Dangerous Extracranial–Intracranial Anastomoses: What the Interventionalist Must Know

Abstract

The extracranial and intracranial circulations are richly interconnected at numerous locations, a functional connectivity which underlies their impressive capacity for adaptive plasticity in the setting of vasoocclusive disease. While evolutionarily beneficial, these connections can also result in inadvertent communication with the intracranial circulation during embolization of extracranial vessels, potentially resulting in stroke or cranial nerve palsy. While these anastomoses are always present to a certain extent, flow through them occurs under predictable circumstances, and thus embolization of the extracranial vasculature can be performed safely when knowledge of functional anatomy is combined with adherence to basic principles. Herein, we will review the anatomy of known extracranial–intracranial anastomoses and strategies for avoidance of unwanted intracranial embolization. We will also review the vascular supply to cranial nerves most at risk during common neurointerventional procedures, as well as blood supply to mucosal structures.

Effectiveness of protocolized management for patients sustaining maxillofacial fracture with massive oronasal bleeding: A single-center experience

“…[20] Embolic agents such as gelfoam may pass through the extracranialintracranial anastomoses, consequently causing embolic complications. [21] No major procedure-related complications were observed in our study.…”

“…The non-survivor group had signi cantly more patients with hypotension (62% vs. 8%; p < 0.001), higher incidence of CPR (85% vs. 8%; p < 0.001), and more units of packed red blood cells (PRBC) transfused within 24 hours (18 [13][14][15][16][17][18][19][20][21][22] vs. 6 [2][3][4][5][6][7][8][9][10][11][12]; p = 0.001) than the survivor group. Non-survivors were associated with higher incidence of head AIS score of > 3 (92% vs. 33%; p < 0.001), skull base fracture (100% vs. 64%; p = 0.011), GCS score of < 9 (100% vs. 50%; p = 0.003), and higher ISS (50 [43-57] vs. 29 ; p < 0.001).…”

Effectiveness of protocolized management for patients sustaining maxillofacial fracture with massive oronasal bleeding: a single-center experience

“…Microcoils and gelfoam pledgets are the embolic agents most frequently used for TAE in maxillofacial trauma [ 20 ]. Embolic agents such as gelfoam may pass through the extracranial–intracranial anastomoses, consequently causing embolic complications [ 21 ]. No major procedure-related complications were observed in our study.…”

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…Rapid advances in endovascular surgery have led to paradigm shifts in the management of cerebrovascular disease [1]. Increasing interventions of the anterior intracranial circulation for vascular malformation, aneurysm, and acute ischemic stroke (AIS) have prompted numerous studies centering on extracranial access and local anatomy of the internal (ICA), external (ECA), and common carotid arteries (CCA) [2][3][4][5][6]. Likewise, endovascular intervention in extracranial carotid disease has risen in popularity, with active investigation becoming increasingly centered on vascular anatomy in patient selection [7].…”

“…As technology and techniques continue to progress, many of the anatomical constraints historically deemed hostile to endovascular intervention have become manageable with advanced methods [1][2][3][4][5][6][7]. In this report we review anatomical considerations in the context of extracranial endovascular carotid intervention for non-traumatic disease and offer guidelines in patient selection and management.…”