another, usually by bypass grafting.

One point that this manuscript does not settle isthe urgency with which a traumatic aneurysm mustbe occluded. Within the last 3 years, I have oper-ated on two patients with traumatic intracranialaneurysms produced by a bullet (or in the mostrecent case, by a shotgun pellet) to the head. Inboth instances, the patient was being “observed”because of the increased intracranial pressure re-lated to the initial wound. Marked enlargement ofthe aneurysm was demonstrated after the second


hemorrhage. Without scientific support, based onthese two cases and anecdotal experience from theliterature and from conversations with my col-leagues, I am developing the concept that theseaneurysms ought to be dealt with as soon as theyare diagnosed, rather than waiting to see what hap-pens on a repeat arteriogram.

Sometimes all that one finds, as in a couple of thecases in this paper, is a slight irregularity in one ofthe intracranial arteries. Frequently, as in one of ourcases, the clue is a disproportionate amount ofsubarachnoid blood. Another clue is a large hema-toma adjacent to a major intracranial vessel. Whenall that the initial angiogram shows is a very slightirregularity of the vessel, there is a temptation towait a week or two and repeat the arteriogram to

see what has happened. How many patients rebleedin the interval? Certainly, my two cases and severalothers I am familiar with from the literature or fromunreported anecdotes suggest that rebleeding fre-quently occurs within the first few days after thedevelopment of a traumatic aneurysm. I would sug-gest that, whenever possible, these aneurysmsshould be dealt with acutely. Fortunately, at least insome cases, interventional endovascular tech-niques, for which even a markedly increased ICP isnot a contraindication, can be used.

Roberto C. Heros, M.D.Department of Neurological Surgery

University of MiamiMiami, Florida

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