Clinical Diagnosis,Treatment And Hemodynamic Study Of Intracranial Traumatic Pscudoaneurysm

Part1 A clinical study of Willis covered stent in the treatment of traumatic pseudoaneurysm of intracranial segment of internal carotid arteryObjective:To assess the safety and effectiveness of Willis Covered Stent in curing traumatic pseudoaneurysm of intracranial segment of internal carotid artery.Method:Analysis the clinical data of 15 patients with traumatic pseudoaneurysm of intracranial segment of internal carotid artery treated with Willis covered stent,6 cases were traffic accident injuries and 3 cases were drifting-down injuries,2 cases of carotid artery injury during tumor resection,1 case of head and neck radiotherapy,2 cases of the bruise injury caused by heavy object,1 case of delayed pseudoaneurysm after TCCF balloon treatment.Result:All 15 patients successfully completed Willis covered stent therapy.Among them,12 cases were successful at one time;2 cases had internal leakage in angiography immediately after Willis covered stent placement;and after compression of carotid artery treatment of 4months,the endoleakage disappeared in DSA reexamination,and the aneurysm did not develop;1 case of internal leakage treated with balloon dilation,and the endoleakage disappeared.All the 14 patients were cured,and no new infarction or bleeding occurred due to surgery.One patient died of traumatic pseudoaneurysm of craniocerebral injury.12 patients were followed up by DSA and CTA 4-8 months after surgery,and none of the patients’ pseudoaneurysms were found to have recurred,and the internal carotid artery was unobstructed without stenosis.2 patients were followed up in clinic and their condition was stable.Conclusion:Willis covered stent is safe and effective in the treatment of traumaticpseudoaneurysm of intracranial segment of internal carotid artery.It should be the first choice for the treatment of traumaticpseudoaneurysm of intracranial segment of internal carotid artery.Part2 Discussion on Surgical Treatment Strategy of Traumatic Intracranial Multiple Pseudoaneurysmand Clinical Research for Identification of the Aneurysm Responsible for HemorrhageObjective:To explore the feasibility,safety and efficacy of DSA and MRI images fusion combined with neuronavigation in the diagnosis and treatment of patients with traumatic intracranial multiple pseudoaneurysm.Furthermore,to discuss and determine the accuracy and effectiveness of CT and DSA images fusion in identifying the aneurysm responsible for hemorrhagein multiple aneurysms.Method:Retrospective analysis of the clinical data,diagnosis and treatment,and follow-up results in a patient with traumatic intracranial multiple pseudoaneurysm,including medical history,injury mechanism,symptoms and vital signs,GCS score,and imaging examinations(preoperative and postoperative head CT Scan and DSA images),surgical procedure and pathological section,summarized the significance of images fusion combined with neuronavigation in the surgical procedures of multiple intracranial pseudoaneurysms.In addition,9 patients with multiple intracranial aneurysms with intracranial hemorrhage hospitalized to the Department of Neurosurgery of the Central Theater General Hospital from January 2016 to January 2021 were collected。The first CT within 6 hours after hemorrhage and 3D-DSA imaging data were input into the workstation for image fusion to obtain fusion images.Accurately determine the responsible aneurysm of the bleeding according to the fusion image,formulate the treatment plan,and finally comprehensively evaluate the value of DSA,CT and MRI fusion images in the determination of the responsible aneurysm of the bleeding and the precise positioning of the deep surgery for multiple intracranial and deep pseudoaneurysm.Results:A 25-year-old female patient with craniocerebral injury developed SAH 2 days after injury.Preoperative head CT showed an intracerebral hematoma near the midline of the left parietal lobe,which was accompanied by subarachnoid hemorrhage.DSA showed multiple pseudoaneurysms at the left anterior cerebral A2 segment bifurcation and pericallosal artery.The fusion of 3D-DSA and CT images determined that the responsible aneurysm was the left pericallosal artery aneurysm.At the same time,the fusion image data of 3D-DSA and MRI is input into the neuronavigation.Under the guidance of the three-dimensional fusion image of neuronavigation,the aneurysm can be accurately found and treated with minimal damage.The bleeding pericallosal aneurysm is clipped first,and then the left anterior cerebral artery is cauterized.Two aneurysms were clipped,cauterized and resectioned through the first-stage operation,and traumatic pseudoaneurysm was confirmed by postoperative pathology.Of the other 9 patients who adopted imagesfusion to determine the responsible aneurysm,2 patients were treated with microsurgical clipping,5 with stent-assisted coiling,and 2 with embolization by simple coils.After successfully treating the responsible aneurysms in the first-stage operation,the non-responsible aneurysms were treated in the second-stage operation by clipping or embolization.The DSA and CTA follow-up(3～6 months)outcomes showed no aneurysm recurrence and the parent artery patency without stenosis in all the patients.Conclusion:3D-DSA and CT fusion images can exactly determine the bleeded aneurysm for hemorrhage in multiple intracranial pseudoaneurysms,and the accuracy of the determination results is verified by craniotomy.The 3D neuronavigation images obtained by inputting 3D-DSA and MRI imaging data into neuronavigation can accurately guide craniotomy for the treatment of inoperable deep brain aneurysms,small arteriovenous malformations and arteriovenous fistulas,created a new method of diagnosis and surgery.Part3 Research on Hemodynamic changes of Willis covered stent in the treatment of traumatic intracranial pseudoaneurysm of the internal carotid arteryObjective:To investigate the hemodynamic changes and clinical significance of the anterior and posterior aneurysm lumens and parent artery in the treatment of traumatic pseudoaneurysm in the intracranial segment of the internal carotid artery with Willis covered stent,and to discover the effectiveness of Willis covered stent in the treatment of intracranial pseudoaneurysm combined with the changes of hemodynamic parameters.Method:Clinical data of 12 patients with traumatic pseudoaneurysm in the intracranial segment of the internal carotid artery(ICA)treated with Willis covered stent from December 2013 to May 2021 in the Department of Neurosurgery of our hospital,including gender,age,etiology,medical history,clinical Data such as presentation and CT bleeding characteristics,treatment progress,etc.were collected.3D-DSA data in Dicom format before and after the patient’s Willis covered stent was gathered.Using the open source Computational Fluid Dynamics(CFD)software OpenFoam[1]for mesh generation and CFD calculations,including wall shear stress(WSS),wall shear stress gradient(WSSG),streamline wall shear stress gradient(SWSSG),oscillatory shear index(OSI)and other hemodynamic parameters were accurately analyzed.The hemodynamic parameters before and after the implantation of the Willis covered stent were statistically analyzed,the hemodynamic characteristics were summarized,and the immediate effect of the Willis covered stent in the treatment of pseudoaneurysm was studied.Result:Among the 12 pseudoaneurysms,9 cases of pseudoaneurysm disappeared immediately,3 cases had a slight endoleak,9 cases of intracranial pseudoaneurysm changed hemodynamic parameters after immediate occlusion,and the minimum value of WSS increased significantly after stent implantation、The maximum value of WSS was significantly decreased、the minimum value of StreamwiseWSSG was significantly increased,、and the maximum value of OSI and the mean value of OSI were significantly decreased(P<0.05),with statistical significance.Conclusion:Embolization with the Willis covered stent altered the hemodynamics of the pseudoaneurysm,isolated the pseudoaneurysm and reconstructed the parent artery.The blood flow velocity and related CFD parameters around the pseudoaneurysm changed significantly,most of the blood flow in the aneurysm lumens disappeared,and the blood flow was basically separated from the pseudoaneurysm,achieving the effect of endovascular exclusion.Thereby,the thrombus and the proliferation of endothelial cells in the blood vessel were accelerated to generate,and the pseudoaneurysm was embolized in time.Therefore,Willis covered stent is an ideal interventional material for the treatment of intracranial pseudoaneurysm.