American Journal of Clinical Neurology and Neurosurgery

Vol. 1, No. 3, 2015, pp. 133-136

http://www.aiscience.org/journal/ajcnn

* Corresponding author

E-mail address: yoshuaesquenazi@gmail.com (Y. Esquenazi)

Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture Following Ventriculostomy

Yoshua Esquenazi1, *, Arthur L. Day1, William W. Ashley2

1Vivian L Smith Department of Neurosurgery, University of Texas Medical School at Houston, Houston TX, USA

2Department of Neurosurgery, Loyola University Medical Center, Maywood IL, USA

Abstract

Percutaneous ventriculostomy (EVD) placement is one of the most important diagnostic and therapeutic tools in neurosurgery.

Although generally considered low risk, it can be associated with significant complications. We report a case of an intracranial

hemorrhage secondary to iatrogenic anterior cerebral artery pseudoaneurysm rupture following ventriculostomy. A 67 year-old

female presented to our institution with a spontaneous cerebellar hemorrhage and obstructive hydrocephalus. She underwent

emergent bedside right frontal EVD placement and was subsequently taken to the operating room for suboccipital craniectomy

and clot evacuation. On postoperative day three, she experienced sudden onset of headache with neurological deterioration,

emergent cranial CT scan demonstrated fresh hemorrhage along the EVD tract and casting of the ventricular system. Cerebral

arteriography revealed a 3.6 x 3.4 mm traumatic pseudoaneurysm arising from a distal anterior cerebral artery branch that was

in contact with the ventricular catheter. After unsuccessful endovascular treatment, the patient was taken to the operating room

for clot evacuation and microsurgical aneurysm obliteration. Despite a long and complicated hospital course the patient

expired. This report describes a case of acute intracerebral hemorrhage as a presenting sign of pseudoaneurysm rupture

following ventriculostomy. Iatrogenic vascular trauma associated with this procedure may be more common than currently

appreciated. In the face of significant hemorrhage along an EVD track, evaluation should include catheter angiography if CTA

is negative.

Keywords

Intracranial Hemorrhage, Pseudoaneurysm, Ventriculostomy Placement

Received: August 10, 2015 / Accepted: August 19, 2015 / Published online: September 10, 2015

@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license.

http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction

Percutaneous external ventricular drain placement is one of

the most important diagnostic and therapeutic tools in

neurosurgery, and is often inserted as a potentially life-saving

procedure. Its widespread use has proven to be an effective

method for cerebrospinal fluid diversion in the management

of intracranial hypertension and acute hydrocephalus, and is

now considered a mainstay of neurosurgical practice. 1)

Despite its widespread and common use, EVD placement has

been associated with infectious and hemorrhagic

complications. (2, 3)

We report a case of an iatrogenic

intracranial dissection/pseudoaneurysm that led to

intracerebral hemorrhage (ICH) following EVD placement,

and present a brief review of the literature.

2. Clinical Case

A 67-year-old hypertensive female presented to our

institution with a large 45 cc spontaneous cerebellar

134 Yoshua Esquenazi: Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture

Following Ventriculostomy

intraparenchymal hemorrhage with associated

hydrocephalus. She underwent emergency bedside right

frontal EVD placement, which was seemingly

uncomplicated. Using surface landmarks, a hand twist drill

was used to create the burr-hole one centimeter in front of the

coronal suture along the mid-pupillary line. The dura mater

was opened sharply with an 11 blade and the ventricle was

cannulated after a single pass. She was subsequently taken to

the operating room for suboccipital craniectomy and clot

evacuation. The patient recovered well without neurologic

deficit, and she was extubated the following day. Routine

postoperative CT scan showed complete cerebellar

hematoma evacuation, and a small IVH without ICH

associated with the ventricular catheter. (Fig 1, a and b)

Figure 1. (a) Postoperative noncontrast cranial computed tomography demonstrates EVD placement (arrow) without associated ICH. (b) A small amount of

IVH (arrow) is appreciated in the right frontal horn and the left cerebellar hematoma has been evacuated.

Figure 2. (a and b) Noncontrast cranial computed tomography demonstrates evidence of ICH along the EVD catheter extending into the ventricular system

with obstructive hydrocephalus (arrows).

On postoperative day three, the patient experienced a sudden

headache associated with spontaneous bloody cerebrospinal

fluid (CSF) drainage from the EVD catheter, followed

rapidly by acute neurologic deterioration. After intubation

and initial resuscitation, an emergent bedside CT scan

showed hemorrhage along the EVD tract with ventricular

extension, casting of the ventricular system and obstructive

hydrocephalus. (Fig 2, a and b) A contralateral EVD was

placed, with minimal neurological improvement. CT

angiography did not show any clear vascular abnormalities.

A cerebral diagnostic angiogram revealed a 3.6 x 3.4 mm

traumatic pseudoaneurysm arising from a distal anterior

cerebral artery (ACA) branch that was in contact with the

ventricular catheter. (Fig 3 a and b) Attempted endovascular

obliteration of the pseudoanerysm was unsuccessful. Due to

mass effect and increased intracranial pressure it was decided

American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 3, 2015, pp. 133-136 135

to take the patient to the operating room for clot evacuation

and surgical pseudoaneurysm obliteration. Despite a long and

complicated hospital course thereafter, her neurologic exam

did not improve, and the patient subsequently expired.

Figure 3. (a) Lateral digital substraction angiogram demonstrates a pseudoaneurysm in a distal branch of the ACA (arrow), (b) 3-D digital substraction

angiography demonstrates the pseudoaneurysm along the location of the EVD catheter (arrows).

3. Discussion

In 1918 Dandy reported that, in experienced hands,

ventricular puncture could be an uncomplicated procedure. 4)

Unfortunately, more experience and regular usage has

demonstrated that EVD placement is associated with

significant infectious and hemorrhagic risks with

hemorrhagic complication rates ranging from 0-41%. 5, 6)

Two

meta-analysis of this procedure have reported an overall

hemorrhagic complication rate of 5.7-7%, with a significant

rate of hemorrhage between 0.8%-1%. 2, 3)

The wide variation

in hemorrhage rates may be associated with specific technical

or anatomic factors, but could also be related to

methodological differences. Variations in patient populations,

coagulation profile thresholds prior to the procedure, routine

post-procedure imaging studies and its timing, inclusion of

hemorrhages caused by ventricular catheter removal, and

operator technique/expertise may be important factors

contributing to the broad range of results, as well as the

retrospective nature of most studies.

Drain related hemorrhages (subdural, epidural, intracerebral

and intraventricular-IVH) are all possible, most probably

occur as the result of a small cortical or pial vessel injuries

caused by the ventricular catheter or drill at the time of

insertion. In most cases, they are not identified because they

are asymptomatic and do not cause any clinical

consequences, and therefore are excluded from published

series. The few cases have been reported have rarely required

surgical evacuation for mass effect. 7-9)

We did not find any reported cases of ICH or IVH proven to

be the consequence of a vessel injury leading to

pseudoaneurysm formation and rebleeding following EVD.

Thus, this phenomenon may be clinically quite rare. One

possible explanation may be that in the majority of cases, the

small hemorrhages related to vessel injury do not expand into

a visible pseudoaneurysm, and the vessel heals without

consequences. In the absence of clinical sequelae, they

remain undetected, with rarely a need to obtain further

diagnostic studies.

In a recently published series of complications related to

EVD placement, 10)

one of the patients developed a 3-mm

pseudoaneurysm arising from a distal right ACA branch that

was adjacent to the shunt tubing. Interestingly this

pseudoaneurysm was not seen on angiography performed a

month earlier and a CT scan after insertion of the EVD did

not demonstrate evidence of hemorrhage. A possible

explanation of the delay presentation may be related to

formation of the aneurysm secondary to thinning of the

vessel wall due to a chronic foreign body reaction secondary

to the shunt tubing, as previously reported in a patient with

traumatic aneurysm formation following ventriculoperitoneal

shunt insertion. 11)

Pseudoaneurysms of the superficial temporal artery

secondary to partial laceration of the vessel wall during

tunneling of the ventricular catheter 10, 12)

, and dural

arteriovenous fistulas after injury of the middle meningeal

artery during EVD placement have been previously reported.

10, 13, 14) Schuette et al,

15) described a case of a pial

arteriovenous fistula resulting from EVD placement. In this

case a CT scan after drain placement demonstrated a

hemorrhage at the EVD site. Interestingly, the fistula was

appreciated on follow-up cerebral angiography 18 months

after the EVD was initially inserted, and a previous 6 month

136 Yoshua Esquenazi: Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture

Following Ventriculostomy

follow-up angiogram did not reveal the lesion. This fistula

was almost certainly the result of a prior clinically silent

EVD related vessel injury that recanalized over time and

became an arteriovenous fistula. To our knowledge, the case

presented here is the first report of an ICH as a consequence

of rupture of a pseudoaneurysm that developed soon after

EVD placement.

In the case of our patient, a routine postoperative CT scan

after cerebellar clot evacuation showed no ICH and a small

asymptomatic IVH likely the result of bleeding as the EVD

entered the ventricle (Fig 1 a and b). After later clinical

deterioration caused by ICH and IVH, an emergent CT

angiogram did not show any vascular abnormalities. A

formal cerebral diagnostic angiogram, however,

demonstrated the pseudoaneurysm arising from the distal

ACA that appeared to be in contact with the EVD. (Fig 3b)

While misplacement of EVD catheters particularly those

traversing the interhemispheric fissure into the contralateral

hemisphere can potentially increase the risk of vascular

injury and potential pseudoaneurysm formation. In the case

of our patient the EVD catheter remained ipsilateral along its

course, and the tip of the catheter ended in the frontal horn.

(Fig 1a and b).

4. Conclusion

Although percutaneous EVD is generally a safe and effective

procedure, iatrogenic vascular trauma associated with this

procedure may be more common than currently appreciated,

and serious complications can arise. The presence of an

expanding hematoma along the EVD tract in a patient with

an uneventful insertion and with a normal coagulation profile

may suggest the presence of vascular injury related to its

placement. In such circumstances, early diagnosis and

treatment may prevent the negative consequences of

rebleeding related to pseudoaneurysm rupture. CT

angiography may not be sufficient in the search of this lesion

and cerebral angiography should be considered.

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