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American Journal of Physical Medicine & Rehabilitation:
doi: 10.1097/PHM.0b013e31817fbaea
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Traumatic Pseudoaneurysm of the Basilar Artery

McElroy, Kevin M. DO; Malone, Richard J. DO; Freitag, Warren B. MD; Keller, Irwin MD; Shepard, Scott MD; Roychowdhury, Sudipta MD

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From JFK Medical Center, JFK Johnson Rehabilitation Institute, UMDNJ-RWJ Medical School, Department of PM&R, Edison, New Jersey (KMM, RM); JFK Medical Center, Edison Radiology Group, Edison New Jersey (WBF); Robert Wood Johnson University Hospital, University Radiology Group, East Brunswick, New Jersey (IK, SR); and Department of Surgery, Section of Neurosurgery, Robert Wood Johnson School of Medicine (SS).

All correspondence and requests should be addressed to Kevin McElroy, DO, 71 Central Avenue, Glen Rock, NJ 07452.

A 62-yr-old male was admitted to a trauma center after being struck in the head by a conveyor belt at work. He suffered an almost immediate loss of consciousness, with an initial Glasgow coma scale score of 7. A computed tomography scan of the head revealed a traumatic subarachnoid hemorrhage with extension into the right sylvian fissure and multiple skull base fractures. Computed tomographic angiography did not reveal any vascular abnormality (Fig. 1). Three weeks later, he was transferred to inpatient brain trauma rehabilitation. A routine follow-up computed tomography scan, done 8 days after admission to inpatient rehabilitation, was suspicious for acute blood in the subarachnoid space that was not the result of his original injury. Computed tomographic angiography revealed a 6.2 × 5 × 5.1-mm pseudoaneurysm at the tip of the basilar artery (Fig. 2). The patient was transferred back to the original trauma center for cerebral angiogram and coiling of the traumatic basilar artery pseudoaneurysm. Magnetic resonance angiography performed 2 wks after coiling of the pseudoaneurysm revealed successful treatment of the pseudoaneurysm. Subsequently, the patient has shown steady progress with rehabilitation.

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Figure 2
Figure 2
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Pseudoaneurysms, or false aneurysms, are differentiated from true aneurysms by the layers of the artery involved. Pseudoaneurysms are the result of the rupture of all three layers of the artery: the tunica intima, media, and adventitia. The aneurysm is contained by an organized hematoma or neighboring connective tissue. With true aneurysms, the outermost layer, the adventitia, remains intact.

As a result of its secure location, injury to the basilar artery is rare.1 Only 10% of traumatic aneurysms in the brain occur in the posterior circulation. As was seen in this case, the majority of basilar artery aneurysms are associated with skull base fractures. In addition, the connective tissue surrounding the basilar artery is usually unable to contain the aneurysm, making it improbable that a patient would survive a traumatic aneurysm in the posterior circulation.2

Rapid treatment is imperative because of the high morbidity and mortality associated with basilar artery pseudoaneurysms. Pseudoaneurysms, in general, grow faster and have a greater chance of rebleeding when compared with true aneurysms. Treatment options are extensive, including open surgical repair, coil embolization, and ultrasound-guided compression or thrombin injection. Recent literature suggests that coil embolization and ultrasound-guided thrombin injection have become the most common treatment options.3,4

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REFERENCES

1. Bank WO, Nelson PB, Drayer BP, Wilkins RH, Rosenbaum AE: Traumatic aneurysm of the basilar artery. AJR Am J Roentgenol 1978;130:975–7

2. Connor SEJ, Martin AJ, Deasy NP, Jeffree MA, Strong AJ: Traumatic basilar pseudoaneurysm with a basilar-cavernous arteriovenous fistula. Neuroradiology 2001;43:249–53

3. Mansour MA, Gorsuch JM: Diagnosis and management of pseudoaneurysms. Perspect Vasc Surg Endovasc Ther 2007;19:58–64

4. Quintana F, Diez C, Gutierrez A, Diez ML, Austin O, Vazquez A: Traumatic aneurysm of the basilar artery. Am J Neuroradiol 1996;17:283–85

© 2008 Lippincott Williams & Wilkins, Inc.

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