Neurovascular injuries

Visish M Srinivasan MD (Dr. Srinivasan of Baylor College of Medicine Neurosurgery has no relevant financial relationships to disclose.)
Jacob Cherian MD (Dr. Cherian of Baylor College of Medicine Neurosurgery has no relevant financial relationships to disclose.)
Edward A M Duckworth MD (Dr. Duckworth, Director of Cerebrovascular and Skull Base Neurosurgery at Baylor College of Medicine, has no relevant financial relationships to disclose.)
Randolph W Evans MD, editor. (Dr. Evans of Baylor College of Medicine received honorariums from Allergan, Avanir, DepoMed, and Pernix for speaking engagements and honorariums from Alder, Lilly, and Promius for advisory board membership.)
Originally released June 15, 1998; last updated October 21, 2016; expires October 21, 2019

This article includes discussion of neurovascular injuries, spontaneous neurovascular injury, blunt trauma-related neurovascular injury, penetrating neurovascular injury, and traumatic arteriovenous fistulae. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Neurovascular injury to the vertebral, basilar, and carotid arteries can occur either extra- or intracranially and can manifest as an arterial dissection, pseudoaneurysm, fistula formation, and thrombosis or occlusion of the involved vessel. This article reviews the pathophysiological mechanisms and sequelae of these injuries, clinical presentation, modes of diagnosis, treatment strategies, and factors affecting prognosis. Primary methods of treatment include medical management and neuroendovascular intervention. Surgical options and current ongoing trials are also discussed.

Key points

 

• Neurovascular injuries can occur spontaneously or following minor or severe, blunt or penetrating trauma to the head and neck.

 

• A high index of suspicion is needed to diagnose vascular injuries accurately and in a timely manner because most patients are asymptomatic on presentation.

 

• Screening is recommended in patients with a head or neck injury and unexplained neurologic abnormalities, those with evidence of arterial bleeding, patients with specific spine, skull base, and facial fractures, and in severe closed head injuries.

 

• Screening can be accomplished using CT angiogram, MRI, MRA, and/or conventional cerebral angiography. Catheter angiography can allow for concurrent treatment of vascular injuries.

 

• Patients with neurovascular injuries are at risk for ischemic sequelae, and the primary treatment is antithrombotic or antiplatelet medications. For those patients who fail medical therapy or are not candidates, endovascular interventions are typically recommended.

Historical note and terminology

Neurovascular injury refers to damage to the major blood vessels supplying the brain, brainstem, and upper spinal cord, including the vertebral, basilar, and carotid arteries. These vessels are located both extra- and intracranially, and injuries can occur in either or both of these locations. Neurovascular injuries can manifest in multiple ways, including arterial dissection, pseudoaneurysm, fistula formation, and thrombosis or occlusion of the involved vessel. Vascular injuries can occur spontaneously or after either severe or mild forms of blunt or penetrating head and/or cervical trauma.

Historically, Ambroise Paré was the first to describe the successful treatment of a carotid artery injury in 1552 when he repaired a penetrating injury to the right common carotid artery caused by a sword. In 1798, John Abernethy ligated the common carotid artery of a man who suffered a bull gore injury to the neck. In 1803, a carotid artery laceration was repaired without neurologic deficit while at sea on the HMS Tonnant. The first reported case of a traumatic intracranial internal carotid artery aneurysm was found at autopsy by Guilbert in 1895. In the 1850s, Maisonneuve successfully ligated the vertebral artery at the transverse foramen after a stab wound to the neck (Charbel et al 2004). Autopsy findings of carotid artery dissections date back to the 1870s (Richaud et al 1980); however, it was not recognized as an etiology for stroke until the 1950s (Jentzer 1954). In the 1940s, Kubik and Adams first described basilar artery insufficiency secondary to basilar artery thrombosis, and a decade later Millikan and Siekert introduced the use of anticoagulation therapy for basilar artery thrombosis (Charbel et al 2004). Today most vascular injuries to the carotid artery or vertebral artery come from blunt injuries to the head or neck, or they are spontaneous in nature. Most blunt injuries are from motor vehicle accidents, and most penetrating injuries come from gunshot wounds (Fleming 1817; Guilbert 1895; Alleyne et al 2004).

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