PMC5767482_01
Preoperative neuroimaging. (A) 3D bone CT reveals the entry (arrow) and exit (dashed arrow) sites of the crossbow bolt. (B) CT imaging demonstrates the crossbow bolt passing nearby the corpus callosum with surrounding contusion. (C, D) Conventional angiography (C) and 3D rotational angiography (D) of the right common carotid artery show the positional relationship between the crossbow bolt and the anterior cerebral arteries (arrowhead: pericallosal artery; blank arrowhead: cortical branches).
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F1
The crossbow bolt had penetrated the head from the right pterion to the left temporal region (Figs. 1A and 1B), with the fletchings buried in the entry site. The crossbow bolt had passed nearby the corpus callosum, and 3D rotational angiography revealed that the bolt had barely missed the pericallosal artery (Figs. 1C and 1D).
CT angiography performed on postoperative day (POD) 1 (A), 8 (B), and 35 (C), and digital subtraction angiography performed prior to the bypass surgery (D) (arrow: vascular wall irregularity and pseudoaneurysm at the bifurcation of the pericallosal artery and right posterior internal frontal artery).
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F2
Follow-up CT/CT angiography (CTA) of the head was performed on postoperative day (POD) 1, 8 (Figs. 2A and 2B), and 15. CTA performed on POD35 showed a 4 mm aneurysm at the bifurcation (Fig. 2C). Catheter angiography showed contrast medium pooling in the aneurysm, indicating pseudoaneurysm formation (Fig. 2D).
(A, B) Illustration demonstrating trapping with the right posterior internal frontal artery (PIFA)-left cortical branch side-to-side bypass and postoperative three-dimensional rotational angiography (3DRA) of the right internal carotid artery (asterisk: aneurysm; arrow: pericallosal artery; small arrow: right PIFA; arrowhead: left cortical branch). Successful revascularization with the bypass is seen on 3DRA. (C) Intraoperative view of the pericallosal artery (arrow), PIFA (small arrow) and pseudoaneurysm (asterisk). (D) Elastica van Gieson stain of the resected specimen (magnification, 40x) shows no internal elastic lamina (arrow: aneurysm lumen).
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F3
After right PIFA-left cortical branch bypass, the aneurysm was trapped and resected (Figs. 3A and 3C). Elastica van Gieson staining of the specimen revealed a lack of internal elastic lamina, confirming the diagnosis of pseudoaneurysm (Fig. 3D). Postoperative angiography showed anterograde flow through the right PIFA-left cortical branch bypass (Fig. 3B), and N-isopropyl-p-[123I] iodoamphetamine single-photon emission CT showed no reduction of flow in the right medial frontal lobe.
(A) Postoperative diffusion-weighted imaging shows no infarction in the right medial frontal lobe. (B) Postoperative magnetic resonance imaging (fluid-attenuated inversion recovery): parenchymal damage was limited to the path of the crossbow bolt.
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F4
Diffusion-weighted imaging showed no infarction in the right medial frontal lobe, and parenchymal damage was limited to the path of the crossbow bolt in a fluid-attenuated inversion recovery imaging (Figs. 4A and 4B).