Elsevier

Critical Care Clinics

Volume 15, Issue 4, 1 October 1999, Pages 811-829
Critical Care Clinics

ENDOVASCULAR THERAPY OF TRAUMATIC INJURIES OF THE INTRACRANIAL CEREBRAL ARTERIES

https://doi.org/10.1016/S0749-0704(05)70089-0Get rights and content

Traumatic injury to the intracranial arteries is an uncommon event but may have sudden and catastrophic consequences. These injuries may occur in a variety of clinical circumstances, including closed-head trauma, penetrating skull injury, inadvertent vascular injury during an extravascular operative procedure, and intravascular injury during angiography. Although catastrophic vascular injury such as carotid artery transection may result in early death at the time of severe head trauma, many traumatic intracranial arterial injuries present in a delayed fashion, making diagnosis and anticipation of treatment challenging. For a variety of reasons, including inaccessibility, urgency, and comorbid conditions, direct surgical treatment of these lesions may be difficult. As endovascular techniques have advanced over the past three decades, therapeutic intravascular embolization and occlusion have come to play an increasing role in the management of intracranial arterial injuries. Concurrently, advances in neurologic critical care have focused attention on monitoring and intervention in the prevention of secondary brain injury in these patients.

Section snippets

PATHOLOGY AND EPIDEMIOLOGY OF TRAUMATIC INTRACRANIAL ARTERIAL INJURIES

Traumatic injuries of the intracranial arteries can be divided into three main categories: dissections, aneurysms, and fistulas. Although there may be overlap between these categories regarding specific lesions, this is a useful distinction in terms of pathologic understanding and treatment planning.

History

Before the advent of CT and MR imaging, diagnostic angiography, usually via a cervical carotid artery puncture, was routinely used for neurodiagnostic purposes in the management of stroke and traumatic brain injury. The ability to treat lesions at the time of angiography has been considered advantageous since catheter-based techniques began to evolve in the 1970s. In fact, some of the earliest considerations of endovascular treatment involved traumatic intracranial arterial injuries. In 1971,

Subarachnoid hemorrhage from traumatic intracranial dissection.

A 42-year-old kickboxer was struck in the left temple during a practice match. He had malaise and headache until 1 week later when he developed sudden, severe headache with associated nausea and vomiting. The neurologic examination was unremarkable, but the head CT revealed extensive subarachnoid blood. Angiography revealed dissection of the intracranial left vertebral artery distal to the posterior inferior cerebellar artery (PICA) with pseudoaneurysm formation (Fig. 2A). He underwent

NEUROCRITICAL CARE ASPECTS OF ENDOVASCULAR TREATMENT

The principal goal of neurologic critical care in patients undergoing endovascular treatment is the prevention of secondary brain injury. Most patients who have traumatic intracranial arterial injuries have sustained some degree of traumatic brain injury, often severe, during the incident trauma. Others present with ischemia from a dissection or intracranial hemorrhage from a ruptured traumatic aneurysm. These patients are at risk for secondary ischemic insults to the brain that may occur from

SUMMARY

Traumatic intracranial arterial injuries represent uncommon complications of both closed-head injury and penetrating head trauma. These injuries include arterial dissections, pseudoaneurysms, and fistulas, both direct and indirect. Although these lesions may be identified while still asymptomatic, they usually present in a delayed fashion with intracranial hemorrhage, focal cerebral ischemia, or, occasionally, severe epistaxis. Endovascular therapy has assumed a major role in the management of

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    Address reprint requests to J. Claude Hemphill III, MD, Department of Neurology, Room 4M62, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110

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