Тhe contribution of computed tomography to the diagnosis of multiple aneurysm in the acute period of aneurysmal intracranial hemorrhage

Introduction. Multiple aneurysms are detected in patients with non-traumatic subarachnoid hemorrhage (nSAH) in 14–45% of cases. The diagnostic algorithm for this pathology can be shortened by performing the non-enhanced CT of head, CT-angiography, and if the localization of hemorrhage according to non-enhanced CT data matches, there is enough evidence to perform direct surgery without obtaining preoperative DCA.Objective. Determination of the diagnostic efficiency of CT and CTA of brachiocephalic arteries (CTA BCA) for planning the surgical treatment in the case of multiple aneurysms of intracranial arteries in the acute period of non-traumatic ICH in an emergency room.Material and methods. Retrospective analysis of the records of radiological examinations in the preoperative period in patients in an acute period of non-traumatic subarachnoid hemorrhage in the acute period performed in an emergency room of the Research Institute — Ochapovsky Regional Hospital no. 1. in the period from September 2017 to July 2018 (cerebral angiography, non-enhanced CT of the brain, CTA BCA).Results. According to the CTA BCA, 60 aneurysms were found: 21 patients had 2 aneurysms each one, 2 patients had 3 aneurysms, one patient had 8 aneurysms, and 4 patients had one aneurysm each. In comparison with DCA, which was performed in 10 patients, additionally there were found 3 miliary aneurysms, one aneurysm was excluded. For patients who did not obtain DCA, CTA scans were compared with intraoperative data on the side of surgical intervention (n=18). According to the CTA BCA, 18 aneurysms were found, according to the intraoperative record were found 17 aneurysms, while in one case a large bilobulated aneurysm was defined by a radiologist as two oppositely directed. The rest of the data was consistent.Conclusion. The presence of nICH on the non-contrast CT of the brain, and the correspondence of the localization of hemorrhage according to the results of CT-angiography, is sufficient for direct surgery without obtaining preoperative DCA, which is especially important in difficult patients. The use of DCA in patients with multiple aneurysms is recommended only in controversial and difficult cases.

Abstract 1122‐000129: Management of Traumatic Carotid‐Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Introduction : Traumatic carotid‐cavernous fistulas (tCCFs) represent abnormal vascular shunt between the carotid artery, in its cavernous segment, and the cavernous sinus, after direct or indirect trauma. Literature on tCCF associated with gunshot wounds (GSW) is scarce and is unique due to potential risk of exsanguination or bleeding into the brain proper. Furthermore, the management of tCCF in the GSW population is particularly relevant as gunshot patients represent a unique challenge be it due to the presence of concomitant cranio‐cervical vascular injury, other organ involvement, or contraindications for anticoagulation and /or antithrombotic use. Methods : Case presentation Case A Patient is a 23 y/o female with GSW to the right side of the head with multiple skull base fractures and right temporal lobe penetrating injury with retained bullet fragment, traumatic subarachnoid hemorrhage in the basal cisterns, diffuse cerebral edema, and a 5mm right to left midline shift. Patient also has a high‐flow right tCCF with significant arterialization of cortical veins. Patient underwent venous coiling of the cavernous sinus with flow diverter stents in the arterial wall of the cavernous segment of the carotid artery. The patient remained in the hospital fifty‐one days and suffered multiple neurological complications, including cerebral vasospasm, development of a pseudoaneurysm in the right anterior choroidal artery that was embolized, and hydrocephalus, requiring ventriculo‐peritoneal shunting (VPS). Patient had a GOSE 2 at the discharge to a long‐term acute care facility. Results : Case B Patient is a 30 y/o male with GSW to the left side of the head with left hemispheric subdural hematoma, left temporal lobe injury, and diffuse traumatic subarachnoid hemorrhage. The injury also resulted in a temporal bone fracture, lateral to the carotid canal, and extensive left facial fractures. Patient also has a high‐flow left tCCF that was also treated successfully with cavernous sinus coiling with flow diverter stenting of the carotid artery at the site of the fistula after initiating antithrombotic agents. Post the tCCF repair the patient developed a CSF leak that necessitated an extensive surgical repair that would not have been possible while on antithrombotic agents. At this point, the patient underwent balloon test occlusion (BTO) and sacrifice of the carotid artery at the site of the fistula. Patient was discharged to acute rehab facility with a GOSE of 5. Conclusions : Traumatic CCF may occur in patient with gunshot wounds to the head, representing an extreme of penetrating mechanisms associated with this type of injury. Current penetrating brain injury guidelines are outdated and provide no consensus on management of this condition. Embolization of the fistula, flow diversion via stenting of the fistula site and finally vessel sacrifice are viable options depending on the size of the fistula, flow grade, collateral flow, phase on injury, and concomitant injury that may dictate permissibility of antithrombotic therapy.

Change of Levels of NGF, ACTH, and AVP in the Cerebrospinal Fluid after Decompressive Craniectomy of Craniocerebral Injury and Their Relationship with Communicating Hydrocephalus

In recent years, the incidence of craniocerebral trauma has increased, making it one of the important causes of death and disability in neurosurgery patients. The decompressive craniectomy (DC) after severe craniocerebral injury has become the preferred treatment for patients with severe craniocerebral injury, but the incidence of postoperative hydrocephalus has become a difficult problem in clinical treatment. This study observed the changes of nerve growth factor (NGF), adrenocorticotropic hormone (ACTH), and arginine vasopressin (AVP) levels in the CSF after DC in patients with craniocerebral injury and analyzed the relationship between the three indicators and communicating hydrocephalus. The results showed that the levels of NGF, ACTH, and AVP in patients with cranial injury after DC were significantly higher than those in healthy subjects, and subdural effusion, traumatic subarachnoid hemorrhage (tSAH), and the levels of NGF, ACTH, and AVP in the CSF were independent risk factors for communicating hydrocephalus. Monitoring the levels of NGF, ACTH, and AVP is of great significance for clinicians to judge the occurrence of traffic hydrocephalus, evaluate the prognosis of patients with craniocerebral injury after DC, and guide clinical treatment.

Robotic Transcranial Doppler in Non-Traumatic Subarachnoid Hemorrhage: A Safety and Efficacy Study

Introduction: Delayed cerebral ischemia (DCI) secondary to vasospasm is a determinate of outcomes following non-traumatic subarachnoid hemorrhage (SAH). SAH patients are monitored using transcranial doppler (TCD) to measure cerebral blood flow velocities (CBFv). However, the accuracy and precision of manually acquired TCD can be operator dependent. The NovaGuide robotic TCD system attempts to standardize acquisition. This investigation evaluated the safety and efficacy of the NovaGuide system in SAH patients in a Neuro ICU.Methods: We retrospectively identified 48 NovaGuide scans conducted on SAH patients. Mean and maximum middle cerebral artery (MCA) CBFv were obtained from the NovaGuide and the level of agreement between CBFv and computed tomography angiography (CTA) for vasospasm was determined. Safety of NovaGuide acquisition of CBFv was evaluated based on number of complications with central venous lines (CVL) and external ventricular drains (EVD) Results: There was significant agreement between the NovaGuide and CTA (Cohen’s Kappa = 0.74) when maximum MCA CBFv ≥120 cm/s was the threshold for vasospasm. 27/48 scans were carried out with CVLs and EVDs present without negative outcomes. Conclusions: The lack of adverse events associated with EVDs/CVLs and the strong congruence between maximal MCA CBFv and CTA illustrates the diagnostic utility of the NovaGuide.

A case of transpetrosal penetrating head injury near the sigmoid sinus

Background: Penetrating brain injury is relatively rare, which occurs in 0.4% of all head trauma. In past reports, the orbit, nasal cavity, and oral cavity are the most common routes of entry of foreign substances into the skull. In this case report, we experienced a rare case of head trauma who injury through the petrosal bone. To the best of our knowledge, there is no similar literature. Case Description: A 69-year-old man accidentally fell from a stepladder with a height of 3 m. There was a sprinkler on the ground, and it went through his posterior part of the right auricle at the collision. He was alert on admission. However, neurological examination showed right trigeminal, abducens, and facial nerve palsy. Computed tomography was performed, and it revealed that the objects penetrated the petrosal bone. Furthermore, it caused traumatic subarachnoid hemorrhage and acute subdural hemorrhage. Fortunately, it did not reach any cerebral artery and cerebral parenchyma. Immediately it was surgically removed with a good outcome. Conclusion: When suspected sigmoid sinus injury in head penetrating injury, craniotomy should be considered with bleeding from the sigmoid sinus during surgery.