Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma

Abstract

Traumatic cerebrovascular injury (TCVI) is an uncommon clinical entity in traumatic brain injury (TBI), yet it may cause devastating brain injury with high morbidity and mortality. Early recognition and prioritized strategic treatment are of paramount importance. A total of 1966 TBI patients admitted between 1999 and 2015 in our tertiary critical care center were reviewed. Screening of TCVI was based on the Guidelines for the Management of Severe Head Injury in Japan. TCVI was confirmed in 33 (1.7%) patients; 29 blunt and 4 penetrating injuries. The primary location of the injury included 16 cervical, 6 craniofacial, and 11 intracranial lesions. On arrival, 15 patients presented with hemorrhage, 5 of these arrived in shock status with massive hemorrhage. Ten presented with ischemic symptoms. Sixteen patients underwent surgical or endovascular intervention, 13 of whom required immediate treatment upon arrival. Surgical procedures included clipping or trapping for traumatic aneurysms, superficial temporal artery - middle cerebral artery bypass, carotid endarterectomy, and direct suture of the injured vessels. Endovascular intervention was undertaken in 7 patients; embolization with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) or coil for 6 hemorrhagic lesions and stent placement for 1 lesion causing ischemia. Patients' outcome assessed by the Glasgow Outcome Scale at 3 months were good recovery in 8, moderate disability in 3, severe disability in 9, persistent vegetative state in 1, and death in 12, respectively. In order to rescue potentially salvageable TCVI patients, neurosurgeons in charge should be aware of TCVI and master basic skills of cerebrovascular surgical and endovascular procedures to utilize in an emergency setting.

Keywords: emergency medicine; microneurosurgery; neurotrauma; traumatic brain injury; traumatic cerebrovascular injury.

Fig. 1

Cervical blunt injury with ischemia. Cerebral angiograpm showing occlusion of the right common carotid artery (CCA) (Grade IV) (A) and an intimal flap in the left CCA (Grade II) (B). Diffusion weighted image (DWI) showing faint hyperintensity change in the right cerebral hemisphere (D). Angiogram after carotid endarterectomy demonstrates a patent left CCA (C). Follow-up DWI shows infarction primarily in the right basal ganglia not including cerebral cortex (E).

Fig. 2

Cervical penetrating injury with hemorrhage. Angiogram showing extravasation of contrast media at the right common carotid artery (A). Balloon occlusion catheter was placed to prepare for intraoperative rerupture (B). Postoperative computed tomographic angiogram showed slight stenosis at the anastomosis site (C).

Fig. 3

Craniofacial blunt injury with hemorrhage. CT showing skull base fracture involving the right carotid canal and the left petrous bone (A). Reconstruction CT image shows fractures in the maxilla and mandibula (B). External carotid angiogram shows multiple extravasation at branches of the internal maxillary artery (C), which was embolized with Gelfoam^®. Angiogram of the internal carotid artery (ICA) showing carotid cavernous fistula and contrast media leaking into the oral cavity (D). Post coil embolization angiogram of right ICA shows confirmation of good collateral (E and F).

Fig. 4

Intracranial blunt injury with hemorrhage. Initial Brain CT showing dense subarachnoid hemorrhage in the prepontine cistern (A) as well as intracranial air and clival fracture (B) and magnetic resonance angiography showing no vascular injury (D). On hospital day 10 a bleeding event was observed and vertebral angiogram shows the presence of a de novo basilar top aneurysm (D).

Fig. 5

Intracranial blunt injury with hemorrhage. Brain CT on admission showing deep bifrontal, left intraventricular, and subarachnoid hemorrhages (A). Left carotid angiogram shows an aneurysm-like lesion arising from the left pericallosal artery (B). Intraoperative picture of a pulsating red neck-less dome projecting from the pericallosal artery (D), which abruptly bursted during the procedure, leaving a laceration defect at the pericallosal artery without aneurysm wall. A picture shows uneventful suturing of the laceration (D).

Fig. 6

Intracranial blunt injury with hemorrhage. Initial brain CT scan demonstrating diffuse SAH in the basal cisterns (A). Three-dimensional computed tomographic angiogram (3D-CTA) shows a small dimple at the anterior wall of the supraclinoid segment of the right ICA (B). 3D-CTA after rebleeding episode shows bizarre configuration contrast media indicating extravasation (C). Postoperative 3D-CTA showing patent superficial temporal artery-middle cerebral artery bypass (arrows) (D).

Fig. 7

Schematic drawing showing relationship between vascular injury, general status and brain injury. Traumatic cerebrovascular injury is categorized by mechanism of injury, affected location, and clinical symptom.