Craniofacial Trauma and Vascular Injury

Abstract

Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.

Keywords: arterial dissections; carotid-cavernous fistulas; craniofacial trauma; extra-axial hematomas; interventional radiology; pseudoaneurysms.

Fig. 1

Direct carotid-cavernous fistula following motor vehicle collision. ( a, b ) Left internal carotid artery (ICA) angiography seen on early and delayed arterial phase showing poor intracranial flow and shunting of blood through cavernous sinus anteriorly into superior ophthalmic vein and posteriorly into the inferior petrosal sinus. Post–transvenous embolization, left ICA angiography in lateral ( c ) and anteroposterior views ( d ) showing no filling of the fistula and good intracranial circulation.

Fig. 2

Indirect carotid-cavernous (CCFs) fistula showing delayed presentation with redness and chemosis of bilateral eyes following motor vehicle collision. ( a, b ) Anteroposterior (AP) and lateral views of right ICA (ophthalmic vein—black arrow) and ( c ) AP view of right external carotid artery angiographies showing fistulous filling of bilateral cavernous sinuses with prominent anterior venous drainage into superior ophthalmic veins. ( d ) Transvenous embolization of bilateral cavernous sinuses through ophthalmic vein showing successful obliteration of the CCF.

Fig. 3

Chronic subdural hematoma. A 48-year-old male was found underneath a semi-truck after being struck. On arrival, the patient was hemodynamically stable. ( a ) CT showed a left frontoparietal subdural hematoma. ( b ) Left external carotid artery angiography showing prominent blush in the left high parietal region, which was confirmed on selective left middle meningeal artery posterior division angiography using microcatheter ( c ). ( d ) Post onyx embolization angiography showing obliteration of the vascular blush.

Fig. 4

Left facial A pseudoaneurysm (black arrow) following stab injury seen on CTA ( a ) and left common carotid artery angiography of the neck ( b ). ( c , d ) Postembolization angiography showing coils beyond and proximal to the aneurysmal neck to prevent reflux filling from collaterals.

Fig. 5

Patient with history of gunshot wound to the right side of the mandible with persistent bleeding; angiography showed lacerated right proximal internal maxillary artery (black arrow) ( a ) which was successfully embolized using coils ( d ). Also seen is the right internal carotid artery (ICA) dissection (chevron arrow) ( a ), and intracranial circulation being filled through left ICA ( b ) and left vertebral artery ( c ) through patent circle of Willis.

Fig. 6

Right lingual artery laceration. A 23-year-old male who presented after motor vehicle collision suffering multiple injuries. ( a, b ) Selective right lingual artery angiography in lateral view showing laceration with active contrast extravasation. ( c, d ) Post–glue embolization of the laceration showing no contrast extravasation.

Fig. 7

Left occipital arteriovenous fistula (AVF) in a 48-year-old male with stab wound to the neck. A left common carotid artery angiography showing AVF fed by muscular branch from the left occipital artery ( a ), which was successfully embolized using micro coils ( b ).