Neuroendovascular Surgery Applications in Craniocervical Trauma

Abstract

Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.

Keywords: angiography; cerebrovascular injuries; craniocervical trauma; head and neck trauma; neuroendovascular surgery; neurointerventional.

Figure 1

An illustration depicting the five grades of blunt cerebrovascular injury.

Figure 2

Illustrative case. A 25-year-old man presented after an assault to the head. An axial non-contrast computed tomography scan of the head showed a left temporal contusion with adjacent subarachnoid hemorrhage (A) and a right temporal contusion and tentorial subdural hematoma (B). Right (C) and left (D) internal carotid artery digital subtraction angiograms (lateral view) obtained on day 10 showed moderate vasospasm of both supraclinoid internal carotid arteries (arrows). Note the traumatic pseudoaneurysm of the cavernous right internal carotid artery.

Figure 3

Illustrative case. A 50-year-old male presented after a motor vehicle accident. A computed tomography angiogram revealed a right internal carotid artery (ICA) pseudoaneurysm with associated stenosis. A digital subtraction angiogram showed a 27 mm right ICA dissecting pseudoaneurysm (arrow) and a right carotid-cavernous fistula (CCF) (arrowhead) (A). Furthermore, the right anterior circulation was noted to fill completely through the left ICA (B). Partial coil embolization was performed at this time to protect the dome of the pseudoaneurysm (C). A repeat angiogram two weeks later showed the right ICA was dissected throughout its entire course and ended in a false lumen in the supraclinoid segment with no antegrade flow or intracranial filling. The CCF, pseudoaneurysm, and dissected ICA were then coiled. A final right common carotid angiogram showed no filling of the ICA, pseudoaneurysm, or CCF (D).

Figure 4

Illustrative case. The radiographic course of an 82-year-old male who presented with a large, septated, chronic right-sided SDH (A). The patient underwent a cerebral angiogram with embolization of the right middle meningeal artery using 50–150 µm Embospheres. An external carotid artery angiogram (B) shows the filling of the middle meningeal artery (arrow). A selective middle meningeal artery angiogram was then performed (C). A post-embolization angiogram of the external carotid artery shows no filling of the middle meningeal artery (D).