E-001 Endovascular management of traumatic intracranial aneurysms from closed head injury

Introduction/Purpose Traumatic intracranial aneurysms (TICAs) comprise a rare and particularly dangerous subset of cerebral aneurysms that can be difficult to both diagnose and manage, owing to their locations, morphologies, and presence of concomitant traumatic brain injury (TBI). Materials and Methods We retrospectively reviewed internal databases comprised of intracranial aneurysms treated at two U.S. academic medical centers from 2010 to 2019. Patients with aneurysms of the intracranial circulation as a result of blunt force trauma treated with endovascular methods were included. All patients underwent initial non-contrast head CT, non-invasive vascular imaging, and diagnostic cerebral angiography. Clinical and radiographic data were recorded. Results Between January 2010 and December 2019, a total of 8 patients with traumatic intracranial aneurysms treated with endovascular methods were included. Patients were aged 9-62 years (mean 35.5) and most were male (n=5). Five of 8 patients (62%) experienced acute intracranial hemorrhage due to aneurysm rupture. All patients but one were found to have an associated fracture on initial CT, including the ipsilateral petrous bone (n=4), anterior clinoid process (n=1), posterior clinoid (n=2), sphenoid body (n=6), clivus (n=2), and carotid canal (n=3), while 6 of 8 patients were noted to have sphenoid hemosinus on initial imaging. The most frequently involved vessel was the internal carotid artery (ICA; n=6), including 2 cavernous segments, 2 supraclinoid segments, 1 ophthalmic segment, and 1 communicating segment. The other vessels involved include the anterior cerebral artery (pericallosal; n=1) and the posterior inferior cerebellar artery (tonsillomedullary segment; n=1). Aneurysm sizes ranged from 2-8 mm (mean, 4.4 mm). Three of 8 aneurysms were treated with flow diversion (FD), one of which had adjuvant coil embolization, while 3 aneurysms were treated with balloon-assisted coiling (BAC). The 2 non-ICA aneurysms were treated with parent vessel sacrifice (PVS), one with liquid embolics and coil embolization, the other with coil embolization alone. Complete angiographic cure was achieved in 5 of 8 patients. Three aneurysm recurrences were found on follow-up imaging, one of which presented as re-rupture, and all of which were re-treated. Re-treatment modalities included FD alone, FD with adjuvant coil embolization, and direct coil embolization alone. Two of 3 treated recurrences were completely cured on angiographic follow-up, while one expired before sufficient time to judge treatment efficacy had passed. Despite technical success in the overwhelming majority of cases, half of the patients were discharged with a poor functional outcome (mRS 3-6). Conclusion TICAs may form acutely or in a delayed manner following blunt force trauma and occur most frequently on the ICA owing to its proximity to the rigid bony and dural structures of the skull base. The presence of cranial fractures and sphenoid hemosinus warrants prompt intracranial vascular imaging, particularly in a TBI patient with acute neurological decline or new neurologic deficit. Endovascular management is effective, particularly FD, which has emerged as an attractive alternative to PVS in carefully selected patients. Outcomes tend to be poor despite technically successful endovascular treatment, and further investigations are needed to show which patients might benefit the most. Disclosures A. White: None. C. Roark: None. D. Case: 2; C; Medtronic. Z. Folzenlogen: None. D. Kumpe: None. D. Ding: None. J. Seinfeld: 2; C; Medtronic.