Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow Diversion: 2-Dimensional Operative Video

Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow... SURGICAL VIDEO Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow Diversion: 2-Dimensional Operative Video ∗ ∗ Gary Rajah, MD , Richard Justin Garling, MD , Leonardo Rangel-Castilla, MD ∗ ‡ Department of Neurosurgery, Wayne State University, Detroit, Michigan; Mayo Clinic Department of Neurosurgery, Rochester, Minnesota Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy119 Correspondence: Richard Justin Garling, MD, 4201 St. Antoine Blvd, Suite 6E, Neurosurgery, Detroit, MI 48201. E-mail: Jgarling@med.wayne.edu We present a case of a traumatic skull base internal trauma and orthopedic surgery, at day 9 after his carotid artery (ICA) pseudoaneurysm treated with initial injury, the patient was loaded with aspirin and endovascular flow diversion stenting. The patient was clopidrogel in preparation for stent reconstruction of a 27-year-old male who was involved in a motorcycle his ICA injury. Under conscious sedation and systemic accident suffering multiple traumatic injuries including heparinization, the patient underwent endovascular a large skull base fracture that extended through the reconstruction of the large pseudoaneurysm using carotid canal. Computed tomography angiography telescoping flow diversion stents. Immediate intra- revealed a 2-cm right ICA pseudoaneurysm. Once aneurysm flow stasis was observed. No procedure- the patient was stable, a digital subtraction angiog- related complications occurred. The patient did raphy demonstrated enlargement of the pseudoa- well and at last follow-up remained neurologically neurysm. After his other injuries were addressed by intact. KEY WORDS: Flow diverter, Pipeline, Endovascular, Traumatic pseudoaneurysm Operative Neurosurgery 0:1, 2018 DOI:10.1093/ons/opy119 Received, September 15, 2017. Accepted, April 20, 2018. patients. 2) The use of telescoped devices allows for longer coverage of Disclosure the involved segment and provides increased metal coverage across the The authors have no personal, financial, or institutional interest in any of the primary pseudoaneurysm site. 3): The authors demonstrate the diffi- drugs, materials, or devices described in this article. culty often met in deploying these devices across large aneurysms/vessels with the risk of device malfunction, flipping, or looping within the lesion. The techniques discussed for loading the system or wagging the COMMENT microwire are well regarded, and as noted, the technical nuances for deployment of these devices still need further refinement. Overall, we he authors present the use of flow-diversion technology in a applaud the authors on this demonstration of carotid reconstruction. patient with post-traumatic ICA pseudoaneurysm where 2 pipeline Instead of vascular deconstruction with occlusion, the use of flow- embolization devices (Medtronic Inc, Dublin, Ireland) were used to diversion technology for vascular reconstruction will likely continue to treat a cervical ICA pseudoaneurysm. The patient had a good outcome improve our ability to deliver innovative and individualized treatment for as demonstrated on follow-up angiogram with reconstruction of his our patients. carotid artery. We have used this technology with similar results and Neil Haranhalli it is worth mentioning the following: 1) Placement of flow diversion Rabih G. Tawk necessitates the use of dual antiplatelet medications and this must be Jacksonville, Florida balanced against the risk of hemorrhage from other injuries in trauma OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/ons/advance-article-abstract/doi/10.1093/ons/opy119/4999291 by Ed 'DeepDyve' Gillespie user on 12 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow Diversion: 2-Dimensional Operative Video

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Publisher
Oxford University Press
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
2332-4252
eISSN
2332-4260
D.O.I.
10.1093/ons/opy119
Publisher site
See Article on Publisher Site

Abstract

SURGICAL VIDEO Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow Diversion: 2-Dimensional Operative Video ∗ ∗ Gary Rajah, MD , Richard Justin Garling, MD , Leonardo Rangel-Castilla, MD ∗ ‡ Department of Neurosurgery, Wayne State University, Detroit, Michigan; Mayo Clinic Department of Neurosurgery, Rochester, Minnesota Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy119 Correspondence: Richard Justin Garling, MD, 4201 St. Antoine Blvd, Suite 6E, Neurosurgery, Detroit, MI 48201. E-mail: Jgarling@med.wayne.edu We present a case of a traumatic skull base internal trauma and orthopedic surgery, at day 9 after his carotid artery (ICA) pseudoaneurysm treated with initial injury, the patient was loaded with aspirin and endovascular flow diversion stenting. The patient was clopidrogel in preparation for stent reconstruction of a 27-year-old male who was involved in a motorcycle his ICA injury. Under conscious sedation and systemic accident suffering multiple traumatic injuries including heparinization, the patient underwent endovascular a large skull base fracture that extended through the reconstruction of the large pseudoaneurysm using carotid canal. Computed tomography angiography telescoping flow diversion stents. Immediate intra- revealed a 2-cm right ICA pseudoaneurysm. Once aneurysm flow stasis was observed. No procedure- the patient was stable, a digital subtraction angiog- related complications occurred. The patient did raphy demonstrated enlargement of the pseudoa- well and at last follow-up remained neurologically neurysm. After his other injuries were addressed by intact. KEY WORDS: Flow diverter, Pipeline, Endovascular, Traumatic pseudoaneurysm Operative Neurosurgery 0:1, 2018 DOI:10.1093/ons/opy119 Received, September 15, 2017. Accepted, April 20, 2018. patients. 2) The use of telescoped devices allows for longer coverage of Disclosure the involved segment and provides increased metal coverage across the The authors have no personal, financial, or institutional interest in any of the primary pseudoaneurysm site. 3): The authors demonstrate the diffi- drugs, materials, or devices described in this article. culty often met in deploying these devices across large aneurysms/vessels with the risk of device malfunction, flipping, or looping within the lesion. The techniques discussed for loading the system or wagging the COMMENT microwire are well regarded, and as noted, the technical nuances for deployment of these devices still need further refinement. Overall, we he authors present the use of flow-diversion technology in a applaud the authors on this demonstration of carotid reconstruction. patient with post-traumatic ICA pseudoaneurysm where 2 pipeline Instead of vascular deconstruction with occlusion, the use of flow- embolization devices (Medtronic Inc, Dublin, Ireland) were used to diversion technology for vascular reconstruction will likely continue to treat a cervical ICA pseudoaneurysm. The patient had a good outcome improve our ability to deliver innovative and individualized treatment for as demonstrated on follow-up angiogram with reconstruction of his our patients. carotid artery. We have used this technology with similar results and Neil Haranhalli it is worth mentioning the following: 1) Placement of flow diversion Rabih G. Tawk necessitates the use of dual antiplatelet medications and this must be Jacksonville, Florida balanced against the risk of hemorrhage from other injuries in trauma OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/ons/advance-article-abstract/doi/10.1093/ons/opy119/4999291 by Ed 'DeepDyve' Gillespie user on 12 July 2018

Journal

Operative NeurosurgeryOxford University Press

Published: May 18, 2018

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