American Journal of Clinical Neurology and Neurosurgery

Vol. 1, No. 3, 2015, pp. 133-136

http://www.aiscience.org/journal/ajcnn

Intracranial Hemorrhage Secondary to Iatrogenic

Anterior Cerebral Artery Pseudoaneurysm
Rupture Following Ventriculostomy
Yoshua Esquenazi1, *, Arthur L. Day1, William W. Ashley2
1
2

Vivian L Smith Department of Neurosurgery, University of Texas Medical School at Houston, Houston TX, USA
Department of Neurosurgery, Loyola University Medical Center, Maywood IL, USA

Abstract
Percutaneous ventriculostomy (EVD) placement is one of the most important diagnostic and therapeutic tools in neurosurgery.
Although generally considered low risk, it can be associated with significant complications. We report a case of an intracranial
hemorrhage secondary to iatrogenic anterior cerebral artery pseudoaneurysm rupture following ventriculostomy. A 67 year-old
female presented to our institution with a spontaneous cerebellar hemorrhage and obstructive hydrocephalus. She underwent
emergent bedside right frontal EVD placement and was subsequently taken to the operating room for suboccipital craniectomy
and clot evacuation. On postoperative day three, she experienced sudden onset of headache with neurological deterioration,
emergent cranial CT scan demonstrated fresh hemorrhage along the EVD tract and casting of the ventricular system. Cerebral
arteriography revealed a 3.6 x 3.4 mm traumatic pseudoaneurysm arising from a distal anterior cerebral artery branch that was
in contact with the ventricular catheter. After unsuccessful endovascular treatment, the patient was taken to the operating room
for clot evacuation and microsurgical aneurysm obliteration. Despite a long and complicated hospital course the patient
expired. This report describes a case of acute intracerebral hemorrhage as a presenting sign of pseudoaneurysm rupture
following ventriculostomy. Iatrogenic vascular trauma associated with this procedure may be more common than currently
appreciated. In the face of significant hemorrhage along an EVD track, evaluation should include catheter angiography if CTA
is negative.
Keywords
Intracranial Hemorrhage, Pseudoaneurysm, Ventriculostomy Placement
Received: August 10, 2015 / Accepted: August 19, 2015 / Published online: September 10, 2015
@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license.
http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction
Percutaneous external ventricular drain placement is one of
the most important diagnostic and therapeutic tools in
neurosurgery, and is often inserted as a potentially life-saving
procedure. Its widespread use has proven to be an effective
method for cerebrospinal fluid diversion in the management
of intracranial hypertension and acute hydrocephalus, and is
now considered a mainstay of neurosurgical practice. 1)
Despite its widespread and common use, EVD placement has
been associated with infectious and hemorrhagic
* Corresponding author
E-mail address: yoshuaesquenazi@gmail.com (Y. Esquenazi)

complications. (2, 3) We report a case of an iatrogenic

intracranial dissection/pseudoaneurysm that led to
intracerebral hemorrhage (ICH) following EVD placement,
and present a brief review of the literature.

2. Clinical Case
A 67-year-old hypertensive female presented to our
institution with a large 45 cc spontaneous cerebellar

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Yoshua Esquenazi: Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture
Following Ventriculostomy

intraparenchymal
hemorrhage
with
associated
hydrocephalus. She underwent emergency bedside right
frontal
EVD
placement,
which
was
seemingly
uncomplicated. Using surface landmarks, a hand twist drill
was used to create the burr-hole one centimeter in front of the
coronal suture along the mid-pupillary line. The dura mater
was opened sharply with an 11 blade and the ventricle was

cannulated after a single pass. She was subsequently taken to

the operating room for suboccipital craniectomy and clot
evacuation. The patient recovered well without neurologic
deficit, and she was extubated the following day. Routine
postoperative CT scan showed complete cerebellar
hematoma evacuation, and a small IVH without ICH
associated with the ventricular catheter. (Fig 1, a and b)

Figure 1. (a) Postoperative noncontrast cranial computed tomography demonstrates EVD placement (arrow) without associated ICH. (b) A small amount of
IVH (arrow) is appreciated in the right frontal horn and the left cerebellar hematoma has been evacuated.

Figure 2. (a and b) Noncontrast cranial computed tomography demonstrates evidence of ICH along the EVD catheter extending into the ventricular system
with obstructive hydrocephalus (arrows).

On postoperative day three, the patient experienced a sudden

headache associated with spontaneous bloody cerebrospinal
fluid (CSF) drainage from the EVD catheter, followed
rapidly by acute neurologic deterioration. After intubation
and initial resuscitation, an emergent bedside CT scan
showed hemorrhage along the EVD tract with ventricular
extension, casting of the ventricular system and obstructive
hydrocephalus. (Fig 2, a and b) A contralateral EVD was

placed, with minimal neurological improvement. CT

angiography did not show any clear vascular abnormalities.
A cerebral diagnostic angiogram revealed a 3.6 x 3.4 mm
traumatic pseudoaneurysm arising from a distal anterior
cerebral artery (ACA) branch that was in contact with the
ventricular catheter. (Fig 3 a and b) Attempted endovascular
obliteration of the pseudoanerysm was unsuccessful. Due to
mass effect and increased intracranial pressure it was decided

American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 3, 2015, pp. 133-136

to take the patient to the operating room for clot evacuation

and surgical pseudoaneurysm obliteration. Despite a long and

135

complicated hospital course thereafter, her neurologic exam

did not improve, and the patient subsequently expired.

Figure 3. (a) Lateral digital substraction angiogram demonstrates a pseudoaneurysm in a distal branch of the ACA (arrow), (b) 3-D digital substraction
angiography demonstrates the pseudoaneurysm along the location of the EVD catheter (arrows).

3. Discussion
In 1918 Dandy reported that, in experienced hands,
ventricular puncture could be an uncomplicated procedure. 4)
Unfortunately, more experience and regular usage has
demonstrated that EVD placement is associated with
significant infectious and hemorrhagic risks with
hemorrhagic complication rates ranging from 0-41%. 5, 6) Two
meta-analysis of this procedure have reported an overall
hemorrhagic complication rate of 5.7-7%, with a significant
rate of hemorrhage between 0.8%-1%. 2, 3) The wide variation
in hemorrhage rates may be associated with specific technical
or anatomic factors, but could also be related to
methodological differences. Variations in patient populations,
coagulation profile thresholds prior to the procedure, routine
post-procedure imaging studies and its timing, inclusion of
hemorrhages caused by ventricular catheter removal, and
operator technique/expertise may be important factors
contributing to the broad range of results, as well as the
retrospective nature of most studies.
Drain related hemorrhages (subdural, epidural, intracerebral
and intraventricular-IVH) are all possible, most probably
occur as the result of a small cortical or pial vessel injuries
caused by the ventricular catheter or drill at the time of
insertion. In most cases, they are not identified because they
are asymptomatic and do not cause any clinical
consequences, and therefore are excluded from published
series. The few cases have been reported have rarely required
surgical evacuation for mass effect. 7-9)
We did not find any reported cases of ICH or IVH proven to
be the consequence of a vessel injury leading to

pseudoaneurysm formation and rebleeding following EVD.

Thus, this phenomenon may be clinically quite rare. One
possible explanation may be that in the majority of cases, the
small hemorrhages related to vessel injury do not expand into
a visible pseudoaneurysm, and the vessel heals without
consequences. In the absence of clinical sequelae, they
remain undetected, with rarely a need to obtain further
diagnostic studies.
In a recently published series of complications related to
EVD placement, 10) one of the patients developed a 3-mm
pseudoaneurysm arising from a distal right ACA branch that
was adjacent to the shunt tubing. Interestingly this
pseudoaneurysm was not seen on angiography performed a
month earlier and a CT scan after insertion of the EVD did
not demonstrate evidence of hemorrhage. A possible
explanation of the delay presentation may be related to
formation of the aneurysm secondary to thinning of the
vessel wall due to a chronic foreign body reaction secondary
to the shunt tubing, as previously reported in a patient with
traumatic aneurysm formation following ventriculoperitoneal
shunt insertion. 11)
Pseudoaneurysms of the superficial temporal artery
secondary to partial laceration of the vessel wall during
tunneling of the ventricular catheter 10, 12), and dural
arteriovenous fistulas after injury of the middle meningeal
artery during EVD placement have been previously reported.
10, 13, 14)
Schuette et al, 15) described a case of a pial
arteriovenous fistula resulting from EVD placement. In this
case a CT scan after drain placement demonstrated a
hemorrhage at the EVD site. Interestingly, the fistula was
appreciated on follow-up cerebral angiography 18 months
after the EVD was initially inserted, and a previous 6 month

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Yoshua Esquenazi: Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture
Following Ventriculostomy

follow-up angiogram did not reveal the lesion. This fistula

was almost certainly the result of a prior clinically silent
EVD related vessel injury that recanalized over time and
became an arteriovenous fistula. To our knowledge, the case
presented here is the first report of an ICH as a consequence
of rupture of a pseudoaneurysm that developed soon after
EVD placement.
In the case of our patient, a routine postoperative CT scan
after cerebellar clot evacuation showed no ICH and a small
asymptomatic IVH likely the result of bleeding as the EVD
entered the ventricle (Fig 1 a and b). After later clinical
deterioration caused by ICH and IVH, an emergent CT
angiogram did not show any vascular abnormalities. A
formal
cerebral
diagnostic
angiogram,
however,
demonstrated the pseudoaneurysm arising from the distal
ACA that appeared to be in contact with the EVD. (Fig 3b)
While misplacement of EVD catheters particularly those
traversing the interhemispheric fissure into the contralateral
hemisphere can potentially increase the risk of vascular
injury and potential pseudoaneurysm formation. In the case
of our patient the EVD catheter remained ipsilateral along its
course, and the tip of the catheter ended in the frontal horn.
(Fig 1a and b).

4. Conclusion
Although percutaneous EVD is generally a safe and effective
procedure, iatrogenic vascular trauma associated with this
procedure may be more common than currently appreciated,
and serious complications can arise. The presence of an
expanding hematoma along the EVD tract in a patient with
an uneventful insertion and with a normal coagulation profile
may suggest the presence of vascular injury related to its
placement. In such circumstances, early diagnosis and
treatment may prevent the negative consequences of
rebleeding related to pseudoaneurysm rupture. CT
angiography may not be sufficient in the search of this lesion
and cerebral angiography should be considered.

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