Interventional radiology in the treatment of intracranial vascular injuries and fistulae

Diagnosis and treatment of traumatic optic neuropathy with carotid artery cavernous segment pseudoaneurysm

OBJECTIVES/HYPOTHESIS

To summarize our experience in diagnosis of carotid cavernous segment pseudoaneurysm in patients with traumatic optic neuropathy, and to make recommendations for treatment.

STUDY DESIGN

Retrospective study.

METHODS

Clinical data of 133 cases with traumatic optic neuropathy (TON) were reviewed. The diagnosis and treatment of four cases with carotid cavernous segment pseudoaneurysm (PSA) were analyzed.

RESULTS

The incidence of traumatic optic neuropathy with pseudoaneurysm for this group of patients was 3.01% (4/133). Preliminary screening was performed with vascular-enhanced computed tomography (CT) scan, and was further confirmed by digital subtraction angiography (DSA). Among the four cases with pseudoaneurysm, three cases were successfully treated with vascular embolization. In one of the three cases, coil embolization was employed; and in the other two cases stent embolization was performed. The pseudoaneurysm disappeared after embolization, and nosebleeds subsided without significant complications. All four patients did not undergo nasal endoscopic optic nerve decompression. There was no recurrence of nose bleeding after embolization in the following 1 to 12 months, and in one case the patient's vision improved from no light perception to perceiving hand movement.

CONCLUSIONS

There is a possibility of fatal epistaxis for traumatic optic neuropathy with carotid artery cavernous segment pseudoaneurysm. Endoscopic optic nerve decompression treatment (EOND) is not suitable for these cases; instead, it is recommended that patients with traumatic optic neuropathy go through vascular-enhanced computed tomography screening. Suspected cases should be diagnosed by digital subtraction angiography and be treated by embolization in a timely manner, with stent vascular interventional embolization being the ideal choice.

Blunt cerebrovascular injuries: diagnosis and management outcomes

BACKGROUND

Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI.

METHODS

This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed.

RESULTS

Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment.

CONCLUSIONS

BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment.