Intracranial Hemorrhage Secondary to Iatrogenic Anterior Cerebral Artery Pseudoaneurysm Rupture Following Ventriculostomy

Percutaneous ventriculostomy (EVD) placement is one of the most important diagnostic and therapeutic tools in neurosurgery. Although generally considered low risk, it can be associated with significant complications. We report a case of an intracranial hemorrhage secondary to iatrogenic anterior cerebral artery pseudoaneurysm rupture following ventriculostomy. A 67 year-old female presented to our institution with a spontaneous cerebellar hemorrhage and obstructive hydrocephalus. She underwent emergent bedside right frontal EVD placement and was subsequently taken to the operating room for suboccipital craniectomy and clot evacuation. On postoperative day three, she experienced sudden onset of headache with neurological deterioration, emergent cranial CT scan demonstrated fresh hemorrhage along the EVD tract and casting of the ventricular system. Cerebral arteriography revealed a 3.6 x 3.4 mm traumatic pseudoaneurysm arising from a distal anterior cerebral artery branch that was in contact with the ventricular catheter. After unsuccessful endovascular treatment, the patient was taken to the operating room for clot evacuation and microsurgical aneurysm obliteration. Despite a long and complicated hospital course the patient expired. This report describes a case of acute intracerebral hemorrhage as a presenting sign of pseudoaneurysm rupture following ventriculostomy. Iatrogenic vascular trauma associated with this procedure may be more common than currently appreciated. In the face of significant hemorrhage along an EVD track, evaluation should include catheter angiography if CTA is negative.