Abstract Number ‐ 84: Importance of Early Detection and Treatment of Traumatic Intracranial Pseudoaneurysms Prior to Decompressive Hemicraniectomy
Authors: Nidamanuri Priya , Nogueira Raul , Malik Kunal , Ruiz Aldo Mendez , McDowell Michael , Al‐Bayati Alhamza 
Published: April 2023

Introduction
Intracranial pseudoaneurysms are rare lesions that represent less than 1% of all intracranial aneurysms.1They typically occur due to disruption of the arterial wall layers and subsequent extramural/extraluminal hematoma formation following traumatic brain injury, resulting in a higher risk of rebleeding than that of saccular cerebral aneurysms.2Pseudoaneurysms have higher incidence in children and young adults, and given their association with high morbidity and mortality, early detection and management is essential.2‐4The purpose of this study is to highlight the importance of early recognition and management of traumatic pseudoaneurysms prior to decompressive hemicraniectomy.

Methods
This is a case report of a six‐year‐old previously healthy male who presented as a level 1 trauma alert after sustaining a gunshot wound to the face while manipulating an unsecured weapon at his residence. Upon arrival, lack of airway protection requiring intubation, entry wound to the anterior forehead, and diffuse forehead and periorbital edema were observed. CT head demonstrated multicompartmental hemorrhage with 6mm right to left midline shift and diffuse cerebral edema. CTA head and neck noted possible thrombosed right anterior cerebral artery (ACA) pseudoaneurysm in the right frontoparietal region (Figure 1‐A). Prior to decompressive hemicraniectomy, neuro‐endovascular consultation was obtained, and emergent cerebral angiogram was recommended. This case highlights the findings demonstrated on cerebral angiography, the technique by which the pseudoaneurysm was detected and secured, and the importance of doing so prior to further neurosurgical interventions.

Results
The patient was taken for diagnostic cerebral angiogram via femoral artery access. Initial angiographic run of the right internal carotid artery demonstrated distal right pericallosal artery slowing without clear evidence of underlying vascular injuries. Given concern for underlying thrombosed pseudoaneurysm and its parent branch, selective catheterization of the proximal pericallosal artery off the distal ACA was performed. Gentle angiographic run was obtained via microcatheter that demonstrated superior parietal artery pseudoaneurysm without active extravasation (Figure 1‐B). The microcatheter was advanced and placed in the proximal portion of the pseudoaneurysm sac and five platinum coils were deployed to fully obliterate the pseudoaneurysm and its parent feeder while protecting the adjacent paracentral artery (Figure 1‐C, 1‐D). Following completion of the endovascular procedure, the patient was transferred to the operative room for right decompressive hemicraniectomy and clot evacuation, which were completed successfully.

Conclusions
Prompt detection and securement of traumatic intracranial pseudoaneurysms are essential prior to invasive neurosurgical interventions to reduce risk of recurrent bleeding. Selective angiographic evaluation of the parent injured vessel(s) is crucial for optimal assessment of the underlying lesion. Neuro‐endovascular interventions including coil embolization, stenting, flow‐diverter implantation, and parental artery occlusion have emerged as alternatives to conventional neurosurgical management.2 This case highlights the successful early detection and treatment of a traumatic intracranial pseudoaneurysm with coil embolization followed by uncomplicated decompressive hemicraniectomy.