Traumatic internal carotid artery pseudoaneurysm

Case contributed by Dr Mate Kover

Presentation

Motor vehicle accident a few days before. Horner syndrome manifested.

Patient Data

Age: 20 years
Gender: Female

Bilateral craniectomy. On the left side, frontoparietal brain contusion is seen.  Frontally on the right side, a circumscribed hemorrhage due to the ventricular drain is visible. There is a subdural hemorrhage on both sides, mainly in the frontoparietal region. The gradient echo sequence show blood products in the circumscribed hemorrhage on the right side and some low signal intensity foci on both sides.
No diffusion restriction is visible.
On the TOF sequence and the postcontrast sequence on the left side at the cavernous segment of the internal carotid artery (C4), abnormal signal intensity and enhancement first suspected a traumatic carotid-cavernous fistula.

DSA (angiography)

Angiography was performed to confirm the carotid-cavernous fistula, but it was excluded. A pseudo-aneurysm was seen, and in the background, post-traumatic internal carotid artery dissection was confirmed. With endovascular coils, the pseudoaneurysm was closed.

Case Discussion

Carotid artery dissection has an important role in stroke in young adults. We can classify the cause as spontaneous dissection (adults with connective tissue disorders),  traumatic dissection as in this case, or it can be iatrogenic ( angiography).
Pseudoaneurysm formation is rare, but it is a severe complication; it has a higher risk for stroke and a higher mortality rate. Usually, it develops hours to years after the trauma.
Usually, the carotid dissection requires conservative therapy ( antiplatelet drugs with or without anticoagulation).
Pseudoaneurysm formation requires endovascular treatment, as in this case, endovascular coil application.

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