8/14/2019 Angiographic Evaluation and Treatment for Head and Neck Vascular Injury http://slidepdf.com/reader/full/angiographic-evaluation-and-treatment-for-head-and-neck-vascular-injury 1/13 11/4/13 www.medscape.com/viewarticle/761133_print www.medscape.com/viewarticle/761133_print 1/13 www.medscape.com Abstract and Introduction Abstract A variety of head and neck vascular emergencies, such as nosebleeds or neoplastic hemorrhages, can occur spontaneously or result from blunt or penetrating trauma. As most traumatic venous bleeding can be resolved with direct pressure, the main focus is on arterial injury. The role of catheter angiography in the acute trauma setting has shifted over the past 15 years, with the concomitant advances in computed tomography (CT) angiography for diagnosis, and development of microcatheters and embolic agents for therapy. Introduction A variety of head and neck vascular emergencies, such as nosebleeds or neoplastic hemorrhages, can occur spontaneously or result from blunt or penetrating trauma. As most traumatic venous bleeding can be resolved with direct pressure, the main focus is on arterial injury. The role of catheter angiography in the acute trauma setting has shifted over the past 15 years, with the concomitant advances in computed tomography (CT) angiography for diagnosis, and development of microcatheters and embolic agents for therapy. Regional trauma associations have proposed algorithms for which patients should be evaluated by CT angiography and/or catheter angiography for traumatic head and neck vascular injuries. [1–3] These include high-risk mechanisms such as: high- energy collisions, neck hyperextension injury, intra-oral trauma, and near-hanging with anoxic brain injury. Additionally, CT or catheter angiography should be considered in patients with LeFort/midface fractures, cervical spine or basilar skull fractures, diffuse axonal injury with Glasgow Coma Scale (GCS) < 6, a new focal neurological deficit, neurological examination incongruous with head CT findings, or imaging evidence of a new cerebral infarct in the setting of trauma. Clinically occult head and neck vascular injury is rare; however, aggressive CT screening in asymptomatic patients has become commonplace given the potentially devastating sequelae of a missed diagnosis, [4–6] combined with ease of access to CT angiography. Ongoing discussion in the trauma community continues regarding patient selection criteria, given the concerns of cost effectiveness of broad screening in asymptomatic patients as well as minimizing unnecessary radiation exposure. There remain cases in which conventional angiogram remains the 'gold standard.' These include CT angiograms limited by artifact from dental implants/amalgam, from metal or shrapnel, situations where appropriate bolus timing cannot be achieved, and hemodynamically unstable patients with a high probability of requiring endovascular intervention. Diagnostic catheter angiogram should always be considered in a patient with high suspicion for cervical vascular injury in the setting of a normal CT angiogram, as this is a dynamic disease process and contrast opacification of a vessel on cross-sectional imaging may not fully reflect flow dynamics and collateral pathways. Large Arterial Lacerations, Pseudoaneurysms, and Arteriovenous Fistulae Damage to the arterial wall can result in life-threatening hemorrhage, and patients with large arterial lacerations due to penetrating trauma have significant mortality before reaching hospital care. Alternatively, hemorrhage may be contained by development of a pseudoaneurysm or diverted through a traumatic arterial-venous fistula. In dealing with a patient with a potential arterial laceration, it is crucial to maintain hemodynamic and ventilatory support throughout the search for and treatment of the active bleeding site. Exploration of anterior neck wounds is usually done surgically, given adequate exposure and direct visualization of the carotid arteries. [7] In patients with active hemorrhage from a carotid or vertebral laceration, there is a high risk of stroke or even death despite aggressive treatment, including surgical ligation or endovascular embolization of the vessel. Given the difficult surgical approach to the carotid artery at the skull base and the vertebral arteries, [8,9] the interventional neuroradiologist can provide great support to the trauma team with an endovascular approach to treatment at these sites. [10,11,12] Additionally, in patients with extensive facial fractures or penetrating injuries, an endovascular approach to control bleeding is preferred (Figure 1). Angiographic Evaluation and Treatment for Head and Neck Vascular Injury Julie Bykowski, MD, Wade Wong, DO, FACR, FAOCR Appl Radio l. 20 12;41(3):10-16 .
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8/14/2019 Angiographic Evaluation and Treatment for Head and Neck Vascular Injury
(A) T1-weighted post-contrast MR image of a 52-year-old man reveals enhancing squamous cell carcinoma of the left sphenoid
sinus and cavernous sinus. Massive arterial hemorrhage occurred after endoscopic biopsy. (B) Left internal carotid arteriogram
reveals development of a cavernous sinus pseudoaneurysm. (C) After test balloon occlusion, coils were deployed into the
pseudoaneurysm. Not surprisingly, several coils ruptured beyond the encasing thrombus. (D) The left internal carotid was
therefore sacrificed with coil occlusion. Post-treatment arteriogram confirms complete occlusion of the left internal carotid with
filling only of the left external carotid. The patient had intact collateral supply from the right internal carotid via the anterior
communicating artery.
Traumatic arteriovenous fistulae can occur in the setting of arterial transection, with resulting communication between theinjured artery and adjacent vein. Most commonly, these occur in the facial arterial or at the cavernous carotid artery, due to the
prevalence of facial and skull base injury, respectively.
Different methods of embolization have been described, depending on the flow rate, site, and available technology.[21–23]
Small fistulous communications may be embolized with polyvinyl alcohol particles (Figure 3). In larger fistulae, deployment of
micro coils, detachable balloons or liquid embolic agents through the fistula may be necessary to obtain cessation of shunting
(Figure 4).
8/14/2019 Angiographic Evaluation and Treatment for Head and Neck Vascular Injury
(A) 38-year-old woman complained of "swooshing" sound after whiplash injury. Right external carotid arteriogram confirms
arteriovenous fistula, supplied by small branches of the right occipital artery. (B) A microcatheter was advanced into the right
occipital artery and successful embolization of feeder branches was performed with 200-micron polyvinyl alcohol (PVA)
particles.
Figure 4.
(A) CT scan in 18-year-old-man with facial trauma revealed an enlarged left superior ophthalmic vein. (B) Left internal carotid
arteriogram confirmed the presence of a carotid cavernous fistula. (C) Arteriogram repeated after detachable balloon placement
in the single hole shunt of the fistula shows occlusion of the fistula.
In situations where vessel sacrifice is considered, occlusion by balloons or coils should only be done after a thorough test
balloon occlusion to ensure there will not be undesired, irreversible neurological sequelae. Unilateral vertebral artery occlusion
is considered more forgiving as long as the contralateral, uninjured vertebral artery has adequate caliber and the embolizationmaterial can be deployed proximal to the posterior inferior cerebellar artery (PICA), preserving collateral supply on the side of
injury.[24,25] A typical balloon test occlusion is performed by anticoagulating the patient with heparin and then advancing an
occlusive balloon across or distal to the site of injury, to cause cessation of blood flow. Neurological testing for the carotid
artery would include evaluation of pronator drift, motor, sensory, and memory function. Vertebral artery neurological testing
during balloon occlusion is less reliable, however, and emphasis should be placed on coordination, motor, and sensory
8/14/2019 Angiographic Evaluation and Treatment for Head and Neck Vascular Injury
revascularization is indicated. If imaging suggests an embolic mechanism for the stroke, techniques similar to stroke
thrombolysis or thromboembolectomy may be used. If a large vessel occlusion is present, angioplasty or stenting may not be
wise as this may cause a reperfusion hemorrhage in the brain.
Branch Vessel Arterial Lacerations
Trauma to the face, neck, and scalp can result in damage to branches of the external carotid arteries that cannot be controlled
by direct pressure alone. Understanding the trauma mechanism and having cross-sectional imaging of the head and neck are
helpful in the acute setting to tailor the angiogram most expeditiously to areas of interest. One should always consider the rich
collateral supply to the face and neck, and the thyrocervical trunk, vertebral artery, and internal carotid artery branches should
also be scrutinized (Figure 6).
Figure 6.
(A) Right common carotid arteriogram in patient with hematochezia reveals active extravasation from a branch of right superior
thyroid artery (arrowhead). (B) Selective arteriogram after embolization with 200-micron PVA particles confirms cessation of
flow distal to the micrcatheter and absence of further extravastion from the right superior thyroid artery.
The goal is to decrease the pressure head within the injured vessel with resulting cessation of bleeding. Generally, it is
important to place the tip of the catheter as close to the bleeding site as practical to avoid occlusion of normal branches.
Additionally, prior to any particle embolization, one should be well aware of potential dangerous anastamotic collaterals.[39]
These include: distal external carotid artery ethmoidal perforators to the ophthalmic artery, superficial temporal artery to themiddle cerebral artery, middle meningeal artery to the ophthalmic artery, and occipital artery to the vertebral artery (Figure 7).
Additional embolization hazards, such as scalp necrosis, should be kept in mind when targeting sit es in the superficial
temporal and occipital arteries.
8/14/2019 Angiographic Evaluation and Treatment for Head and Neck Vascular Injury
17. Yi AC, Palmer E, Luh GY, et al. Endovascular treatment of carotid and vertebral pseudoaneurysms with coveredstents. AJNR Am J Neuroradiol . 2008;29:983–987.
18. Coldwell DM, Novak Z, Ryu RK, et al. Treatment of posttraumatic internal carotid arterial pseudoaneurysms with
endovascular stents. J Trauma. 2000;48:470–472.
19. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce
stroke rate. Arch Surg. 2004;139:540–545.
20. DuBose J, Recinos G, Teixeira PG, et al. Endovascular stenting for the treatment of t raumatic internal carotid injuries:
48. Sorial E, Valentino J, Giv en CA, et al. The emergency use of endografts in the carotid circulation to control hemorrhagein potentially contaminated fields. J Vasc Surg. 2007;46:792–798.