traumatic intracranial pseudoaneurysm is a rare condition , accounting for less than 1% of all aneurysms.7 ) of these , post - traumatic vertebral artery pseudoaneurysm is not well known , because the incidence of isolated trauma to the vertebral artery is extremely low .
majidi et al.4 ) reported that incidence of vertebral artery dissection was 0.01% of patients with head and neck trauma .
traumatic pseudoaneurysm ruptures are associated with a high mortality rate , because of high risk of rebleeding or regrowth .
we report on a rare case of post - traumatic pseudoaneurysm arising from the right v4 segment of the vertebral artery .
a 9-year - old child was admitted to the emergency room after a pedestrian car accident . on admission ,
motor power of all extremities showed a good grade but movement showed abnormal flexion in response to painful stimuli .
brain computed tomography ( ct ) showed subarachnoid hemorrhage ( sah ) with intraventricular hemorrhage ( ivh ) , multiple facial bones , and temporal bone fracture ( figure 1 ) .
external ventricular drainage and suboccipital craniectomy were performed for acute hydrocephalus and decompression of posterior fossa swelling .
follow - up ct demonstrated resolution of the hemorrhage and his clinical condition recovered to stupor mentality . on the 15th hospital day , the patient showed decreased mentality into semicoma and ct scan revealed the onset of a new 3rd , 4th ventricle hemorrhage and aggravation of hydrocephalus .
ct angiography and digital subtraction angiography confirmed a pseudoaneurysm measuring approximately 15 mm in size arising from the right v4 segment of the vertebral artery , near the origin of the posterior inferior cerebellar artery ( pica ) ( figure 2 ) .
the dominancy of the vertebral artery was even in size and blood flow to the right pica territory was supplied from the right anterior inferior cerebellar artery ( aica ) , meaning the aica - pica complex ( figure 3 ) . therefore , we decided to occlude the parent artery for complete obliteration of the pseudoaneurysm .
final angiography confirmed complete obliteration of the pseudoaneurysm with preservation of the right aica - pica complex ( figure 4 ) .
after endovascular treatment , the patient did not show worsening of neurological condition . despite receiving intensive neurosurgical care
, he died of acute respiratory distress syndrome on the 52nd hospital day ( figure 5 ) .
the mechanism is direct vessel injury from the foreign body or bony fragments due to skull fracture , or vascular torsion , stretching , and pressure against adjacent structures .
the location of these pseudoaneurysms is varied , and they are commonly found in the anterior circulation .
biffl et al.2 ) reported that vertebral artery injuries are presented in 0.5% of blunt cervical traumas .
detection of traumatic pseudoaneurysms is still a clinical challenge due to its diverse presentation and lack of widely accepted diagnosis and management guidelines.5 ) clinical manifestation of vertebral pseudoaneurysm rupture could be a local neck mass , or neurologic symptoms related to posterior circulation due to microembolization .
these pseudoaneurysms carry significant risk of embolic stroke and mortality , with cited figures of 13% , respectively.13 ) however , some pseudoaneurysms of the vertebral artery , like v3 or v4 segment , which proceeds from c1 to a junction with the contralateral vertebral artery , could present with intracranial hemorrhage .
in general , deterioration of traumatic pseudoaneurysms may occur within several weeks after initial trauma .
after the formation of a pseudoaneurysm , sudden onset of rebleeding could be associated with increased intracranial pressure or clot lysis .
the pseudoaneurysms might be safely observed because spontaneous thrombosis could occur , but rebleeding could sometimes occur.6 ) therefore , early diagnosis and proper treatment of a pseudoaneurysm is also mandatory and highly important .
intervention could also be an effective method for management of pseudoaneurysm , particularly posterior circulation with poor clinical grade . in the current case ,
the patient presented with post - traumatic sah and ivh , which was mistaken for simple traumatic sah , and there was no initial evaluation for vascular injury .
formation of a pseudoaneurysm should be suspected in patients with trauma , if there is thick sah accompanying a basal skull fracture .
the mechanism of traumatic brain injury is also an important consideration for development of pseudoaneurysm .
on the 15th hospital day with deterioration of level of consciousness , angiography confirmed a rupture of a pseudoaneurysm arising from the right v4 segment of the vertebral artery . at the time of admission
, there was no cervical spine injury that could affect dynamic injury to the vertebral artery .
the child was pushed by a reversing school minivan with very low velocity immediately after leaving his car .
then , he fell down and was run over by the right rear wheel . therefore , the exact mechanism of vascular injury is ambiguous ; however , considering angiographic findings , we thought that pseudoaneurysm formation was due to the rupture of a perforating artery by traction injury or dissection .
the definite treatment of traumatic pseudoaneurysm is a destructive method , meaning parent artery occlusion .
we could occlude the right vertebral artery just proximal to the aica origin , because there was no visualization on initial angiography and non - dominant vertebral artery compared with the contralateral side .
we report an extremely rare case of traumatic pseudoaneurysm rebleeding arising from the intracranial vertebral artery . post - traumatic intracranial pseudoaneurysm should be considered in any patient who exhibits neurological deterioration after head trauma .
therefore , brain ct angiography is mandatory for evaluation of vascular injuries in patients with traumatic sah and for achievement of a better outcome , especially in cases showing thick sah around the brain stem or sah with accompanying basal skull fractures .
 this case report describes a traumatic pseudoaneurysm arising from the right v4 segment of the vertebral artery , near the origin of the posterior inferior cerebellar artery . 
 post - traumatic vertebral artery pseudoaneurysm is rare , but associated with a high mortality rate . 
 we report on an extremely rare case of post - traumatic pseudoaneurysm of the vertebral artery with delayed manifestation . 
 a 9-year - old child was admitted to the emergency room after a pedestrian car accident . 
 a computed tomography ( ct ) scan showed subarachnoid hemorrhage with intraventricular hemorrhage ( ivh ) , multiple facial bones , and temporal bone fracture . 
 external ventricular drainage and decompressive suboccipital craniectomy were performed for acute hydrocephalus and posterior fossa swelling . 
 the patient 's clinical condition became suddenly aggravated on the 15th hospital day , and brain ct confirmed appearance of a new 4th ventricle ivh . 
 digital subtraction angiography revealed a ruptured pseudoaneurysm arising from the right v4 segment of the vertebral artery . 
 parent artery occlusion using detachable coils was achieved . despite intensive care , 
 the patient 's clinical condition showed continuous deterioration and the patient died of respiratory complications on the 52nd hospital day . 
Introduction
Case Report
Discussion
Conclusion