Traumatic aneurysms of brain due to high velocity missile head wounds

Two hundred twenty-three of 255 consecutive patients underwent cerebral angiography 16.9 +/- 11.6 days (SD) after high velocity missile injury to the head over a 29-month study period. Shell fragments were the most frequent projectiles (73.7%), and penetrating wounds were the most frequent injuries (61%). During the study, 2 patients (1 with an ophthalmic and the other with an anterior cerebral artery aneurysm) presented with delayed traumatic intracerebral hematoma; the first patient had had negative angiography 90 days earlier, and the second patient was admitted from a rehabilitation center after operation in another center 25 days earlier for a penetrating left frontal shell fragment injury. Six of 223 patients (2.7%) had dormant aneurysms (4 middle and 2 anterior cerebral arteries). Seven of 8 patients were operated on again to exclude their aneurysms from the cerebral circulation. Two of 8 patients died postoperatively (1 within 24 hours and another 51 days after discharge from the hospital in a vegetative state). Fragments penetrating temporal, temporoparietal, or pterional areas had a significantly greater chance of causing arterial injury (chi 2 = 11.46, P less than 0.001). There was a significant chance of having an aneurysm if a hematoma was seen at operation or on computed tomography of the head (chi 2 = 4.18, P less than 0.05). The penetrating mode of injury and shell fragments crossing the midline were two variables for which the statistical significance had a P value of 0.08. It is concluded that war casualties with penetrating shell fragment injuries near the pterion, especially when harboring intracerebral hematomas, should undergo cerebral angiography to rule out vascular injuries of the brain.