Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents

Post-Traumatic Intracranial Pseudoaneurysm Presenting as Epistaxis

Background

Epistaxis is a frequent presenting complaint in the Emergency Department (ED). Roughly 60% of the population will suffer from epistaxis in their lifetime. The most common causes of epistaxis include nose picking, facial trauma, foreign bodies, and coagulopathies. There are other causes that are much less common, such as intracranial pseudoaneurysms. There are multiple causes that precipitate intracranial pseudoaneurysm formation, with head trauma accounting for less than 1% of inciting events.

Case Report

A 24-year-old female with history of traumatic brain injury with associated skull fractures due to a gunshot wound to the head 6 months prior presented to the ED in hemorrhagic shock secondary to epistaxis. After stabilization with the administration of blood products, Computed Tomography with Angiography (CTA) imaging of the head and neck was obtained and revealed a 3.1 × 2.2 × 2.5 cm pseudoaneurysm of the cavernous portion of the right internal carotid artery penetrating through the base of the skull into the ethmoidal sinus. The patient was taken for formal angiography by interventional radiology-and a partially thrombosed daughter sac of the initial aneurysm was identified and believed to be the source of the hemorrhage. The aneurysm was successfully coiled and occluded using ONYX embolization. Postoperatively, the patient returned to her baseline mental status without any acute complaints. The patient was discharged back to her nursing home 2 days later with a 3-week follow-up CTA revealing persistent occlusion of the aneurysm and a patent internal carotid artery.

Conclusion

Awareness and consideration of intracranial vascular etiology for common complaints in the emergency room, such as Epistaxis, especially in patients with any history of head injury/trauma, known intracranial aneurysms or prosthetic devices from prior surgery may help guide decision-making in managing critically ill patients.

A Case Series of Late Vascular Lesions of Traumatic Etiology: Endovascular and Surgical Approaches

There is a broad spectrum of pathology in traumatic vascular injury. Arteriovenous fistula (AVF) is an abnormal communication between the high-flow arterial system and the low-flow venous network, directly connecting the afferent artery and nearby draining veins without the regular intervention of the capillary bed. Most of these fistulas occur due to incidental or iatrogenic injury. A retrospective review of procedures performed by an endovascular surgeon in a tertiary center identified 15 cases of vascular injuries that encompassed all these different clinical scenarios, including post-traumatic, iatrogenic, or spontaneous origin. The information collected, including patient age, sex, previous symptoms, and treatment, was gathered from medical records. In addition, information on procedural technique, endovascular devices used, and specific intraprocedural details were collected from procedure notes and angiographic images. A broad spectrum of injuries can present as late trauma complications (over three months); endovascular treatment is a safe and effective approach for intracranial and extracranial injuries. Endovascular treatment can be a sole option or adjuvant to other hybrid therapies and has emerged as essential for treating these lesions as a first option. We have described standard techniques to treat different vascular pathologies, sometimes with limited resources.

Covered stent delivery in tortuous internal carotid artery for treatment of direct carotid cavernous fistula

Direct carotid cavernous fistulas (dCCF) are high-flow shunts between the internal carotid artery (ICA) and cavernous sinus and are commonly caused by traumatic injuries. Endovascular intervention using detachable coils, with or without stenting, is often the treatment of choice; however, migration or compaction of the coils can occur due to high-flow nature of dCCFs. Alternatively, deployment of a covered stent in ICA can be considered for treatment of dCCFs. We report a case of dCCF with tortuous intracranial ICA successfully treated by placement of a covered stent graft and we will illustrate the technical aspects of the procedure. In the presence of a tortuous ICA navigation and deployment of covered stents is technically complicated and requires modified maneuvers.

Treatment of Traumatic Intracranial Pseudoaneurysms: A Single-Center Experience

Background and Purpose: As a rare lesion secondary to brain trauma, traumatic intracranial aneurysms (TICAs) lead to high mortality and morbidity, and multiple treatment modalities have been applied for TICAs. All patients diagnosed with TICAs in our institution from 2010 to 2020 were included in the report, and their clinical features, treatment, and outcomes are described in detail. The purpose of this study is to illustrate the characteristic of different therapeutic methods of TICAs, and focus on the endovascular treatment.

Methods: A total of 20 patients were included in this study. The 3 patients who declined treatment all died. Five of the other 17 patients were treated surgically, including clipping, wrapping, and trapping with or without EC-IC high-flow bypass, with only 1 case of parent artery preservation. Twelve patients underwent endovascular treatment, including bare coil embolization (1 case), stent-assisted coiling (2 cases), balloon-assisted coils/Onyx glue embolization (1 case) and covered stents (8 cases), with only 1 case of parent artery sacrifice.

Results: 20 patients were included in the present study with 17 males, and the mean of age on 27 years (IQR: 22, 44 years). Eight patients presented with epistaxis, followed by 5 patients with coma, 3 patients with visual defects and 2 patients with CSF leakage. There were 18 TICAs located at the internal carotid artery (ICA); The other 2 TICAs located at pericallosal artery and A1 segment anterior cerebral artery (ACA). One case of diplopia occurred due to sacrifice of the ICA. Occlusion of the ophthalmic artery occurred in 3 patients after placement of a covered stent, with 1 patient suffering an irreversible vision decrease. None of the other patients who underwent the treatment have experienced an aggravation of their symptoms since the treatment; During the imaging follow-up, 1 case of recurrence and 1 case of endoleak occurred in this case series.

Conclusions: TICAs are associated with significant morbidity and mortality, and endovascular treatment has emerged as a valuable option, which may be promising to improve the clinical outcomes due to their advantages of preserving the parent artery if occlusion of the side branch artery can be avoided.

Endovascular management of internal carotid artery dissection with associated aneurysm using a multilayer flow modulator

Extracranial carotid artery dissection represents up to 22% of acute neurovascular disease in young patients. There are no specific guidelines regarding indication for endovascular management of carotid artery dissection with stenting and its complications. We describe three patients with carotid artery dissection and associated dissecting aneurysm who underwent endovascular stenting with the multilayer flow modulator. At 12-month follow-up, the dissecting aneurysms were resolved, and positive clinical outcome was achieved in all patients. Our results suggest that the multilayer flow modulator may be an alternative option for endovascular interventions in patients with carotid artery dissection and pseudoaneurysms because it favors laminar flow, and it may promote spontaneous healing of the wall by progressively reducing the vascular stress in the aneurysm wall. However, further studies are needed to confirm these findings.

Complications, outcomes, and management strategies of non-missile penetrating head injuries

OBJECTIVE

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors.

METHODS

Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed.

RESULTS

One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge.

CONCLUSIONS

The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Covered Stenting Is an Effective Option for Traumatic Carotid Pseudoaneurysm with Promising Long-Term Outcome

Objective

Covered stenting is an optional strategy for traumatic carotid pseudoaneurysm, especially in malignant conditions of potential rupture, but the long-term outcomes are not clear. Our aim was to determine if covered stenting is an effective option for traumatic carotid pseudoaneurysm with promising long-term outcomes.

Methods

Self-expanding Viabahn and balloon-expandable Willis covered stents were separately implanted for extra- and intracranial traumatic carotid pseudoaneurysm. The covered stent was placed across the distal and proximal pseudoaneurysm leakage under roadmap guidance. Procedural success was defined as technical success (complete exclusion of the pseudoaneurysm and patency of the parent artery) without a primary end point (any stroke or death within 30 days after the procedure). Long-term outcomes were evaluated as ischemic stroke in the territory of the qualifying artery by clinical follow-up through outpatient or telephone consultation and as the exclusion of the pseudoaneurysm and patency of the parent artery by imaging follow-up through angiography.

Results

Five patients with traumatic carotid pseudoaneurysm who underwent covered stenting were enrolled. The procedural success rate was 100%. No ischemic stroke in the territory of the qualifying artery was recorded in any of the five patients during a mean clinical follow-up of 44±16 months. Complete exclusion of the pseudoaneurysm and patency of the parent artery were maintained in all five patients during a mean imaging follow-up of 39±16 months.

Conclusion

Satisfactory procedural and long-term outcomes were obtained, suggesting that covered stenting is an effective option for traumatic carotid pseudoaneurysm.

Εndovascular Repair of Extracranial Carotid Artery Aneurysms: A Systematic Review

OBJECTIVE

Both true and false extracranial carotid artery aneurysms (ECAA) are a potential source of morbidity and mortality. While ECAA have historically been treated surgically, endovascular reconstruction with stenting is an emerging treatment option. The aim of our study was to report clinical/radiologic outcomes following endovascular repair of ECAAs.

METHODS

A comprehensive systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 68 case reports and case series, comprising 162 patients, were included. Most patients presented with at least one symptom or sign related to the ECAA (89.5%; N = 145/162). In 42.6% (N = 69/162) and 46.3% (N = 75/162) of the cases polytetrafluoroethylene covered and uncovered stents were deployed respectively. Immediate post-procedural imaging demonstrated complete aneurysm exclusion in 86.4% (N = 140/162) of the cases and minimal filling of the aneurysm sack in 10.5% (N = 17/162) of all cases. Perioperative adverse event rates were 3.1% for stroke, 1.2% for transient ischemic attack (TIA) and 4.3% for mortality. During a mean follow-up of 21.8months, there were additionally observed one stroke, two TIAs and three deaths. Overall 88.6 % of the patients (N = 117/132) remained asymptomatic, partially recovered or at least did not suffer from new neurologic deficits during follow up, with no signs of stenosis or occlusion of the carotid artery.

CONCLUSIONS

Endovascular stenting for the treatment of ECAAs is feasible with acceptable short- and long-term clinical and radiologic outcomes. Prospective real-world studies are needed to further validate the safety and the long-term patency of endovascular repair.

Contemporary Strategies in the Management of Civilian Neck Zone II Vascular Trauma

Neck trauma is the leading cause of death mainly in younger persons posing to surgeons the dilemma whether to proceed with reconstruction of vascular injuries either in the presence of coma or in severe neurological deficit. Vascular injuries in zone II predominate over the other injuries located in zones I/III of the neck. Conventional open repair of carotid injuries with primary closure or interposition grafting is always recommended due to the effective long-term results for penetrating injuries or for patients unfit for endovascular intervention. In cases of blunt trauma, anticoagulation or antiplatelet therapy should be administered first in neurologically stable patients. In case of worsening of the neurological status of the patient despite adequate anticoagulation endovascular means should be considered in cases of appropriate anatomy of the arterial trauma. We provide an update on penetrating/blunt trauma in zone II of the neck, giving emphasis on the anticoagulant and endovascular treatment.

Flow-diverting Stent in the Treatment of Cervical Carotid Dissection and Pseudoaneurysm: Review of Literature and Case Report

BACKGROUND

The endovascular technique has been recommended over the past few years to extracranial carotid dissection and pseudoaneurysm with promising results, especially after medical therapy failure. Flow-diverting stents are an alternative for complex cases. These stents have proven to be effective treatment devices for intracranial aneurysms.

METHODS

The reference list of Pham's systematic review, published in 2011, and Seward's literature review, published in 2015, was considered, as well as all new articles with eligible features. Search was conducted on specific databases: MEDLINE and Literatura Latino-Americana e do Caribe em Ciências da Saúde.

RESULTS

For carotid dissection and pseudoaneurysm, our review yielded 3 published articles including 12 patients. The technical success rate of flow-diverting stent was 100% with no procedural complication described. Mean clinical follow-up was 27.2 months (range 5-48), and in 5 months' angiographic follow-up, all lesions had healed. No new neurological events were reported during the clinical follow-up.

CONCLUSIONS

Flow diverter stent use on intracranial and peripheral vascular surgery demonstrates satisfactory initial results, but it is still under investigation. There are very few cases treated till now and the initial results with flow-diverting stents to cervical carotid dissection are promising. In well-selected cases, where simple embolization or conventional stent is not appropriate, this technic may be considered.

Endovascular stenting for extracranial carotid artery aneurysms: Experiences and mid-term results

The aim of this study was to investigate the safety and effectiveness of endovascular stenting for extracranial carotid artery aneurysms (ECAAs) and evaluate the mid-term outcomes.Twelve consecutive symptomatic patients (mean age 43.8 ± 14.9 years; 8 men) with ECAAs who were treated with endovascular stenting between 1997 and 2015 were retrospectively analyzed. Clinical follow-up data including symptoms and neurological events were obtained from outpatient records. Imaging follow-up with duplex ultrasound and/or computed tomographic angiography (CTA) was performed to examine the aneurysm obliteration and patency of the stents at 3, 6, 12 months and yearly thereafter.A total of 5 true aneurysms and 7 pseudoaneurysms were included in our series. Neurological symptoms (n = 5, 41.7%) and a pulsatile neck mass (n = 5, 41.7%) were the most common presenting symptoms. Endovascular stenting procedures were technically successful in all cases; 3 patients received bare stents, and 9 patients received covered stents. No perioperative neurologic or cardiopulmonary complications occurred. Over a period of follow-ups (mean 21.8 ± 25.1 months), all patients were alive and free from neurological or other adverse events. All aneurysms were completely excluded except for 1 patient who was exposed to a residual medium leaking into the aneurysm sac. No reintervention was performed in this specific patient because aneurysm growth or significant clinical symptoms did not occur. Recurrent restenosis assessed by CTA imaging at 12 months occurred in 1 (8.3%) patient in our series. Target lesion revascularization for this hemodynamic restenosis was treated with placement of an additional stent.In our series, endovascular stenting for ECAAs was found to be safe, effective, and proved to have promising mid-term results. Although long-term results need to be further explored, advantages including less procedure-related complications and a shorter recovery time make endovascular stenting an attractive option for ECAAs, especially for the patients who are unfit for traditional open surgery.

Spontaneous Arteriovenous Fistula of the Vertebral Artery

Three cases of spontaneous arteriovenous fistulas of the vertebral artery (VAF) are reported. In one case the only symptom was a cervical bruit; in the other two cases, symptoms of multiple cervical radiculopathy were also observed. Definitive diagnostic findings were obtained by Doppler ultrasonography, computed tomography, magnetic resonance imaging, and angiography. Clinical signs of radiculopathy disappeared after endovascular balloon occlusion of the fistula, in about 1 month. In one case the vertebral artery was occluded without clinical consequences.

Percutaneous Management of Concomitant Post-Traumatic High Vertebrovertebral and Caroticojugular Fistulas Using Balloons, Coils, and a Covered Stent

Purpose:

To describe the endovascular management of vertebrovertebral and caroticojugular fistulas in the same patient using a combination of endovascular techniques including covered stent placement in the high extracranial internal carotid artery.

Case Report:

A 22-year-old man presented with ipsilateral vertebrovertebral and caroticojugular fistulas at the C1 level several weeks after sustaining a solitary penetrating knife injury below the right ear. The right vertebral artery was sacrificed after a failed endovascular attempt to close the vertebrovertebral fistula. The caroticojugular fistula was treated with a self-expanding covered stent (Wallgraft) with exclusion of the fistula and preservation of flow through the carotid artery.

Conclusions:

Preservation of the extracranial arteries should be the preferred goal of treatment in traumatic extracranial arteriovenous fistulas. The use of covered stents in the extracranial vessels can accomplish this goal.

Endovascular treatment of traumatic internal carotid artery pseudoaneurysm

INTRODUCTION

Traumatic internal carotid artery pseudoaneurysm (TICAP) is the most common cause of stroke in young adults. The treatment of TICAP with open surgery poses excess risk, thus during last decade endovascular treatment strategies have been applied.

AIM

To assess the efficacy and the existing experience of endovascular treatment of TICAP.

METHODOLOGY

A systematic review of the literature was undertaken to identify all reported cases of endovascular treatment of TICAP from 1998 to 2015 in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials.

RESULTS

A total of 193 patients (139 males, 75%) with mean age of 30.8±2.2 years in 23 case studies, were treated for their TICAP with endovascular treatment. The main causes of TICAP were road traffic accidents 51%, assaults 12%, fall from height 8% and other miscellaneous causes were 29%. In 8/23 studies, the patients were operated emergently, in 9/23 at least 1 month after the carotid injury, and in 6/23 the time between the injury and the operation was not reported. The total success rate of pseudoaneurysm occlusion was 84% (162/193). The reported peri-procedural morbidity rate was 6% (11/185; 3 TIA, 7 strokes and 1 subclavian artery dissection), and the peri-operative mortality rate was 1.2% (2/162). Most patients received post-operatively antiplatelet therapy (either single or dual) and the duration of the administration ranged from 3 months to long term. During their follow up (ranging from 4 days to 13 years) only 6 patients required re-intervention, and this was undertaken with endovascular approach.

CONCLUSION

Endovascular therapy tends to be an effective option for the treatment of TICAP with low morbidity and mortality rates.

Use of Pipeline Embolization Devices for treatment of a direct carotid-cavernous fistula

BACKGROUND

The use of minimally porous endoluminal devices (MPEDs) such as the Pipeline Embolization Device (PED) has been described for the treatment of brain aneurysms. The benefit of using MPEDs to assist embolization of a direct high-flow carotid cavernous fistula resulting from a ruptured cavernous carotid artery aneurysm is not well documented.

METHODS

We describe our experience with deploying a tailored multidevice PED construct across the cavernous internal carotid artery (ICA) wall defect in combination with transarterial coil embolization using the "jailed microcatheter" technique.

RESULTS

A 59-year-old woman presented with acute left-sided ophthalmoplegia. Diagnostic cerebral angiography demonstrated a ruptured giant cavernous carotid aneurysm with fistulous outflow via the ipsilateral left superior ophthalmic vein and into the pterygoid venous plexi bilaterally. Via the Marksman microcatheter, a total of three PEDs measuring 4.5 mm × 18 mm, 4.5 mm × 20 mm, and 4.75 mm × 16 mm were telescoped within the ICA across the aneurysm neck. Coiling of the aneurysm fundus and cavernous sinus via the "jailed" Rapidtransit microcatheter was subsequently achieved. A 2-year follow-up digital subtraction angiography (DSA) demonstrated stable obliteration of the aneurysm and the fistula, coincident with complete resolution of the patient's symptoms.

CONCLUSIONS

Based on our long-term clinical and angiographic results, we advocate that the presented method be a valid treatment option for selected cases.

Contribution of Antemortem Computed Tomography Findings to Cause of Death Determination: An Unusual Fatal Stroke

In the case reported here, the antemortem computed tomography scan (CT scan) was essential in the forensic investigation. A 32-year-old man was found fully awake with a facial abrasion, after what seemed to be a car accident. He lost consciousness suddenly one hour after initial management. Successive CT scan showed a facial fracture and a metallic foreign body in the carotid canal associated with an occlusion/dissection of the left internal carotid, a pseudoaneurysm, and a carotid-cavernous fistula. The victim died from a stroke. Autopsy confirmed that the facial abrasion was a gunshot entrance wound, the metallic foreign body being a projectile. Intracranial vascular injuries linked with gunshot wounds are most of the time isolated and due to pelet embolism. The observed vascular injury association has never been described in the existing literature. The CT scan provided a better understanding of the chronology of events that led to death.

Endovascular embolization is applicable for large and giant intracranial aneurysms: experience in one center with long-term angiographic follow-up

BACKGROUND

Endovascular treatment of large and giant intracranial aneurysms and long-term results of angiographic follow-up of these aneurysms treated endovascularly are not known currently.

PURPOSE

To investigate the outcome of endovascular treatment of large and giant aneurysms and the long-term angiographic follow-up results.

MATERIAL AND METHODS

A retrospective analysis of all patients with endovascular treatment of large and giant aneurysms between 1998 and 2009 was performed. There were 90 large or giant aneurysms treated with coiling alone, stent-assisted coiling, covered-stent deployment, or parent artery occlusion (PAO) in 88 patients (female/male, 54/34; age range, 23-92 years; mean age, 56 years).

RESULTS

Immediately after the initial endovascular embolization procedure, complete occlusion was achieved in 56.7%, near complete occlusion in 37.8%, and incomplete occlusion in 5.5%. The total periprocedural complication rate excluding subarachnoid hemorrhage (SAH)-induced vasospasm was 10.2% with a mortality rate of 2.3%. Follow-up angiography was performed in all of the aneurysms with the longest follow-up duration of 131 months. Among 38 aneurysms initially treated with coiling alone and 17 initially treated with stent-assisted coiling, 22 (57.9%) and four (23.5%) recurred, respectively, during follow-up. No recurrence occurred in aneurysms initially treated with covered-stent deployment or PAO. Aneurysm recurrence was predominantly seen in older and female patients, in larger aneurysms, and in aneurysms treated with coiling alone. Twenty-three aneurysms were successfully retreated endovascularly.

CONCLUSION

Endovascular intervention with coiling alone or stent-assisted coiling for large and giant cerebral aneurysms is not very effective, while covered stents are more promising. Better endovascular devices are needed to obtain more secure closure.

Extracranial Carotid and Vertebral Artery Dissection: A Review

Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.

Iatrogenic traumatic intracranial aneurysm after endoscopic sinus surgery

Iatrogenic traumatic intracranial aneurysms are rare, but their clinical impact is significant secondary to their risk of intracranial hemorrhage and in their frequent complexity in management. We report an adult patient with a history of chronic sinusitis who, while undergoing elective endoscopic polypectomy, suffered an iatrogenic injury to an A2 segment branch of the left anterior cerebral artery, resulting in a pseudoaneurysm. Management included endovascular coiling and a bicoronal craniotomy approach, using a split-thickness cranial graft and abdominal fat graft to repair the associated left cribriform plate defect.

Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm

The rarely occurring vertebrovertebral arteriovenous fistula (VVAVF) is characterized by abnormal direct communications between the vertebral artery or its branches and the neighboring venous system. We present our experience using a stent graft to occlude a chronic, traumatic VVAVF. A 40-year-old woman with dizziness and loud bruits from the occiput underwent digital subtraction angiography (DSA), which revealed a VVAVF with pseudoaneurysm at the C5-C6 level, with retrograde flow from the right vertebral artery. A stent graft was placed across the fistula after balloon dilation. The fistula and pseudoaneurysm disappeared immediately. After 9 months, the patient remained asymptomatic with a patent stent.

Contemporary management of combat-related vertebral artery injuries

BACKGROUND

Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations.

METHODS

A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected.

RESULTS

Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy.

CONCLUSION

VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Endovascular therapy for acute trauma: a pictorial review

The traditional role of radiology in the multidisciplinary approach to modern trauma care has been primarily diagnostic and noninvasive. With the advent of more sophisticated and faster imaging equipment, computed tomography has further entrenched its role as the workhorse of trauma imaging. However, the specialty has evolved over the years with various therapeutic techniques now part of the interventional radiology armamentarium. Several of these techniques have become essential for the management of critically ill trauma patients. This article provides an overview of the common imaging findings of vascular and solid organ trauma from head to toe and subsequent endovascular interventions in these critically ill trauma patients.

Bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage treated by staged coil trapping and covered stents graft

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

False traumatic aneurysms and arteriovenous fistulas: retrospective analysis

BACKGROUND

The purpose of this study was to analyze the incidence, clinical presentation, diagnosis, and treatment of false traumatic aneurysms and arteriovenous fistulas as well as the outcomes of the patients.

METHODS

A retrospective, 16-year survey has been conducted regarding the cases of patients who underwent surgery for false traumatic aneurysms (FTA) of arteries and traumatic arteriovenous fistulas (TAVF). Patients with iatrogenic AV fistulas and iatrogenic false aneurysms were excluded from the study. There were 36 patients with TAVF and 47 with FTA. In all, 73 (87.95%) were male, and 10 (12.05%) were female, with an average age of 36.93 years (13-82 years).

RESULTS

In 25 (29.76%) cases TAVF and FTA appeared combat-related, and 59 (70.24%) were in noncombatants. The average of all intervals between the injury and surgery was 919. 8 days (1 day to 41 years) for FTA and 396.6 days (1 day to 9 years) for TAVF. Most of the patients in both groups were surgically treated during the first 30 days after injury. One patient died on the fourth postoperative day. There were two early complications. The early patency rate was 83.34%, and limb salvage was 100%. There were no recurrent AV fistulas that required additional operations.

CONCLUSIONS

Because of their history of severe complications, FTA and TAV fistulas require prompt treatment. The treatment is simpler if there is only a short interval between the injury and the operation. Surgical endovascular repair is mostly indicated.

Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the literature

Background:

Covered stents are used endovascularly to seal arterial wall defects while preserving vessel patency. This report describes our experience with the use of covered stents to treat cervical pathology, and a review of the literature in regards to this topic is presented.

Case Description:

Two patients presenting with the carotid blowout syndrome and one patient with a vertebrojugular fistula were treated with covered stents. This allowed for preservation of the vessel and was a treatment alternative to cerebral bypass.

Conclusion:

Covered stents provide a viable means of preserving the cervical vessels in selected patients; however, long-term follow-up is necessary to determine stent patency and permanency of hemostasis.

Reconstructive endovascular treatment of intracranial aneurysms with the Willis covered stent: medium-term clinical and angiographic follow-up

Object

Placement of covered stents has emerged as a promising therapeutic option for cerebrovascular diseases. However, the medium- and long-term efficacy and safety of covered stents in the treatment of these diseases remain unclear. The purpose of this study was to evaluate the medium-term clinical and angiographic outcomes of covered stent placement for the treatment of intracranial aneurysms.

Methods

The authors' institutional review board approved the study. Thirty-four patients (13 females and 21 males; mean age 41.9 years) with 38 intracranial aneurysms were treated with the Willis covered stent. Clinical and angiographic follow-up were performed at 3 months, at 6–12 months, and annually thereafter. The initial procedural and follow-up outcomes were collected and analyzed retrospectively.

Results

Forty-two covered stents were successfully implanted into the target artery in 33 patients with 37 aneurysms, and 1 covered stent navigation failed in 1 patient. A complete aneurysm exclusion was initially achieved in 24 patients with 28 aneurysms, and a minor endoleak occurred in 9 patients with 9 aneurysms. Postoperatively, 2 patients died of complications related to the procedure. Angiographic and clinical follow-up data are available in 30 patients. The angiographic follow-up (17.5 ± 9.4 months [mean ± SD]) exhibited complete occlusion in 28 patients with 31 aneurysms, and incomplete occlusion in 2 aneurysms, with an asymptomatic in-stent stenosis in 3 patients (10%). The clinical follow-up (26.7 ± 13 months [mean ± SD]) demonstrated that 16 patients (53.3%) experienced a full recovery, and 14 patients (46.7%) improved. No aneurysm rupture, thromboembolic events, or neurological deficits resulting from closure of a perforating vessel by covered stent placement occurred.

Conclusions

Endovascular reconstruction with the Willis covered stent represents a safe, durable, and curative treatment option for selected intracranial aneurysms, yielding an excellent medium-term patency of the parent artery and excellent clinical outcomes.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

A traumatic pseudoaneurysm of the vertebral artery

Although uncommon, vertebral artery pseudoaneurysms harbour significant risk of embolic stroke and their presence should be considered in cases of blunt cervical trauma. We illustrate a case of a traumatically ruptured vertebral artery pseudoaneurysm treated with coil embolisation.

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.

Endovascular treatment of penetrating traumatic injuries of the extracranial carotid artery

PURPOSE

To describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the extracranial carotid artery.

MATERIALS AND METHODS

The clinical and angiographic features of 36 traumatic injuries of the carotid artery during a 12-year period were reviewed. There were 35 male patients (97.2%) and 1 female patient (2.8%) with an average age of 28.8 years (range 13-60 years). Of the 36 lesions of the carotid artery, 29 (80.6%) were the result of gunshot injury, and 7 (19.4%) were secondary to stab wounds. In 24 (66.7%) instances, the injury resulted in a pseudoaneurysm; in 7 (19.4%), in an arteriovenous fistula (AVF); in 4 (11.1%), in a dissection; and in 1 (2.8%), in inactive bleeding. All patients were treated with an endovascular approach using different techniques (balloon occlusion, embolization, or stent deployment).

RESULTS

Endovascular therapy resulted in documented lesion occlusion in 34 (94.4%) patients. Two patients declined any follow-up postprocedural imaging; however, they have remained asymptomatic. Clinical improvement was documented in 35 (97.2%) patients, and there was one procedure-related complication with fatal consequences.

CONCLUSIONS

In this series, endovascular techniques were an effective method of treatment. It was possible to use different endovascular reconstructive techniques or parent artery occlusion depending on the degree of vessel damage, with resolution of clinical symptoms and avoidance of surgery in most cases.

Interventional neuroradiological techniques for the treatment of aneurysms of the supra-aortic extracranial arteries

Aneurysms in the supra-aortic extracranial arteries are rare in neurovascular pathology. Conventional surgery is effective but technically demanding and successful endovascular repair is reported. We treated 5 patients with supra-aortic extracranial artery aneurysms at our hospital (mean age 53.8 years). There were 2 aneurysms of the common carotid artery, 1 of the extracranial internal carotid artery, 1 of the subclavian artery, and 1 located at the innominate artery. Four patients were symptomatic. The lesion was the result of trauma in 3 patients. The procedure was conducted using bare stent placement and coil embolization of the aneurysm in 2 patients, covered stent in 2 patients, and bare stent only in 1 patient. No periprocedural complications occurred. Follow-up angiography revealed asymptomatic stent thrombosis in a patient treated using a covered stent, but the remaining 4 patients showed successful treatment of the aneurysms with the parent arteries remaining patent. Follow-up clinical assessment ranged between 30 and 81 months. The patient with stent thrombosis died of unrelated pathology; the remaining patients did not experience aneurysm recurrence, hemorrhage, or distal thromboembolism.

Middle ear aneurysm treated with an innovative, vessel-preserving, aneurysm-occluding stent

Middle ear aneurysms are rare and difficult to treat. An innovative, parent vessel-preserving, aneurysm occlusion stent is a treatment alternative. It redirects blood flow away from the aneurysm, resulting in stasis within, and ultimate aneurysm thrombosis. Concurrent coiling is not needed with this stent, eliminating the risk of coils extruding or migrating, or acting as a nidus for infection in the middle ear. We review a successful treatment using this device.

Unstable stenosis of the internal carotid artery caused by a craniofacial nail-gun injury-case report-

A 30-year-old carpenter suffered accidental piercing of his jaw by a 3-inch nail from a nail gun. No neurological deficits were found on admission. Computed tomography showed that the tip of the nail had reached the foramen lacerum. Cerebral angiography revealed severe stenosis at the C(4) portion of the left internal carotid artery (ICA) and marked decrease in the flow of the distal ICA. He had developed right hemiparesis and sensory aphasia by the following morning. T(2)-weighted and fluid-attenuated inversion recovery magnetic resonance imaging showed a focal hyperintense signal in the left central region indicating cerebral infarction. Repeat angiography demonstrated that the antegrade blood flow from the occluded point on the admission day had partially resumed, and endovascular trapping of the ICA was successfully carried out. The nail was then removed safely without problematic bleeding. The patient suffered no additional deficit, and his sensory aphasia and right hemiparesis gradually improved. The fluctuating blood flow through the unstable stenosis of the ICA related to nail movement possibly caused the delayed cerebral infarction. To avoid the occurrence of such events, rapid treatment after necessary investigations is recommended in patients with craniofacial penetrating injuries that affect the ICA.

Endovascular treatment of epistaxis

Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Covered Stent Implantation for the Treatment of Direct Carotid-Cavernous Fistula and Its Mid-Term Follow-up

SUMMARY

Carotid-cavernous fistulas are abnormal arteriovenous communications either directly between the internal carotid artery and the cavernous sinus or between the dural branches of the internal and external carotid arteries. These fistulas predominantly present with ocular manifestations and they are treated mainly by endovascular techniques in most cases. A detailed review of the literature allowed us to make a complete analysis of the information available on the topic. We describe a case of a direct carotid-cavernous fistula occluded by endovascular implantation of a covered stent, showing the persistence of results after three years.