Diagnosis and treatment differences between iatrogenic and traumatic intracranial pseudoaneurysms

Objective To investigate the differences in the diagnosis and treatment between iatrogenic intracranial pseudoaneurysms (II-PSAN) and traumatic intracranial pseudoaneurysms (TI-PSAN). Methods In this retrospective study, 11 patients with intracranial PSAN admitted to the Department of Neurosurgery of Huashan Hospital Affiliated to Fudan University between January 2013 and December 2017 were enrolled. Among those 11 cases, TI-PSAN was diagnosed in 9 cases and II-PSAN in 2. In the 9 TI-PSAN cases, there were 11 PSAN including 7 undergoing embolization treatment (PSAN and parent artery), 2 receiving revascularization (stent and Guglielmi detachable coil placement in 1 and double stents placement in 1), 1 undergoing surgery and the other 1 receiving no treatment. For the 2 cases with II-PSAN, 1 received embolotherapy and 1 received revascularization using LVIS stent and GDC. At the follow-up, the DSA, CTA or MRI was performed to evaluate the recurrence and residue of PSAN and assess the outcomes by using the modified Rankin score (mRS). Results Among the 13 PSAN of 11 patients, 12 showed satisfactory outcomes after surgery. One TI-PSAN patient died from intracranial hemorrhage at 1 day post surgery and no postoperative hemorrhage was reported in the other 10 cases. The 10 cases were followed up for 1-36 months, with an average of 13 months. Among them, 6 received DSA in the follow-up and the other 4 received CTA or MRA in the follow-up. Among 8 cases with TI-PSAN, no revascularization or recurrence of PSAN was reported in the 6 cases undergoing embolization and the vascular compensation was satisfactory. In the other 2 cases undergoing revascularization, 1 showed no residual or recurrent PSAN and 1 showed residue in the aneurysm neck. In the 2 II-PSAN cases, there was no residual or recurrent PSAN. Eight TI-PSAN cases showed the mRS score of 0-2 and 2 cases with II-PSAN showed the mRS score of 0. The outcomes were all good. Conclusions Unlike TI-PSAN, the symptoms of II-PSAN are not typical. Thus, much attention should be paid to the diagnosis of II-PSAN. For the II-PSAN patients or TI-PSAN patients with mild vascular injury and good integrity, vascular reconstruction is preferred. For PSAN patients with poor vascular integrity and compliance to reconstruction, occlusion of PSAN combined with vascular bypass surgery should be considered in advance. Key words: Intracranial pseudoaneurysm; Iatrogenesis; Traumatism; Diagnosis; Endovascular treatment; Difference