PMC4943964_01
Assessment of initial injury from intracranial nail. (A) AP skull plain radiograph demonstrating nail penetration depth. (B) Axial image from head CT demonstrating basilar traumatic subarachnoid hemorrhage. (C) Lateral projection of a left internal carotid angiogram demonstrating nail positioning in the vicinity of a left M3 branch (nail head highlighted by black arrow), with no aneurysms, vessel occlusions/transections, or active extravasation.
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F1
Vascular imaging demonstrated a nail trajectory immediately subjacent to a left M3 branch, with no aneurysms, pseudoaneurysms, vessel occlusions/transections, or active extravasation (Figure 1).
Ventricular tract hemorrhage following intracranial nail removal. (A-D) Serial oblique projections of a left internal carotid angiogram immediately after nail removal, demonstrating active hemorrhage (white arrows) from a small left M3 branch extending down the puncture tract into the lateral ventricle. (E) Lateral left internal carotid angiogram confirming resolution of hemorrhage after no active extravasation was seen on serial M3 microcatheterizations. No aneurysmal dilatation or flow-limiting stenosis is seen. (F) Axial T2-weighted flair brain MRI demonstrating only mild local inflammation 5 days after nail removal.
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F2
Immediate injection of the left internal carotid revealed active contrast extravasation from a small M3 branch arising from the inferior trunk in the area of the anterior parietal artery and extending down the puncture tract into the left lateral ventricle (Figures 2A-D). Resolution of hemorrhage was confirmed on repeat internal carotid angiogram (Figure 2E). Post-operative MRI revealed gliosis along the nail tract, but not global infectious or ischemic processes (Figure 2F).
Delayed pseudoaneurysm formation. (A) Left internal carotid angiogram demonstrating a left anterior parietal MCA branch pseudoaneurysm (white arrow), successfully treated via proximal branch embolization [(B); black arrow highlighting area of branch sacrifice].
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F3
A delayed pseudoaneurysm in the anterior parietal branch of the left MCA was identified on 3-month follow-up imaging, and uneventfully treated via branch sacrifice with n-butyl cyanoacrylate (n-BCA) liquid embolic glue (Figure 3).