Endovascular therapy of traumatic injuries of the intracranial cerebral arteries

Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain?

Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature

BACKGROUND

Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population.

METHOD

We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs.

RESULTS

Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis.

CONCLUSION

Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury

BACKGROUND

This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome.

METHODS

We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome.

RESULTS

Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI.

CONCLUSION

Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Use of Pipeline™ embolization device for the treatment of traumatic intracranial pseudoaneurysms: Case series and review of cases from literature

OBJECTIVE

Intracranial traumatic pseudoaneurysms (PSA) are a rare but dangerous subtype of cerebral aneurysm. Reports documenting use of flow-diverting stents to treat traumatic intracranial PSAs are few and lack long-term follow-up. To our knowledge, this is the largest case-series to date demonstrating use of Pipeline Endovascular Device (PED) for traumatic intracranial PSAs.

PATIENTS AND METHODS

Retrospective review of 8 intracranial traumatic PSAs in 7 patients treated using only PED placement. Patients were followed clinically and angiographically for at least 6 months.

RESULTS

Seven patients with a mean age of 37 years were treated for 8 intracranial pseudo-aneurysms between 2011-2015. Six aneurysms were the result of blunt trauma; 2 were from iatrogenic injury during transsphenoidal surgery. Mean clinical and angiographic follow-up in surviving patients was 15.2 months. In patients with angiographic follow-up, complete occlusion was achieved in all but one patient, who demonstrated near-complete occlusion. No ischemic events or stent-related stenosis were observed. One patient developed a carotid-cavernous fistula after PED, which was successfully retreated with placement of a second PED. There were two mortalities. One was due to suspected microwire perforation remote from the target aneurysm resulting in SAH/IPH. The other was due to a traumatic SDH and brainstem hemorrhage from an unrelated fall during follow-up interval.

CONCLUSIONS

Use of PED for treatment of intracerebral PSAs following trauma or iatrogenic injury showed good persistent occlusion, and acceptable complication rate for this high-risk pathology. Risks of this procedure and necessary antiplatelet therapy require appropriate patient selection. Larger prospective studies are warranted.

Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging

BACKGROUND

Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking.

METHODS

We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience.

RESULTS

Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping.

CONCLUSIONS

We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.

Current trends in endovascular management of traumatic cerebrovascular injury

BACKGROUND

The role of catheter angiography in the diagnosis and management of traumatic cerebrovascular injury has evolved rapidly with advances in CT and MR angiography and continued development of endovascular techniques.

OBJECTIVE

To identify the modern spectrum of traumatic arterial injury encountered during catheter neuroangiography and to examine current patterns of endovascular treatment.

METHODS

Records of trauma patients undergoing catheter neuroangiography over a 4 year period at two high volume centers were retrospectively reviewed. The sample comprised 100 separate arterial lesions that were classified according to mechanism, location, acuity, and endovascular treatment. Follow-up imaging and clinical notes were reviewed to identify procedural complications.

RESULTS

Of 100 arterial lesions, 81% were related to blunt trauma. Distribution of lesions by location was 42% intracranial, 39% cervical, and 19% extracranial. The most common injuries were pseudoaneurysm (38%), fistula (29%), and dissection (19%). In total, 41% of lesions underwent endovascular treatment, with trends favoring treatment of non-acute, penetrating, non-cervical, and high grade lesions. Therapy involved coil embolization for 89% of treated lesions. There were a total of two immediate neurovascular complications and one delayed neurovascular complication; one of these resulted in a permanent neurological deficit.

CONCLUSIONS

Our experience in a large cohort of patients suggests that a relatively high proportion of traumatic arterial lesions identified by catheter angiography are treated by endovascular means, with a low rate of immediate and delayed neurovascular complications.

Successful treatment of a traumatic carotid pseudoaneurysm with the Pipeline stent: Case report and review of the literature

BACKGROUND

Traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to treat. In the case of traumatic pseudoaneurysms that may not be treated with parent vessel sacrifice, some flow diversion strategy such as stent-assistance or use of a flow diversion device is usually necessary.

CASE DESCRIPTION

In this study we describe endovascular parent vessel wall-remodeling/endoluminal reconstruction and traumatic pseudoaneurysm thrombosis through the use of the Pipeline stent and review recent reports concerning indications, safety, and efficacy for alternative pathology.

CONCLUSION

Although currently not routinely employed in the treatment of traumatic pseudoaneurysms, the Pipeline stent may represent a safe and effective treatment alternative achieving complete endoluminal reconstruction of the damaged vessel wall.

Endovascular treatment and radiographic follow-up of proximal traumatic intracranial aneurysms in adolescents: case series and review of the literature

PURPOSE

Traumatic intracranial aneurysms are rare lesions that are relatively more common in the pediatric population. Proximal traumatic aneurysms occur near the skull base. Direct surgical repair of these lesions is difficult due to the anatomically confined area, clinical status of a head injury patient, and the transmural nature of the injury. These lesions often lack a definable neck or wall suitable for clipping. While the indications and capabilities of endovascular treatment continue to expand, there are unanswered questions about the durability of treatment, especially in young patients. There are few reports examining the radiographic outcomes of endovascular treatment specifically for traumatic intracranial aneurysms. Therefore, we examined our experience treating these rare proximal lesions in an adolescent population.

METHODS

A retrospective review of prospectively collected data from 2000-2008 in a large, multidisciplinary neurovascular and trauma center was performed.

RESULTS

Three pediatric patients received endovascular treatment for traumatic intracranial aneurysms near the skull base. All patients had successful obliteration of their lesion without vessel sacrifice; however, two patients required multiple procedures for coil compaction or refilling of the aneurysm. There were no complications or ischemic events related to treatment. Follow-up imaging ranged from 6 months to 3.5 years.

CONCLUSIONS

Traumatic intracranial aneurysms at the skull base can be successfully treated with endovascular methods; however, close follow-up is necessary.

Wartime Traumatic Aneurysms

OBJECTIVE

Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management.

METHODS

A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study.

RESULTS

A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically.

CONCLUSION

The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve.

Imaging of Traumatic Neurovascular Injury

Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.

Interventional Neuroradiology Adjuncts and Alternatives in Patients with Head and Neck Vascular Lesions

Vascular lesions of the head and neck can result from a variety of neoplastic and traumatic conditions that may cause local neurologic symptoms or may compromise the carotid or vertebral arteries, leading to ischemic deficits. Management of lesions involving vascular structures at the skull base may require a temporary balloon occlusion tolerance test or endovascular transarterial embolization as part of the preoperative management. Endovascular techniques can also be used as a salvage measure for severe head and neck bleeding and can assist with the management of vascular injury occurring in the operative or perioperative setting. Familiarity with the role of endovascular techniques in this group of patients may favorably influence patient management and outcome.

Traumatic arteriovenous fistula of the posterior inferior cerebellar artery treated with endovascular coil embolization: case report

BACKGROUND

High-flow intracranial arteriovenous (AV) fistulas associated with giant varices are rare lesions. These varices can present with symptoms from mass effect, spontaneous hemorrhage, and seizures to cardiac failure. Direct AV fistulas of the posterior inferior cerebellar artery (PICA) are extremely rare lesions, with only two cases reported in the literature.

CASE DESCRIPTION

The authors present an unusual case of a 25-year-old male with a direct AV fistula of the PICA that resulted from a fracture of the occipital condyle. This high-flow AV fistula drained into a giant varix of the vein of the lateral recess that compressed the brainstem, resulting in a Wallenberg syndrome. The patient underwent embolization of the proximal PICA feeding the fistula with a Guglielmi detachable coil (GDC), which resulted in thrombosis of the varix. A postembolization angiogram showed occlusion of the PICA AV fistula and draining varix. A computed tomography (CT) scan performed at a 10-month follow-up visit showed dramatic decompression of the brainstem. Although the patient continued to have some sensory changes secondary to Wallenberg syndrome, he was otherwise doing well neurologically.

CONCLUSION

The treatment of this lesion is difficult because of its location near the brainstem. Postocclusion edema or hemorrhage can result in mass effect and life-threatening brainstem compression. Our patient, whose AV fistula was caused by trauma, was treated effectively with GDC embolization.

Medical Devices of the Head, Neck, and Spine

There are many medical devices used for head, neck, and spinal diseases and injuries, and new devices are constantly being introduced. Many of the newest devices are variations on a previous theme. Knowing the specific name of a device is not important. It is important to recognize the presence of a device and to have an understanding of its function as well as to be able to recognize the complications associated with its use. The article discusses the most common and important devices of the head, neck, and spine, including cerebrospinal fluid shunts and the Codman Hakim programmable valve; subdural drainage catheters, subdural electrodes, intracranial electrodes, deep brain stimulators, and cerebellar electrodes; coils, balloons, adhesives, particles, and aneurysm clips; radiation therapy catheters, intracranial balloons for drug installation, and carmustine wafers; hearing aids, cochlear implants, and ossicular reconstruction prostheses; orbital prostheses, intraocular silicone oil, and lacrimal duct stents; anterior and posterior cervical plates, posterior cervical spine wiring, odontoid fracture fixation devices, cervical collars and halo vests; thoracic and lumbar spine implants, anterior and posterior instrumentation for the thoracic and lumbar spine, vertebroplasty, and artificial disks; spinal column stimulators, bone stimulators, intrathecal drug delivery pumps, and sacral stimulators; dental and facial implant devices; gastric and tracheal tubes; vagus nerve stimulators; lumboperitoneal shunts; and temperature- and oxygen-sensing probes.

Blunt carotid artery injury

Blunt carotid artery injury is an uncommon injury with a potentially devastating outcome. Although treatment is often unhelpful for an established neurologic deficit, there is frequently a delay between the episode of trauma and the onset of neurology. This delay provides a window of opportunity where early detection and intervention may significantly improve outcome and prevent lifelong morbidity in a generally young trauma patient population. This paper will review the literature regarding incidence, outcome, treatment options and optimal methods of diagnosis for this lesion. The following synopsis of a case seen at Royal Perth Hospital Emergency Department illustrates several of the classical features of blunt carotid injury, including delayed presentation and pattern of associated injuries. The patient, a 19-year-old female, presented following a single vehicle motor crash. On arrival she had a Glasgow Coma Scale (GCS) of 14 with no focal neurologic deficit. Multiple injuries were identified, including a large scalp laceration, a compound fracture of the mandible, pneumothorax, sternal fracture, subcapsular haematoma of the liver, and a knee laceration. Initial computed tomography (CT) scan of the head was normal. Twenty hours after the motor vehicle accident the patient's conscious state deteriorated to GCS 9. Repeat CT head demonstrated changes consistent with a left middle cerebral artery infarct. Cerebral angiography revealed traumatic dissection of the left internal carotid artery with complete occlusion of the lumen just distal to its origin. After 13 days in the intensive care unit and 2.5 months in the rehabilitation unit, she was discharged with a persistent severe receptive and expressive aphasia, as well as a dense right hemiparesis. She is now living at home with community supports.

Traumatic vascular injuries and their management

Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.

Cervical vascular injuries: carotid and jugular venous injuries

This article explores the management of carotid arterial injuries, detailing the historical evolution for the management of these injuries and delineating techniques for cerebral perfusion and preservation with shunts. It discusses the role of autogenous versus synthetic grafts in the management of these injuries and the issue of vascular complications and potential pitfalls. Jugular venous injuries are addressed also, with emphasis on the controversies of primary repair versus ligation.

Dissecting hematoma of intracranial internal carotid artery in an 8-year-old girl

BACKGROUND

An 8-year-old girl had a minor fall without head trauma and she collapsed the following day while playing. She was awake but mute with focal neurologic signs when admitted to hospital. Radiologic imaging studies showed a progressive left cerebral infarct with left hemisphere vascular narrowing and beading. She died on the third hospital day.

METHODS

Autopsy including exploration of neck vessels and neuropathological examination was performed. Postmortem studies included immunostaining for immunoglobulins and fixed complement.

RESULTS

Subtotal subintimal dissections of both proximal supraclinoid internal carotid arteries were found microscopically. On the left, the subintimal dissection extended into the major branches of the left internal carotid artery as dissecting hematomas with a major compromise of the arterial lumina. Specific IgM deposition at the dissection sites was found. A literature review shows that subintimal dissection of the intracranial internal carotid artery or its branches occurs rarely, it is often fatal, and it is present in patients with a mean age of 17.5 years in cases studied pathologically. Trauma and physical exertion are the most common associated factors.

CONCLUSIONS

Among the causes of ischemic stroke in young individuals, dissecting hematomas of the intracranial portions of the internal carotid artery system rank low. Few reported cases have identifiable pre-existing pathology. The pathogenesis of dissecting hematomas in this region is reviewed and expanded with speculation regarding relevant developmental, anatomical, flow stress and possibly humoral factors that are involved in the disruption of the arterial elastica and subsequent development and extension of a subintimal hematoma resulting in luminal closure and often death.