Endovascular therapy for cerebrovascular injuries after head and neck trauma

Abstract

Cerebrovascular injuries after blunt or penetrating head and neck trauma often lead to significant disability from ischemic stroke, hemorrhagic stroke and uncontrolled extracranial hemorrhage. Trauma causes carotid or vertebral dissection, occlusion, pseudoaneurysm, arteriovenous fistula, vessel transection, traumatic epistaxis, venous sinus thrombosis and carotid cavernous fistula. The rapid development of neuroendovascular techniques over the past two decades has led to effective therapies for each of these injuries. Controlled lesion embolization may use coils, liquid embolics (onyx or n-butyl cyanoarcrylate), polyvinyl alcohol particles or detachable balloons; there is stent angioplasty with uncovered, overlapping and covered stents or mechanical thrombolysis using stent-retrievers or aspiration catheters and the use of balloon occlusion tests and supraselective angiography to delineate safety of vessel sacrifice and to diagnose occult lesions respectively. Furthermore, the proliferation of stroke centers has increased local availability of rapid neuroendovascular expertise at many major trauma centers. Neuroendovascular therapies are less invasive than surgery, can often preserve the injured parent vessels and aid in treating conditions where surgery may be limited. In the absence of randomized controlled trials we present a narrative review of current endovascular therapeutic applications for each of these injuries. This expands the therapies at trauma teams' disposal in the continued effort to control bleeding, reduce secondary injury and prevent disability after trauma. Further research is necessary to inform the role of endovascular techniques after trauma. In particular, comparative studies are necessary to quantify the risk and benefits in conditions where surgical options also exist.

Trends and outcomes in the management of vascular trauma: institutional experience at a level 1 trauma center

“…Alderazi et al demonstrate the significant impact of vascular injuries in the neck, with high mortality and significant morbidity secondary to stroke, both haemorrhagic and ischaemic. 22 Our findings are consistent with this, with a mortality rate of 17.8%. Neck trauma also had the highest rate of non-operative management, which likely reflects vertebral artery injuries often being managed non-operatively, as well as often non-survivable injuries to the cervical vasculature and other associated injuries.…”

“…Neck trauma also had the highest rate of non-operative management, which likely reflects vertebral artery injuries often being managed non-operatively, as well as often non-survivable injuries to the cervical vasculature and other associated injuries. 22,23 Thoracic vascular injuries are often devastating, with an extremely high mortality rate reported in the literature. 24 Thoracic aortic trauma has been suggested as the 2 nd most common cause of death in trauma, behind only intracranial injury.…”

Acute Management of Iatrogenic Injury to Vertebral Artery With Central Venous Catheter in a Critically Ill Patient

“…Resorting to open surgical repair was associated with a mortality rate of 6.93% in a retrospective review of VA injuries involving 101 patients (92 penetrating injuries, three iatrogenic, and one blunt trauma). In cases of injury to surrounding structures, failed endovascular intervention, expanding hematoma, airway obstruction, active/uncontrolled bleeding or hemodynamic instability the patient should be considered for immediate surgery [ 7 - 8 ]. In a retrospective study Hatzitheofilou et al reported a 20% mortality rate in 20 patients who underwent emergency neck exploration following VA injury, with all deaths occurring in unstable patients who were in shock upon arrival [ 9 ].…”

Locked-In Syndrome Following Cervical Manipulation by a Chiropractor: A Case Report

“…Stenting of the vertebral artery is another therapeutic approach. Roth et al, ( 2010) reported an improvement in the NIHSS of > 10 points, and 50% of patients showed an mRS < 2 at 90 days after stent-assisted mechanical recanalization [2,3,5,6,7,8].…”