Endovascular management of neurovascular arterial injuries in the face and neck

Abstract

The diagnosis and treatment of traumatic vascular injuries continues to improve as new tools and techniques are developed. In addition to locoregional hemorrhagic complications, injuries to blood vessels in the neck and face can result in ischemic injuries to the brain and cervical spinal cord. Surgical access to these lesions may be difficult, and endovascular techniques, including stenting and embolization, now serve as definitive treatments in many instances. This article reviews the endovascular management of patients with arterial injuries in the neck and face.

Keywords: N-butyl cyanoacrylate; Trauma; embolization; neurointervention; stent.

Figure 1

A 25-year-old man with gunshot wound to the face and enlarging hematoma. The patient presented to the emergency department after sustaining gunshot wounds to the face and abdomen. He was taken to the operating room for repair of a colonic injury. His facial hematoma, initially stable, started to enlarge 24 hours after admission. He was brought to the neuroangiography suite. (A) Right common carotid angiography, lateral view, showing injury of the maxillary artery with contrast stagnation, no active leak, and no distal opacification. (B) A 6-French guide catheter (Envoy; Cordis Neurovascular, Miami Lakes, FL) was placed within the origin of the right external carotid artery, and a 2.3-French microcatheter (Prowler Plus, Cordis Neurovascular) advanced into the damaged arterial segment over a 0.014-inch guide wire (Transend, BSC, Fremont, CA). Superselective angiography of the maxillary showed moderate contrast extravasation, indicating partial tamponade of the transected maxillary artery by the closed hematoma. (C) The microcatheter was withdrawn into the maxillary artery stump, proximal to the site of transection. Two detachable microcoils (GDC, BSC) were deployed, followed by several pushable fibered microcoils (Vortex, BSC). (D) Right common carotid angiography, lateral view. This final control angiogram shows the configuration of the coil pack securing the transected arterial segment. Superselective angiography performed prior to the removal of the microcatheter had confirmed the absence of extravasation.

Figure 2

A 27-year-old man with gunshot wounds to the neck. The patient presented to the emergency department with neck, chest, and abdomen gunshot wounds. Computed tomographic (CT) angiography documented a left vertebral artery occlusion. The patient became hemodynamically unstable and was taken to the operating room where he underwent small bowel resection. (A) CT angiography, coronal reconstruction, obtained at admission, immediately prior to abdominal surgery. The left vertebral artery is opacified proximally (V1 segment, arrow), but the V2 and V3 segments are absent. Note the metallic artifacts related to bullet fragments at C2. Comminuted left facet fractures of C2 and C3 were noted as well (not shown). (B) Left vertebral artery injection, anteroposterior view. A diagnostic angiogram was prompted by the documentation of a small left cerebellar stroke on a skull base CT obtained 24 hours after admission. The angiogram showed that the previously occluded segment of the left vertebral artery had recanalized. The V2 and V3 segments were markedly irregular, with two pseudoaneurysms (only one visible in this projection, white arrow). In addition, an arteriovenous fistula draining into the vertebral epidural plexus (white arrowheads) was present. Note the large bullet fragment (black arrow) and a prominent anterior spinal artery originating from the V2 segment (artery of the cervical enlargement, black arrowheads). (C) The decision was made to sacrifice the left vertebral artery. A compliant microballoon (Hyperform 7 × 7 mm, eV3 Irvine, CA; arrowheads) was inflated within the V2 segment, distal to the takeoff of the anterior spinal artery (black arrowheads), and a 1.7-French microcatheter (Echelon 10, eV3) was placed distally within the damaged segment of the vertebral artery. The balloon and the microcatheter were advanced coaxially within the same 6-French guide catheter (Envoy, Cordis Neurovascular, Bridgewater, NJ). (D) The V2 and V3 segments were then embolized with 37 detachable coils (GDC 10 and 18, BSC, Fremont, CA). (E) Left vertebral artery injection, anteroposterior view after embolization, confirming the patency of the anterior spinal artery and the absence of opacification of the damaged portion of the left vertebral artery. (F) Right vertebral artery injection, anteroposterior view, showing collateral flow to the left V4 segment and the left posterior inferior cerebellar artery (PICA) via the right vertebral artery, but no retrograde opacification of the damaged segment or the arteriovenous fistula.

Figure 3

A 22-year-old man with gunshot wound to the face and massive nasopharyngeal hemorrhage. The patient arrived to the emergency department bleeding profusely; he had a large facial wound with maxillary and hard palate defects and several disrupted teeth. Emergent tracheostomy was performed, and a Foley balloon catheter was inflated in each nasal cavity, providing only partial hemostasis. The patient was sent to the neuroangiography suite. (A) Left external carotid artery injection, oblique view, showing brisk contrast extravasation from a severed left superior alveolar artery. Note the presence of diffuse arterial vasospasm typically associated with gunshot injuries. (B) A 1.7-French microcatheter (Prowler 10, Cordis Neurovascular, Miami Lakes, FL) was advanced into the superior alveolar artery through the 5-French diagnostic catheter (JB-1, Terumo, Piscataway, NJ). Superselective angiography confirmed the site of extravasation. (C) N-butyl cyanoacrylate (NBCA) glue was injected through the microcatheter (mixture of 1 mL of Ethiodol for 1 mL of NBCA). (D) Left external carotid artery injection, oblique view, obtained after withdrawal of the microcatheter, confirming that hemostasis has been achieved.

Figure 4

A 43-year-old man with enlarging neck hematoma. This patient admitted for relapsing acute leukemia with kidney failure and disseminated intravascular coagulation presented an enlarging neck hematoma shortly after placement of a central venous line. (A) Computed tomographic angiography revealed that the 7-French triple lumen catheter (arrowhead) had been mistakenly inserted into a branch of the right subclavian artery (arrow), with its distal tip lying within the aortic arch. (B) Right subclavian artery injection, oblique view, confirming the presence of the 7-French catheter within the subclavian artery (arrowheads). (C) An attempt at keeping percutaneous access to the injured artery by passing an exchange-length guide wire through the 7-French catheter failed as the latter was withdrawn. The access was lost, and a pulsatile neck hemorrhage started. A 6-French guiding catheter with a distal balloon (Corail, Balt, Montmorency, France) previously placed at the origin of the right subclavian artery as a safety measure was immediately inflated, achieving partial control of the hemorrhage. (D) A 2.3-French microcatheter (Prowler Plus, Cordis Neurovascular, Bridgewater, NJ), which was already parked within the 6-French guide catheter, was advanced into the stump of the damaged subclavian branch, and embolization was performed with N-butyl cyanoacrylate (NBCA) glue (mixture of 0.5 mL of Ethiodol and 1.0 mL of NBCA). The microcatheter was withdrawn, and the hemorrhage had stopped. (E) Right subclavian artery injection, oblique view, after embolization, confirming the absence of extravasation. Note the subtraction artifact related to the NBCA glue deposit (arrowheads).

Figure 5

An 18-year-old man with gunshot wound to the face and active hemorrhage. A massive hemorrhage was controlled in the emergency department by inflation of a Foley balloon catheter in the bullet entry wound, and the patient was sent to the neuroangiography suite. (A) Right external carotid angiography, lateral view. After initial four-vessel diagnostic angiography, a 6-French guiding catheter with a low-pressure distal balloon (Corail, Balt, Montmorency, France) was advanced into the origin of the right external carotid artery. The Foley catheter was deflated and selective angiography obtained, showing massive contrast extravasation through a maxillary artery transected by a large bullet fragment. (B) Right external carotid angiography (N-butyl cyanoacrylate [NBCA] injection), lateral view. Control of the extravasation was obtained by inflating the distal balloon of the guide catheter. A 1.9-French microcatheter (Echelon 10, eV3 Irvine, CA) already present within the guide catheter was advanced over a 0.014-inch guide wire (Transend 14, BSC, Fremont, CA) into the stump of the transected artery. Three detachable microcoils (GDC 10, BSC) were deployed at the site of the transection. The balloon was slightly deflated and a control angiogram performed, showing persistent extravasation. The balloon was reinflated. NBCA glue was prepared (fast polymerization mixture with 0.1 mL of Ethiodol, 1.0 mL of NBCA, and tantalum powder) and injected through the coil pack. The microcatheter and the guide catheter were both removed at the end of the glue injection. (C) Right common carotid angiography, lateral view. The final angiogram confirms that control of the hemorrhage has been achieved. Note vasospasm of the internal carotid artery, a finding typically observed in arteries located nearby the bullet path.

Figure 6

A 44-year-old man with traumatic carotid pseudoaneurysm. This patient presented with right-sided weakness and aphasia and was diagnosed with bilateral carotid pseudoaneurysms, for which he was started on warfarin. After 2 years of conservative management, the right-sided pseudoaneurysm has regressed, and the left-sided one remained unchanged in size. (A) Left common carotid artery injection, oblique view. A large pseudoaneurysm arises from the proximal segment of the left internal carotid artery. (B) A 5-French guide catheter (Envoy, Cordis Neurovascular, Miami Lakes, FL) is placed in the common carotid artery, and a 1.9-French microcatheter (Echelon 14, eV3 Irvine, CA) advanced into the aneurysmal cavity, which was first framed with 0.018-inch microcoils (GDC 18, BSC, Fremont, CA). (C) A dense coil pack was achieved by the combination of 0.010 (×18) and 0.018 (×10) microcoils (GDC 360 10 and 18, BSC). (D) Left common carotid artery injection, oblique view obtained immediately after coiling, showing residual opacification of the proximal component of the pseudoaneurysm. However, it was decided to stop the procedure at this point rather attempt more complex maneuvers (stent or balloon-assisted coiling) in a sinuous vessel prone to dissection. The patient was discharged on aspirin and clopidogrel and scheduled for follow-up angiography 6 months later. (E) Left common carotid artery injection, oblique view, obtained 6 months later, showing complete obliteration of the pseudoaneurysm with reconstitution of a normal-looking internal carotid artery.

Figure 7

A 53-year-old man with traumatic carotid pseudoaneurysms and multiple transient ischemic attacks. This patient with known fibromuscular dysplasia and bilateral carotid dissections sustained while being assaulted with a nunchaku was admitted for recurrent right hemispheric transient ischemic attacks occurring despite antiplatelet therapy. (A) Right common carotid artery injection, lateral view, showing a sinuous and irregular cervical segment, with a wide-necked pseudoaneurysm located immediately below the skull base (arrow), and a second, more proximal, and smaller lesion (arrowhead). Note the presence of fibromuscular dysplasia in the vessel (also noted on the opposite side as well as in both vertebral arteries). (B) Right internal carotid artery injection, unsubtracted lateral view obtained after stent deployment (Acculink 6 × 40 mm, Abbott Vascular, Redwood City, CA), and placement of two microcoils (GDC, BSC, Fremont, CA). Note how the stent keeps the coils within the pseudoaneurysm cavity despite the absence of true aneurysmal neck. (C) Right common carotid artery injection, lateral view, obtained after placement of 10 coils. Note complete occlusion of the pseudoaneurysm and reconstitution of regular luminal contour. The stent also covers the smaller aneurysm, which now shows significantly delayed opacification and stagnation as an effect of the hemodynamic change resulting from the stent placement and parent artery straightening.