Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma

Abstract

The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.

Keywords: blunt injury; endovascular treatment; extracranial internal carotid artery.

Figure 1

The anatomy of the extracranial ICA region. A-B: Lateral view (A) and posterior anterior view (B) of CTA showing carotid veins around the extracranial ICA. C-D: Lateral view (C) and posterior anterior view (D) of CTA showing that the extracranial ICA extends from the bifurcation to the skull base, and the extracranial ICA belongs to the C1 segment of the Bouthiller classification (asterisk). Abbreviations: CTA: computed tomography angiography; ICA: internal carotid artery

Figure 2

Traumatic extracranial ICA occlusion. A: CTA soft tissue reconstruction shows the left face injury in front of the ear. B: CT showed the left MCA high-density sign (arrow). C: CTA reconstruction showed maxillary bone fracture (black ellipse) and extracranial ICA occlusion (arrow). D: CTA reconstruction showed a thin intracranial MCA (asterisk). E: MRA showed the connections from AcomA and PcomA to MCA. F: Follow-up CT showed infarction of the left basal ganglia region. Abbreviations: AcomA: anterior communicating artery; CT: computed tomography; CTA: CT angiography; ICA: internal carotid artery; MCA: middle cerebral artery; MRA: magnetic resonance angiography; PcomA: posterior communicating artery

Figure 3

Carotid stent deployment for traumatic extracranial ICA dissection with severe stenosis. A: The preoperative DSA revealed a long dissection with severe stenosis of the extracranial ICA, and the intracranial blood supply was poorly visible. B: DSA after carotid stenting showed that the extracranial ICA recovered to a normal diameter, and the intracranial blood supply was normal. Abbreviations: DSA: digital subtraction angiography; ICA: internal carotid artery; MRA: magnetic resonance angiography; MCA: middle cerebral artery; PcomA: posterior communicating artery

Figure 4

Covered stent deployment for the traumatic extracranial ICA pseudoaneurysm. A-B: CTA (A) and DSA (B) showed a pseudoaneurysm in the high segment extracranial CIA (arrow in B). C: A covered stent (MicroPort Medical Co., Shanghai, China) crossed the pseudoaneurysm (arrows show the distal and proximal markers). D: After covered stent deployment, endoleak was observable (arrow). E: After the balloon dilation was repeated, the endoleak disappeared. F: X-ray showing the covered stent (white frame). Abbreviations: CTA: CT angiography; DSA: digital subtraction angiography; ICA: internal carotid artery