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Incidence of Traumatic Intracranial Aneurysms after Gunshot Wounds to the Head Significantly Increases with Acute Vessel Imaging

Friday, May 3, 2024

Presenting Author(s)

Jesse A. Stokum, MD, PhD

Resident
University of Maryland School of Medicine
Baltimore, Maryland, United States

Co-Author(s)

RS

Riccardo Serra, n/a

Resident
University of Maryland Medical Center
Baltimore, Maryland, United States
Bizhan Aarabi, MD

Professor
University of Maryland Medical Center
Baltimore, MD, US
Ub

Uttam bodanapally, MD

Professor
University of Maryland Medical Center
Baltimore, Maryland, United States
CC

Chen Chixiang, MS

Professor
University of Maryland Medical Center, United States
JO

Jeffrey Oliver, MD

Fellow
Geisinger Health
Baltimore, Maryland, United States
Gary Schwartzbauer, MD, PhD

Professor
University of Maryland Medical Center
Baltimore, Maryland, United States
JS

J. Marc Simard, MD, PhD

Professor
University of Maryland Medical Center
Baltimore, Maryland, United States
Bradley Wilhelmy, MD (he/him/his)

Medical Student
University of Maryland Medical Center
Baltimore, MD, US

Introduction: In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (penetrating traumatic brain injury - pTBI) was approximately 3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission CT angiography (aCTA) in pTBI.

Methods: Over the 2017-22 period, 341 patients were admitted to Shock Trauma Center with pTBI. 136 subjects had aCTA ~3 (SD 3.5) hours post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, outcomes were analyzed.

Results: Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission GCS was 6 (SD 3.9). Entry site was frontal in 40, temporal in 50, frontobasal-temporal in 1, parietal in 19, occipital in 6, suboccipital in 9. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subjects. 25 were located along the MCA, 5 in the ACA, 3 in the ICA, 1 in the PCA, 1 in the MMA. Eleven TICAs resolved spontaneously in 9 patients. Eight aneurysms were treated by endovascular means, one via combined endovascular/open approaches. Forty-nine patients succumbed, 10 of whom had 15 TICAs. Eighty patients developed ICHs. Regression models showed that the presence of an intracerebral hematoma (ICH) was the main predictor of TICA in pTBI.

Conclusion : Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with pTBI suggest hidden TICAs. Nearly 30 percent of patients had spontaneous resolution within a week. When CTA was performed acutely, TICAs were ten times more frequent in pTBI compared to previous literature, and more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of pTBI.