Case Archives — Ventriculostomy (EVD) Hematoma — Another Curious Case for the Angiogram

According to my neurosurgical source, Dr. Matthew Potts, the incidence of track hemorrhage during EVD placement is ~10%, of which ~1% will be clinically significant.  The etiology is, I believe, usually ascribed to disruption of brain veins and maybe arteries, which is intuitive.

A patient underwent diagnostic cerebral angiography for evaluation of a spontaneous large subdural hematoma (red, also involved infratentorial compartment) and EVD placement through the more medial of the two burr holes (yellow).

MMA extravasation CT 1

Injection of the right ECA shows contrast extravasation (purple) from a frontal branch of the MMA (orange) MMA extravasation angio

Microcatheter injection before nBCA, again showing the extravasation; a communication with a vein directed towards the superior sagittal sinus is present (blue).  Notice how the pooled contrast material oulines the burr hole (black arrow). MMA extravasation angio 2

Glue cast images below, with microcatheter advanced as close as possible to the area of extravasation, with glue setting on both arterial and venous sides.

Post embolization ECA injection

Post-embolization ECA injection:

Post embolization ECA injection

Post-embolization CT shows the glue cast (black)

MMA extravasation CT 2

Another instance of the more unusual role for cerebral angiography; to what extent should we look for these injuries?

Case courtesy of Dr. Tibor Becske, NYU Langone Medical Center.