TECHNICAL NOTE J Neurosurg Pediatr 20:239–246, 2017 D irect carotid artery injuries are rare but may be life threatening. Resulting pseudoaneurysms, or false aneurysms, are by defnition extraluminal, contained hematomas, whereas true aneurysms show in- volvement of all 3 layers of the vessel wall. The pseudo- aneurysm wall is composed only of the adventitial layer, adjacent tissues, or sometimes just by hematoma. Pseudo- aneurysms also differ from a traumatic arterial dissection, where separation of the intimal layer from the outer layers occurs due to extravasation of blood. Pseudoaneurysms are rare, accounting for less than 1% of all intracranial aneurysms, but are associated with signifcant morbidity and mortality. 22,25,29,47 These false aneurysms are typically caused by adjacent bone fractures due to trauma but can also be caused by iatrogenic arterial injury during neu- rosurgical procedures, such as aneurysm clipping, tumor removal, and transsphenoidal surgery. 2,3,10,36,44 However, development of an internal carotid artery (ICA) pseudo- ABBREVIATIONS ACA = anterior cerebral artery; CCA = common carotid artery; ICA = internal carotid artery; MCA = middle cerebral artery. SUBMITTED July 9, 2016. ACCEPTED March 31, 2017. INCLUDE WHEN CITING Published online June 16, 2017; DOI: 10.3171/2017.3.PEDS16370. Endovascular plug for internal carotid artery occlusion in the management of a cavernous pseudoaneurysm with bifrontal subdural empyema: technical note Sunil Manjila, MD, 1 Gagandeep Singh, MD, 2 Obinna Ndubuizu, MD, PhD, 1 Zoe Jones, BA, 3 Daniel P. Hsu, MD, 4 and Alan R. Cohen, MD 5 1 Division of Pediatric Neurosurgery, Rainbow Babies and Children’s Hospital, Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center; 2 Division of Interventional Neuroradiology, Department of Radiology, University Hospitals Case Medical Center, Cleveland; 3 Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio; 4 Kaiser Permanente Neuroscience Center, Redwood City, California; and 5 Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphe- noidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by infating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors’ institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifce, obviating the need for numerous coils and antiplatelet therapy, has a role in the set- ting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively. https://thejns.org/doi/abs/10.3171/2017.3.PEDS16370 KEY WORDS endovascular plug; subdural empyema; pseudoaneurysm; carotid artery; sphenoid sinus; vascular disorders; surgical technique ©AANS, 2017 J Neurosurg Pediatr Volume 20 • September 2017 239 Unauthenticated | Downloaded 10/13/22 08:03 PM UTC