Traumatic vertebrobasilar pseudoaneurysms: diagnostic pitfalls on CT angiography with forensic implications - two...

Area of Science:

• Vascular Surgery
• Neuroradiology
• Forensic Pathology

Background:

• Traumatic pseudoaneurysms of the vertebrobasilar artery are rare vascular injuries.
• These lesions may occur without associated skull fractures.
• Standard computed tomography angiography (CTA) can miss or misinterpret these injuries due to technical limitations and low clinical suspicion, leading to diagnostic and medicolegal errors.

Purpose of the Study:

• To highlight the diagnostic challenges and potential pitfalls in identifying traumatic pseudoaneurysms of the vertebrobasilar artery.
• To present cases where optimized thin-slice CTA was crucial for diagnosis.
• To emphasize the importance of considering these injuries in cases of isolated traumatic subarachnoid hemorrhage.

Main Methods:

• Review of two cases with fatal isolated traumatic subarachnoid hemorrhage (iTSAH).
• Utilization of optimized thin-slice CTA for detailed vascular imaging.
• Confirmation of pseudoaneurysm diagnosis through histopathology.

Main Results:

• Optimized thin-slice CTA successfully identified pseudoaneurysms of the posterior inferior cerebellar artery (PICA) and vertebral artery (VA, V4 segment) in both cases.
• The identified pseudoaneurysms were confirmed by subsequent histopathological examination.
• These findings underscore the utility of advanced CTA techniques in diagnosing subtle vascular trauma.

Conclusions:

• Traumatic pseudoaneurysms of the vertebrobasilar artery, though rare, are a critical consideration in cases of iTSAH, even without skull fractures.
• Optimized thin-slice CTA is a valuable tool for detecting these lesions, overcoming limitations of standard CTA.
• Histopathological confirmation is essential for definitive diagnosis and understanding the injury mechanism.