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Journal of Neurological Disorders & Stroke

Cite this article: Perrotta F, Denittis N, Recchia A, Simeone A, Del Gaudio A (2018) The Diagnostic Role of Angio-CT in the Post-Traumatic Subarach-noid Hemorrhage (SAH): A Case Report. J Neurol Disord Stroke 6(3): 1148. 1/2

*Corresponding authorDel Gaudio A, Department of Anesthesia, “Casa Sollievo Della Sofferenza” Hospital San Giovanni Rotondo, Italy, Email: freddydelgaudio@libero.it

Submitted: 10 November 2018

Accepted: 27 November 2018

Published: 29 November 2018

Copyright© 2018 Gaudio et al.

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Keywords•Closed head trauma•Aneurysm•Posterior cerebral circulation

Case RepoRt

The Diagnostic Role of Angio-CT in the Post-Traumatic Subarachnoid Hemorrhage (SAH): A Case ReportPerrotta F1, Denittis N1, Recchia A1, Simeone A2, and Del Gaudio A1*1Department of Anesthesia, “Casa Sollievo Della Sofferenza” Hospital San Giovanni Rotondo, Italy2Department of Radiology, “Casa Sollievo Della Sofferenza” Hospital San Giovanni Rotondo, Italy

Abstract

Subarachnoid hemorrhage (SAH) secondary to closed head injury is rarely associated with traumatic aneurysm of the posterior circulation. We report a case of SAH and delayed re bleeding in a young patient with head trauma after a fight. The first line CT scan was negative for aneurysm. We analyzed the causes of posterior aneurysm formation and underline the necessity of a prompt angiography for the diagnosis and to exclude the source of the bleeding.

INTRODUCTIONAngio-CT is worldwide considered the first line in the

diagnosis of the post-traumatic SAH [1]. Angio CT has a number of advantages over catheter angiography including the ability not only to evaluate the vessels from their origin at the aortic arch to the intracranial portion but also assess non-vascular neck structures and brain parenchyma. It is also less expensive and at lower risk to the patient.

It must, however, consider the great variability of the pathology and mostly the variability in time of this kind of lesions [2]. We report the case of post-traumatic SAH caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA) without skull fractures.

CASE PRESENTATIONA 25 years old male patient with an history of closed head

trauma was transferred to the Neuro–ICU of our hospital from the first line hospital where he showed a GCS=8 ad the admission. An Angio-CT scan (Figure 1) performed in the first line hospital after sedation and airway control showed a posttraumatic SAH (grade IV) with cerebral edema and hydrocephalus without evidences of vascular lesions and skull fractures.

The patient underwent surgery with ventriculostomy and bilateral osteodural decompression after intracranial pressure (ICP) measure over 30 mmhg. After surgery cerebral homeostasis was guaranteed for seven days and tracheotomy was performed after six days. CT control and neurologic recovery evidenced improvement of the patient until day 9 when patient showed a sudden clinical worsening with coma and re bleeding trough ventriculostomy. CT and Angio CT scan (Figure 2,3) evidenced re

bleeding in intracranial posterior fossa, left intracranial vertebral artery dissection at V4 level with a left PICA aneurysm. General massive vasospasm including anterior regions was indentified. The successive cerebral angiography showed irregular PICA aneurysm like the cause of the bleeding and widespread vasospasm of anterior and posterior cerebral circulation with closure of right vertebral artery. After 48 hours somato sensorial evoked potentials (SSEP) and magnetic nuclear resonance (MNR) showed bilateral ischemic outcomes.

Figure 1 Angio-CT performed in the first line hospital showing no evidence of aneurysmatic lesion on the left PICA.

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Gaudio et al. (2018)Email: freddydelgaudio@libero.it

J Neurol Disord Stroke 6(3): 1148 (2018) 2/2

Perrotta F, Denittis N, Recchia A, Simeone A, Del Gaudio A (2018) The Diagnostic Role of Angio-CT in the Post-Traumatic Subarachnoid Hemorrhage (SAH): A Case Report. J Neurol Disord Stroke 6(3): 1148.

Cite this article

threatening aneurysm.

In practice the combination of the following criteria supports the diagnosis: the history of the trauma, the young age of the patient, the absence of skull fractures and the site of the SAH [2,7]. When all these criteria are present we think that it is reasonable to perform an early cerebral angiography [2]. This issue is in our opinion decisive in emergency for the diagnosis and to exclude the source of the bleeding. Angio-CT follow up remains in our opinion the first line of the diagnosis but it needs to be completed in presence of the criteria mentioned above by cerebral angiogram to identify underlined lesions [1].

CONCLUSIONPosttraumatic dissecting cerebral aneurysm in absence of

skull fractures is a rare life-threatening complication of traumatic brain injury; often under diagnosed. The few cases reported in literature permit no consensus on the optimal modality and timing of the imaging tests. In the presence of cisternal SAH associated with trauma without skull fractures there is considerable practice variability. Moreover it is important to distinguish a traumatic intracranial aneurysm (TICA) from a dissecting aneurysm as the treatments, risks and outcomes can be significantly different [2,8]. For all these reasons, especially in emergency, the treatment of these lesions needs a multispecialized experienced team including neurosurgeon, an interventional neuroradiologist and emergency physician.

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Figure 2 Angio-CT performed on day 9 after rebleeding showing dissecting aneurysm of left PICA and widespread vasospasm.

Figure 3 Angiogram showing left PICA dissecting aneurysm.

DISCUSSIONPosttraumatic aneurysms may occur as the result of blunt

head trauma in young adults. In closed head trauma SAH may be consequent to a direct injury to the vessels or to the stretching of the vessels by adjacent forces. These kinds of lesion have a predilection for intra-clinoidalinternal carotid artery or basilar artery in skull base fracture [3,4]. Posttraumatic aneurysms arising from posterior circulation, like in our case, are rare [5]. Interestingly in the literature are described same cases of acute subarachnoid hemorrhages secondary to posttraumatic aneurysms with a typical average delay from the initial trauma of three weeks [6]. All this could suggest to further investigating mild and severe trauma brain injury (TBI) to disclose a life

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The Diagnostic Role of Angio-CT in the Post-Traumatic Subarachnoid Hemorrhage (SAH): A Case ReportAbstractIntroductionCase Presentation Figure 1Figure 2Figure 3ConclusionReferences