title: Natural History and Management of Blunt Traumatic Pseudoaneurysms of the Internal Carotid Artery: The Harborview Algorithm Based Off a 10-Year Experience.
abstract: OBJECTIVE
  To define the natural history of, and treatment strategy for, blunt traumatic internal carotid artery (ICA) pseudoaneurysms.
  
  
  BACKGROUND
  The natural history and management of traumatic ICA pseudoaneurysms is controversial.
  
  
  METHODS
  We retrospectively identified all traumatic ICA pseudoaneurysms diagnosed on head/neck computed tomographic angiography at a high-volume trauma center over a 10-year period. Radiographic and clinical data were recorded, and a treatment algorithm was derived.
  
  
  RESULTS
  Forty-three pseudoaneurysms were diagnosed in 39 patients. All patients were treated with daily aspirin unless contraindicated, and 82% underwent daily transcranial Doppler ultrasonography with embolic monitoring. A rate of 8 or more emboli per hour was predictive of embolic stroke (P = 0.0076). Acute ischemic or embolic stroke was seen in 7 patients (16%) with an overall mortality in this subpopulation of 42% (n = 3). Four patients (9%) underwent acute surgical treatment (parent vessel sacrifice and/or arterial bypass) for ongoing ischemia. Long-term radiographic and clinical follow-up was obtained for 36 surviving patients (mean = 8 months; range: 1 week-5 years), all of whom were maintained on daily aspirin. No delayed ischemic or embolic events were reported. For ICA pseudoaneurysms treated with aspirin and observation alone, 9 (28%) increased in size, 17 (53%) decreased or stabilized, and 6 (19%) resolved. Enlargement of 5 mm or more in maximal diameter underwent delayed endovascular treatment with a 100% obliteration rate and no complications.
  
  
  CONCLUSIONS
  Traumatic ICA pseudoaneurysms are safely treated with daily aspirin, embolic monitoring, and radiographic surveillance. Acute stroke or hemorrhage, or delayed radiographic progression, are indications for endovascular or surgical treatment.
authors.affiliation: *Department of Neurosurgery, University of Washington at Harborview Medical Center, Seattle, WA †Department of Radiology, University of Washington at Harborview Medical Center, Seattle, WA.
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Morton
authors.forename: Michael R
authors.initials: MR
authors.lastname: Levitt
authors.forename: Samuel
authors.initials: S
authors.lastname: Emerson
authors.forename: Basavaraj V
authors.initials: BV
authors.lastname: Ghodke
authors.forename: Danial K
authors.initials: DK
authors.lastname: Hallam
authors.forename: Laligam N
authors.initials: LN
authors.lastname: Sekhar
authors.forename: Louis J
authors.initials: LJ
authors.lastname: Kim
authors.forename: Randall M
authors.initials: RM
authors.lastname: Chesnut
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D017541:Aneurysm, False / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D002340:Carotid Artery Diseases / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging; D000066491:Clinical Decision-Making; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome; D014463:Ultrasonography; D014949:Wounds, Nonpenetrating / Q000150:complications*