Description

A patient sustained a gunshot, which entered the nose and exited the parietal region. The patient was intubated, with reactive pupils and minimal extremity movement (Glasgow Coma Scale 3 T). Initial CT angiogram was unrevealing, but MRI performed 1 week later revealed a 4.5 mm traumatic intracranial aneurysm (TICA) close to the bullet path (figure 1A). Cerebral angiography confirmed the aneurysm (figure 1B), and the patient underwent coil embolisation of it with sacrifice of the distal pericallosal artery using Onyx (figure 1C). The discharge Glasgow Coma Scale was 14, but with left hemiparesis. On recent follow-up, the patient was talking and was able to use the right upper and both lower extremities.

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Figure 1

MRI (A) and cerebral angiogram (B) revealing a traumatic intracranial aneurysm at the junction of the pericallosal and callosomarginal arteries, in proximity to the bullet path, which was treated by coil and Onyx embolisation (C).

Penetrating and blunt head injuries can cause haemorrhage, vessel dissection or thrombosis, as well as the formation of TICAs. Low-velocity penetrations are believed to be more prone to TICA development.1 TICAs are commonly reported in children,2 with risk factors including wound tracts that traverse multiple dural components or penetrating injuries that involve the skull base, face or orbit, in addition to the intracranial compartment.3 Patients often present with life-threatening intracranial haemorrhage or epistaxis due to TICA rupture. Other presentations include cranial nerve palsies, headaches, hydrocephalus and blindness.1 Early diagnosis is key, but the ideal optimal time for angiography, the gold standard, is not known. TICAs often take time to manifest, with an average of 21 days from initial trauma to haemorrhage onset.1 Treatment modalities include open surgical techniques, as well as endovascular obliteration with possible sacrifice of the parent artery.