False aneurysms of the intracavernous carotid artery--report of 7 cases

Iatrogenic pseudoaneurysm after surgery: Stay away from the evil. Case report and review of the literature

BACKGROUND

Intracranial pseudoaneurysms are rare and account for less than 2% of all intracranial aneurysms. They most frequently occur after head injury, but they also can be caused by iatrogenic arterial injury during neurosurgical or ENT procedures. No clear guidelines are established concerning the treatment and surveillance of such aneurysms.

METHODS

In this article, we present 2 cases of iatrogenic pseudoaneurysms treated conservatively and we propose a review of literature of the management and outcome of intracranial iatrogenic pseudoaneurysms.

CASE REPORT AND RESULTS

The first case is one during a transcranial approach and the second one during a transsphenoidal approach, that were both conservatively treated with a close follow-up and a spontaneous healing of the aneurysm.

CONCLUSION

Endovascular treatment or surgical clipping are 2 valid therapeutic options in iatrogenic pseudoaneurysms, which should be preferred when feasible with a reasonable risk. In contrast, in case of a small pseudoaneurysm, important risk and complex procedures, conservative treatment with a close follow-up appears to be a valuable alternative.

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.

Internal Carotid Artery Pseudoaneurysm in a Patient Presenting With Recurrent Epistaxis: A Case Report and Literature Review

Traumatic pseudoaneurysms are uncommon vascular lesions that can result from traumatic injuries to the nasal and facial areas. They pose a significant clinical challenge due to their potential to cause recurrent and life-threatening epistaxis. Understanding the underlying vascular anatomy, causes, and treatment options is essential for optimizing patient outcomes. In this case report, we present a 55-year-old man who developed a traumatic pseudoaneurysm of the sphenoid sinus, arising from the cavernous segment of the internal carotid artery following a traumatic incident. This case was successfully managed with stent-assisted coil embolization.

Recurrent epistaxis secondary to nasal haemangioma with a misleading CT angiogram

The majority of epistaxes are anterior in nature, resolve with simple first aid measures and require no further follow-up. However, some cases pose more of a diagnostic challenge and prove resistant to standard investigation and treatment. We present a case of recurrent epistaxis, refractory to multiple treatment modalities and with CT imaging suggestive of a vascular aetiology which was ultimately disproved. The case highlights the shortcomings of CT imaging and importance of thorough examination technique. Nasal haemangiomas are a rare but recognised cause of epistaxis and should be considered in refractory cases.

Surgical Treatment of Traumatic Intracranial Aneurysms: Experiences at a Single Center over 30 Years

OBJECTIVE

Traumatic intracranial aneurysm (tIA) is rare and is associated with high rates of morbidity and mortality. We describe our experiences with tIA at our institution.

METHODS

We retrospectively reviewed records from patients who underwent treatment for tIA between January 1986 and December 2015.

RESULTS

Data from 5532 patients with cerebral aneurysms between January 1986 and December 2015 were reviewed. Of these, 13 cases (0.23%) were tIA. Most occurred after blunt brain trauma (12/13; 92%). The most common location was the distal anterior cerebral artery (7/13; 53%) followed by the internal carotid artery (5/13; 38%). One patient had a tIA in the distal middle cerebral artery. Delayed intracerebral hemorrhage was the major presentation at the time of aneurysmal rupture (70%). Most patients underwent surgical treatment (10/12; 83.3%), which included clipping (5/10), trapping (3/10), aneurysmal excision and bypass (1/10), and aneurysmal excision and coagulation (1/10). In 2 cases, tIA located in the internal carotid artery was treated with coil embolization and detachable balloon occlusion, respectively. Most patients had good recovery (5/12; 41.7%); 3 patients and 1 patient had moderate and severe disability, respectively; 1 patient was in a vegetative state; and 2 patients died.

CONCLUSIONS

tIA is an uncommon complication of head trauma. tIA should be considered when unexpected new symptoms develop in patients with head trauma. Early diagnosis and prompt treatment could help to improve final clinical outcomes.

Cavernous Carotid Artery Pseudoaneurysm Following a Radical Cavernous Sinus Resection

Iatrogenic cavernous carotid pseudoaneurysms are a special group among other intracranial aneurysms. They can occur during the dissection phase of the surgery if the tumor encases a vessel. Complications of their rupture as hemorrhage or stroke are life threatening. Early recognition and treatment is mandatory to avoid catastrophic sequelae. We present the successful diagnosis and endovascular treatment of a postoperative cavernous carotid pseudoaneurysm following radical cavernous sinus resection.

Clinical Analysis of Traumatic Cerebral Pseudoaneurysms

Objective

Traumatic pseudoaneurysms are rare but life-threatening lesions. We investigated the patients with these lesions to clarify their clinical characteristics and therapeutic strategies and we also reviewed the literatures on the treatment principles, possible options, and outcomes.

Methods

There were a total of 8 patients who were treated with traumatic intracranial pseudoaneurysms between April 1980 and January 2009. Medical charts and the imaging studies were reviewed for analysis. The outcome was measured with modified Rankin Scale (mRS) score at 6 months after treatment.

Results

All 8 patients were male and the mean age was 25 years old. Six of those were located at the cavernous segment of the internal carotid artery (ICA) and the other 2 was located at the M2 segment of middle cerebral artery. The causes of trauma were car accidents in 6, penetrating injury through the orbit in 1, and slip down injury in 1 patient. Massive epistaxis or hematemesis occurred in all patients with a pseudoaneurysm at the cavernous and ophthalmic segment of the ICA. All 6 patients of the cavernous and ophthalmic ICA group showed favorable outcome of mRS 0 to 1. The outcome of patients with middle cerebral artery pseudoaneurysm was mRS 2 to 3.

Conclusion

Upon prompt diagnosis and proper treatment planning, it is possible to achieve favorable outcome in these patients. Lesions located at the cavernous segment of the ICA favored endovascular treatment while those at the middle cerebral artery favored surgical treatment.

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.

Management of carotid artery trauma

With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.

Evolution of management strategies for cavernous carotid aneurysms: a review

OBJECTIVE

Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.

METHODS

The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.

RESULTS

Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.

CONCLUSIONS

A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery: case report and review of the literature

Background Bioabsorbable plates are frequently utilized in the repair of skull base defects following transsphenoidal operations. Traumatic intracranial pseudoaneurysms are a rare complication of transsphenoidal surgery. To date, iatrogenic carotid pseudoaneurysm associated with the use of an absorbable plate has been reported once. Results A 57-year-old man with a large nonfunctional pituitary macroadenoma underwent an endoscopic transsphenoidal operation with gross total resection. An absorbable plate was placed extradurally to reconstruct the sellar floor. He experienced delayed repeated epistaxis, followed by a right middle cerebral artery distribution embolic stroke. Computed tomorgraphy (CT) angiogram 6 weeks postoperatively revealed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery. Stent coiling was used to successfully obliterate the pseudoaneurysm, and the patient fully recovered. Conclusion Delayed erosion of the carotid artery wall caused by a plate used to reconstruct the sellar floor may manifest with epistaxis or embolic stroke. The authors' preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence of intraoperative cerebrospinal fluid (CSF) leaks, unless it is required to buttress a large skull base defect. Short-segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations.

Carotid artery injury after endonasal surgery

Carotid artery injury during endonasal surgery is the most feared and catastrophic complication. Internal carotid artery injury is more frequent during skull base surgery, and risk factors include acromegaly, previous revision surgery, and prior radiotherapy and bromocriptine therapy. Nasal packing is frequently used to gain hemostasis, often resulting in vascular occlusion. Recent research recommends the crushed muscle patch treatment as an effect hemostat that maintains vascular patency. Endovascular techniques are recommended for vascular control and complication management. Coil or balloon embolization is preferred in patients with adequate collateral cerebral blood flow, and stent-graft placement or bypass surgery is indicated in those who do not.

Internal carotid artery pseudoaneurysm with life-threatening epistaxis as a complication of deep neck space infection

Pseudoaneurysm of the cervical internal carotid artery is a very rare, potentially fatal complication of a neck space infection in children associated with high mortality and morbidity. A 3-year-old boy presented with spontaneous massive epistaxis 45 days after a deep neck space infection caused by a peritonsillar abscess. During nasopharyngeal packing, he evolved with cardiac arrest. Intra-arterial angiography was then performed that revealed a large pseudoaneurysm. Endovascular treatment using detachable balloons achieved complete exclusion of the pseudoaneurysm. The child made an uneventful recovery and was discharged with mild left hemiparesis and no deficit of sensory or cognitive functions. Pseudoaneurysms of the internal carotid artery after a deep neck space infection can be associated with delayed and potentially fatal massive epistaxis. Furthermore, a regional (ie, extranasal) blood vessel should be promptly investigated when there are signs of hypovolemic shock. A high level of suspicion and definitive treatment are essential for successful management of these patients.

Bony protuberances on the anterior and posterior clinoid processes lead to traumatic internal carotid artery aneurysm following craniofacial injury

Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.

Endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis

Objective

To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis.

Materials and Methods

For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography.

Results

Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention.

Conclusion

In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.

Endovascular embolization of intracranial iatrogenic pseudoaneurysms. A report of two cases and review of the literature

Iatrogenic pseudoaneurysm is a rare but severe complication of intracranial surgery. Treatment of the condition is difficult. The purpose of this report is to draw attention to the fact that endovascular embolization of pseudoaneurysms with parent artery preservation is possible. We describe two cases of endovascular embolization and review the literature. The conclusion is that endovascular treatment can be safe and curative.

Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality

Arterial bleeding during transsphenoidal surgery for pituitary adenoma is known complication. This usually happens due to rupture of intracavernous carotid or delayed hemorrhage due to the carotico-cavernous fistula and/or pseudoaneurysm. There is also evidence that cavernous carotid aneurysms may occur with pituitary tumors, yet largest series failed to demonstrate any link between aneurysm formation and pituitary tumors. Usually such an aneurysm rupture results in formation of carotico-cavernous fistula. However, pituitary apoplexy and even epistaxis have been reported. In this paper we present a patient with recurrent pituitary adenoma and cavernous carotid artery aneurysm, which caused significant hemorrhage during the surgery. Although retrospective analysis of MRI disclosed that the patient had the aneurysm before the first surgery, it remained silent until the second operation. Therefore neurosurgeons should be very susceptive to any signal changes on preoperative MR images, especially in recurrent cases, where normal anatomical relations are disturbed by fibrotic tissue. Also, we reviewed the vascular complication of pituitary surgery based on the literature.

Common carotid artery pseudoaneurysm formation following foreign body ingestion

OBJECTIVE

To report an unusual case of pseudoaneurysm formation following ingestion of a thin wire.

METHOD

Case report, including management, and review of the world literature concerning pseudoaneurysm and its management.

RESULTS

A 15-year-old boy presented as an emergency with a two-week history of painful swallowing, and a one-week history of a progressively enlarging, right-sided swelling of the lower neck. A foreign body had been ingested two weeks previously. Radiological investigation showed a pseudoaneurysm of the right common carotid artery. The neck was explored, the foreign body removed and the common carotid artery repaired. The patient was discharged on the 10th post-operative day without neurovascular complication.

CONCLUSION

This is an unusual presentation of pseudoaneurysm of the common carotid artery following accidental ingestion of a foreign body, reported for its rarity and management.

Massive epistaxis resulting from an intracavernous internal carotid artery traumatic pseudoaneurysm: complete resolution with overlapping uncovered stents

Blunt traumatic injuries of the intracranial carotid arteries can result in pseudoaneurysm formation. A pseudoaneurysm of the intracavernous carotid artery may rupture into the cavernous sinus, causing life-threatening epistaxis. We report a case of intracavernous traumatic psedoaneurysm presenting with delayed massive epistaxis. The endovascular treatment with overlapping self-expanding stents achieved complete exclusion of the pseudoaneurysm with preservation of the intracavernous carotid artery.

Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management

OBJECTIVE

We report a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery.

METHOD

The management of this unusual complication and a review of the literature are presented.

RESULTS

A 65-year-old woman presented with intractable epistaxis four days following endoscopic sphenoid sinus surgery. Initial, conservative measures were unsuccessful in controlling bleeding. The clinical picture of delayed, severe epistaxis after a sphenoid sinus exploration raised the possibility of injury to the internal carotid artery and subsequent formation of a false aneurysm. The patient's pseudoaneurysm was managed, without visualising it, by packing the sphenoid sinus (achieved by palpating 1 cm above the shoulder of the posterior choana) in order to gain control of the haemorrhage, followed by endovascular occlusion.

CONCLUSION

An awareness of this rare complication is essential in order to manage this life-threatening condition efficiently.

Traumatic carotid cavernous fistula concomitant with pseudoaneurysm in the sphenoid sinus

SUMMARY

This study was designed to elucidate the generating mechanism, diagnosis and treatment of traumatic carotid cavernous fistula (tCCF) concomitant with pseudoaneurysm in the sphenoid sinus. Six cases of tCCF concomitant with pseudoaneurysm in the sphenoid sinus were analyzed in this study. Clinical history, neurological examination, CT and MRI scans, pre- and postembolization cerebral angiograms and follow-up data were included. All patients presented with massive epistaxis and symptoms of tCCF. The pseudoaneurysms and fistulas were occluded with detachable balloons, and preservation of the parent artery in two cases. One patient also had indirect carotid cavernous fistula (CCF) on the contralateral side embolized by transfacial vein approach with microcoils. Complete symptom resolution was achieved in all cases, without procedure related complications. During the follow-up period all patients returned to work. Falling from a high speed motorcycle without wearing a helmet may be one of the main causes of this disease. The site of impact during the accident mostly localizes in the frontal and lateral of the orbit. Intracavernous sinus hypertension of tCCF combining with fracture of the lateral wall of the sphenoid may lead to the formation of a pseudoaneurysm in the sphenoid sinus. MRI scan is very helpful in the diagnosis of this disease before the patient receives angiography. Detachable balloon occlusion of the pseudoaneurysm and fistula is a safe and efficient treatment.

Pericallosal artery pseudoaneurysm secondary to endoscopic-assisted ventriculoperitoneal shunt placement. Case report

Complications following cerebrospinal fluid (CSF) diversion procedures are protean. The formation of pseudoaneurysms after the placement of a ventricular catheter as part of a CSF diversion procedure is presumably quite rare. The authors report the case of a child in whom a pericallosal artery pseudoaneurysm developed following the endoscopic insertion of a ventricular catheter as part of a ventriculoperitoneal shunt placement procedure. Significant intraventricular bleeding signaled vascular injury. Angiography revealed a right pericallosal artery pseudoaneurysm. The patient subsequently underwent surgical trapping of his pseudoaneurysm and physical therapy for left leg monoparesis. This appears to be the first reported case of pseudoaneurysm formation following the placement of a ventricular catheter for a CSF diversion procedure. This case underlines a rare but serious risk involved with the routine placement of CSF shunts.

Cavernous carotid artery pseudo-aneurysm treated by stenting in acromegalic patient

We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance.

Growing blood clot mimicking an aneurysm on postoperative computerized tomography and magnetic resonance imaging studies. Case report and review of the literature

The authors describe the case of a 15-year-old boy who underwent resection of a large left temporal tumor. During a normal postoperative course, computerized tomography (CT) scanning demonstrated a spherically hyperdense structure near the internal carotid artery, enlarging on a control CT scan. A suspected false aneurysm was confirmed on magnetic resonance imaging; angiographic studies were negative. The authors believed they were dealing with a thrombosed false aneurysm and they performed operative revision. Intraoperatively the "aneurysm" could be dissected off the internal carotid artery and no lesion of the arterial wall was obvious. Histological findings showed a fresh blood clot. This case demonstrates that a blood clot may mimic an aneurysm on CT and magnetic resonance studies, which has not been described earlier. The origin of the blood clot remains unclear.

Traumatic intracranial carotid tree aneurysms

OBJECTIVE

This study was designed to elucidate the requirements for angiographic evaluation in blunt head injuries, the timing of angiography, and the selection of appropriate therapeutic approaches.

METHODS

Twelve cases of traumatic aneurysms (TAs) in the intracranial carotid tree were analyzed in this study. Neurological examination results, computed tomographic scans, pre- and postembolization cerebral angiograms, and follow-up data were included.

RESULTS

In 11 of 12 cases, TAs were of cranial base origin; in 1 case, the aneurysm was located in the distal anterior cerebral artery. In seven of the cases with cranial base lesions, aneurysms were located in the intracavernous segment of the internal carotid artery; all of the computed tomographic scans for these cases demonstrated sphenoid sinus wall fractures and hematoma in the sphenoid sinus. In two cases, although the initial angiograms revealed no lesions, a second study performed 2 weeks later demonstrated the presence of aneurysms. Nine of the aneurysms were treated with endovascular techniques, two were managed conservatively, and the remaining one patient died with massive epistaxis while awaiting surgical treatment. No morbidity or additional permanent neurological deficits occurred in the endovascularly treated patient group.

CONCLUSION

Patients with head trauma who present with sphenoid sinus fractures and massive epistaxis should be evaluated for the development of TAs as soon as possible. If the patients exhibit fractures without epistaxis, angiography should be deferred for 2 to 3 weeks; if the first angiographic evaluation reveals normal findings, repeated epistaxis should prompt a second angiographic evaluation. Current treatment of TAs involves occlusion of the main artery through the use of endovascular techniques. Cases involving internal carotid artery TAs of cranial base origin and patients who do not tolerate test occlusion require extracranial-to-intracranial bypass surgery.

Long-term graft patency rates and clinical outcomes after revascularization for symptomatic traumatic internal carotid artery dissection

INTRODUCTION

Surgical management of traumatic internal carotid artery (ICA) dissection remains controversial. Therefore, the delayed outcomes and graft patency rates of patients who underwent bypass procedures for symptomatic traumatic ICA dissection were studied.

METHODS

Between September 1989 and August 1996, 13 patients (9 male and 4 female patients; mean age, 30.6 yr) underwent 16 revascularization procedures for symptomatic traumatic ICA dissection. The duration of clinical follow-up averaged 47.3 months (range, 12-94 mo) from the date of diagnosis. The duration of radiographic follow-up (catheter or magnetic resonance angiography, duplex Doppler ultrasonography) averaged 24 months (range, 12-60 mo).

RESULTS

ICA dissection was caused by blunt (n = 11) or penetrating trauma (n = 2). Associated angiographic abnormalities included seven ipsilateral ICA occlusions, six dissecting aneurysms, two carotid-cavernous fistulae, and six contralateral traumatic ICA dissections. Patients requiring early revascularization (n = 6) underwent bypass procedures an average of 19.2 days after their injuries. Medically managed patients who developed ischemia later were revascularized a mean of 7.8 months after injury. The mean Glasgow Coma Scale score at the time of presentation was 10 (range, scores of 6-15), and the mean Glasgow Coma Scale score before revascularization was 14 (range, scores of 9-15). There were 14 saphenous vein ICA bypasses (8 cervical-to-petrous, 3 cervical-to-middle cerebral artery, 3 petrous-to-supraclinoid) and 2 superficial temporal artery-to-middle cerebral artery bypasses. There was one early postoperative graft occlusion, which responded to surgical thrombectomy. One patient with multiple other traumatic injuries died as a result of a pulmonary embolus 12 months after revascularization. All remaining patients had Glasgow Outcome Scale scores of 5, with patent bypass grafts confirmed during follow-up.

CONCLUSION

Revascularization for persistently symptomatic traumatic ICA dissection eliminated ischemia and was associated with excellent long-term outcomes and graft patency rates.