Endovascular management of external ventricular drain-associated cerebrovascular injuries

Abstract

Background:Placement of external ventricular drains (EVDs) is a common, life-saving neurosurgical procedure indicated across a variety of settings. While advances have made the procedure quite safe, the potential for iatrogenic morbidity and mortality continues. We document our experience with the endovascular management of three pseudoaneurysms associated with EVD placement and discuss the endovascular treatment options for EVD-associated cerebrovascular injury.Methods:We performed a retrospective analysis to identify all EVDs placed from 2008 through 2013 at our institution. In instances of EVD-associated cerebrovascular injury, all admission and subsequent radiographic studies were reviewed, including cerebral angiograms and computed tomography (CT) scans where available. Angiograms were reviewed to record the extent of vascular injury and outcomes after treatment.Results:One female and two male patients (age range, 40-75 years) were found to have developed vascular injuries associated with EVD placement. Three pseudoaneurysms, of the posterior communicating artery (PCOM), pericallosal artery branch, and the middle meningeal artery, respectively, were treated by coil and/or glue embolization.Conclusions:Although EVD-associated cerebrovascular injury remains a rare phenomenon, such procedures are not entirely benign. Endovascular repair for such lesions proves a viable, effective option.

Iatrogenic pseudoaneurysms associated with cerebrospinal fluid diversion procedures

“…The anterior cerebral artery (ACA) or one of its distal branches was involved in 6 cases of pseudoaneurysm formation following EVD or VP shunt insertion,[3415182834] with only one case involving a fusiform traumatic aneurysm of the MCA,[16] and one pseudoaneurysm involving the posterior communicating artery. [4] A pseudoaneurysm involving the middle meningeal artery (MMA) presented as an epidural hematoma owing to the anatomical location of the injured vessel. [4] ACA pseudoaneurysms were associated with a medial catheter trajectory; the entry point in these cases was typically located in the middle or posterior cerebral artery territory, suggesting that vessel injury occurred during passage of the catheter with the guiding stylet, rather than during drilling or opening the dura.…”

“…[4] A pseudoaneurysm involving the middle meningeal artery (MMA) presented as an epidural hematoma owing to the anatomical location of the injured vessel. [4] ACA pseudoaneurysms were associated with a medial catheter trajectory; the entry point in these cases was typically located in the middle or posterior cerebral artery territory, suggesting that vessel injury occurred during passage of the catheter with the guiding stylet, rather than during drilling or opening the dura. The one reported case of a fusiform traumatic aneurysm involving the distal MCA likely formed due to an inflammatory reaction from the adjacent shunt catheter over years.…”

“…Traumatic aneurysms of the MMA were reported on two occasions in addition to multiple dural arteriovenous fistulas secondary to VP shunt or EVD catheter insertion;[412] interestingly, the MMA was involved in all reported cases of catheter-associated fistulas except one. The anatomical location of the MMA, specifically when the burr hole is made lateral to Kocher's point, was hypothesized to be responsible for this high correlation, especially when the procedure causes a dual insult to the MMA and one of the cortical veins, either during drilling, dural opening, or catheter insertion.…”

“…Endovascular coiling was the preferred treatment modality in six of the cases, but was found to be of limited value when the pseudoaneurysm involved cortical vessels of small diameter, which limits catheter access. [341518] Open surgical resection was the treatment modality in four cases. [16283134] In the case reported by Shirane et al ., open intervention was necessary to evacuate the associated hematoma and reconstruct the proximal ICA due to an anterior choroidal avulsion injury.…”

Commentary to: External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications

“…On a few occasions, the use of EVD has been associated with vascular injury. 2 It should be clearly stated that the goal of any aneurysm intervention is preventing rebleeding. Incidence of aneurysmal rebleeding is high within the first few hours after the aneurysm rupture, being associated with a mortality rate of up to 50%.…”