Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

Delayed treatment of a traumatic left subclavian artery pseudoaneurysm

A 22-year-old man sustained 4 gunshot wounds to the upper torso resulting in left pneumothorax, an expanding right neck hematoma, left humerus fracture, a traumatic arteriovenous fistula from the right subclavian artery to the right brachiocephalic vein, and pseudoaneurysm formation from partial transection of the right subclavian artery. The patient underwent emergent repair of the confluence of the right internal jugular, subclavian and brachiocephalic veins, and laparotomy secondary to compartment syndrome. Seven weeks later, with the pseudoaneurysm enlarged to 6 cm, it was repaired with combined access via the right common femoral artery and right brachial artery. The pseudoaneurysm was covered with a 7 mm x 8 cm fluency-covered stent graft and postdilated with a 7 mm x 4 cm balloon. Postoperatively, the patient had palpable pulses, occlusion of the pseudoaneurysm, and excellent blood flow into the arm.     

Vertebral arteriovenous fistulae. Report of two cases and review of the literature

Summary Two patients with vertebral arteriovenous fistulae were treated at the Neurosurgical Clinic of the City Hospital of Hannover between 1981 and 1988. Both patients were males, 19 and 29 year old. The fistulae were secondary to cervical gunshot wounds. Both patients complained of a loud cephalic noise; 1 patient had a non pulsating neck mass. A systolic cervical bruit was heard in both cases. One patient had an incomplete mid-cervical Brown-Sequard syndrome. The fistulae involved the second portion of the vertebral artery; 1 fistula was fed, in addition to the vertebral artery, by the deep cervical artery. Venous drainage was through intraspinal plexus, vertebral vein, deep cervical veins and internal jugular vein. One patient was treated with a direct surgical trapping of the vertebral artery proximal and distal to the fistula; the other patient, in addition to direct surgical vertebral artery trapping, received an endovascular balloon occlusion of the deep cervical artery. After treatment the fistulae disappeared, both clinically and angiographically.Dr. Mario Ammirati is a recipient of a fellowship from the Alexander von Humboldt Foundation, Bonn, FRG.     

Haemodialysis catheter-related right transverse cervical artery pseudoaneurysm and treatment by coil embolization

In patients with end-stage renal disease, temporary placement of venous catheters for haemodialysis (HD) is often necessary, and the right internal jugular (RIJ) vein is the usual preferred site of HD catheter placement. We report here a patient who experienced complications because of the development of a pseudoaneurysm of the transverse cervical artery following an apparently uneventful RIJ vein cannulation for temporary HD, using the blind landmark-guided technique. This is a rare complication of RIJ vein cannulation and HD catheter placement. The pseudoaneurysm presented 3 weeks after the procedure and was diagnosed by using colour-Doppler ultrasound, followed by an angiogram, and it was successfully occluded using endovascular coil embolization.     

Traumatic vertebro-vertebral arteriovenous fistula manifesting as radiculopathy. Case report

A 58-year-old man presented with a traumatic vertebro-vertebral arteriovenous fistula (VVAVF) after attempting suicide by thrusting scissors into his right anterior cervical region. Two months later he noticed weakness and numbness of the right upper extremity. Examination revealed bruit in the right neck, no cranial nerve palsy, and weakness of the right deltoid and biceps muscles. Hypalgesia and hypesthesia were noted in the right C5 and C6 dermatomes. Magnetic resonance imaging demonstrated a mass lesion on the right ventral aspect of the spinal canal from C2 to C7. Right vertebral artery angiography showed a pseudoaneurysm of the right vertebral artery and a high-flow arteriovenous fistula between the right vertebral artery and vein. The right vertebral artery was occluded with detachable coils because the fistula showed high blood flow and the right posterior inferior cerebellar artery was well opacified from the left vertebral artery. This procedure resulted in complete obliteration of the arteriovenous fistula. The preoperative motor and sensory symptoms improved. Endovascular treatment by coil embolization was effective in our patient with traumatic VVAVF.     

Transverse cervical artery pseudoaneurysm: a rare complication of internal jugular vein cannulation

Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization. Internal jugular vein catheterization is associated with a high rate of successful catheter placement. However, significant complications such as internal carotid artery (ICA) puncture, pneumothorax, vessel erosion, thrombosis, airway obstruction and infection can occur. The most common complication is ICA puncture. More recently a few cases of thyrocervical trunk pseudoaneurysm and fistula following internal jugular vein and subclavian vein catheterization attempts have been reported. Patients with renal failure who are on hemodialysis may have to undergo multiple catheter placements and vascular access interventions. This, along with their comorbid conditions, increases the risk of such complications. Here we report a patient on hemodialysis who developed transverse cervical artery pseudoaneurysm following an attempted right internal jugular vein catheterization. We report this case because of its rarity, to raise awareness of such a complication and to discuss different treatment options, in particular endovascular coil occlusion. A review of relevant literature is also presented.     

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.     

Endovascular treatment of false aneurysm of the thyrocervical trunk

The thyrocervical trunk is the second superior branch off the subclavian artery. Pseudoaneurysm of the thyrocervical trunk has been reported after attempted internal jugular vein cannulation for central venous or hemodialysis access. The treatment of pseudoaneurysms of the thyrocervical trunk depends on the findings from color flow Doppler ultrasonography and angiography. Although pseudoaneurysms of the thyrocervical trunk are rare, the treatment options should be clear. Surgical ligation is an effective technique that is safe and well-defined, but control through a cervical incision may be difficult. Endovascular treatment of the pseudoaneurysm may be accomplished with coil embolization of the artery, which is described.     

Carotid artery pseudoaneurysm following internal jugular vein cannulation

A case of right common carotid artery pseudoaneurysm following internal jugular vein cannulation is reported. The aneurysm appeared three days after removal of the catheter, which had been in the right internal jugular vein for three weeks. There was a pin-hole communication between the common carotid artery and the pseudoaneurysm, which was successfully obliterated by surgery. Carotid pseudoaneurysm formation is a rare complication of internal jugular vein cannulation, and there has been no report of its formation after apparently successful jugular vein cannulation. This complication is difficult to predict, and careful observation after removal of the catheter is mandatory.     

Traumatic pseudoaneurysms of the head and neck: early endovascular intervention

BACKGROUND: Trauma to the head and neck with military munitions often presents with complex multisystem injury patterns. Vascular evaluation typically focuses on the carotid and vertebral arteries; however, trauma to branches of the external carotid artery may also result in devastating complications. Pseudoaneurysms are the most frequent finding on delayed evaluation and can result in life-threatening episodes of rebleeding. METHODS: Patients evacuated from the Afghanistan and Iraq conflicts with penetrating injury to the face and neck were evaluated by the vascular surgery service to determine the potential for unsuspected vascular injury. Patients with significant penetrating injury underwent computed tomography angiography (CTA) as the initial evaluation and subsequent arteriography in cases where injuries were suspected or metallic fragments produced artifacts obscuring the vasculature. Data on all vascular evaluations were entered prospectively into a database and retrospectively reviewed. RESULTS: Between February 2003 and March 2007, 124 patients were evaluated for significant penetrating trauma to the head and neck. Thirteen pseudoaneurysms of the head and neck were found in 11 patients: two in the internal carotid artery, one of the vertebral artery, and 10 involving branches of the external carotid. Seven pseudoaneurysms were symptomatic, of which two presented with episodes of massive bleeding and airway compromise. Seven pseudoaneurysms were treated with coil embolization, 1 with Gelfoam (Upjohn, Kalamazoo, Mich) embolization, 2 with stent grafts, 2 with open repair, and 1 with observation alone. None of the patients undergoing embolization had complications; however, a stent graft of the internal carotid artery occluded early, without stroke. All of the pseudoaneurysms had resolved on follow-up CTA or angiogram. CONCLUSIONS: Pseudoaneurysms are a common finding in patients with high-velocity gunshot wounds or blast injuries to the head and neck. Most involve branches of the external carotid artery and can be treated by embolization. CTA should be performed on all patients with high-velocity gunshot wounds or in cases of blast trauma with fragmentation injuries of the head and neck.     

Angiographic embolization of a traumatic pulmonary pseudoaneurysm

We present a case report of a 50-year-old male who sustained a gunshot wound to the right chest. The initial thoracotomy demonstrated a nonbleeding gunshot wound in the middle lobe and was otherwise unremarkable. Later that day, after continued resuscitation, his chest tube output dramatically increased and he was taken back for redo thoracotomy. An injury to the lateral branch of the middle lobe pulmonary artery was encountered and suture ligated. The patient presented several weeks later with hemoptysis. Computed tomography of the chest demonstrated pooling of contrast in the middle lobe. Angiography confirmed the diagnosis of a pulmonary artery pseudoaneurysm and was coil embolized without difficulty. This report represents a case of coil embolization of traumatic pulmonary artery pseudoaneurysm.     

Endovascular trapping using a tandem balloon technique for a spontaneous vertebrovertebral fistula associated with neurofibromatosis type 1

We report a rare case of a young man who had spontaneous left vertebrovertebral fistula associated with neurofibromatosis Type 1. His complaints were severe pain in the left neck and numbness in the left upper extremity. Cervical MR images showed a large abnormal flow void to the left of the spinal canal. An angiogram demonstrated a fusiform aneurysm and a high flow arteriovenous fistula in the left vertebral artery that drained into the internal vertebral plexus and formed a large venous varix. The occipital artery, the thyrocervical artery and the contralateral vertebral artery were associated with the fistula. The arteriovenous fistula was treated by endovascular coil embolization, using a tandem balloon technique. For this fistula, exhibiting the combination of high flow and multiple associated arteries, the flow control technique during the coil embolization, using tandem balloons in both the subclavian artery and the distal portion of the fistula of the vertebral artery, was safe and feasible for preventing coil migration.     

Trauma-induced ascending pharyngeal artery-internal jugular vein fistula: case report

BACKGROUND: Ascending pharyngeal artery-internal jugular vein fistulas are rare. Only 2 spontaneous cases and one complicated neck surgery have been reported. We describe a trauma-induced case. CASE DESCRIPTION: A 31-year-old man presented left-sided tinnitus and a pulsating bruit for 5 months after head trauma. Cerebral angiography demonstrated a fistula between the left ascending pharyngeal artery and left internal jugular vein. Embolization of the fistula was performed using platinum fibrous microcoils. CONCLUSIONS:This case and a review of the literature illustrate the causes, manifestations, image studies, and treatment for a fistula between the ascending pharyngeal artery and internal jugular vein.     

A delayed case of renal artery pseudoaneurysm presented with gross hematuria and azotemia in solitary kidney following percutaneous nephrostomy: treated by transcatheter coil embolization

Renal arteriovenous fistula or pseudoaneurysms developing after invasive procedures are either asymptomatic or show only transient symptoms. We describe here a case of symptomatic renal artery pseudoaneurysm that presented with gross hematuria and azotemia. The pseudoaneurysm of renal artery was diagnosed by ultrasonography and abdominal magnetic resonance imaging (MRI), and it was successfully treated by percutaneous transcatheter coil embolization. A high index of suspicion is essential for the early diagnosis and treatment of delayed gross hematuria in patients with history of percutaneous nephrostomy.     

Internal mammary artery subclavian vein fistula following internal jugular vein catheterization. A case report and review of the literature

We have recently treated a patient with an arteriovenous fistula that developed after a right internal jugular vein catheterization. The patient was found to have a pulsatile hematoma and a bruit five days after removal of a temporary pacemaker catheter. Digital subtraction arteriography documented a fistula between the right internal mammary artery and subclavian vein. The fistula was surgically repaired via the cervical route. To our knowledge, an arteriovenous fistula between the internal mammary artery and subclavian vein has not been previously described as a complication of a percutaneous internal jugular vein catheterization.     

Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report

Internal carotid artery (ICA) pseudoaneurysm formation following transsphenoidal surgery is a rare but potentially lethal complication. Direct surgical repair with preservation of the ICA may be difficult. The feasibility of endovascular coil embolization with parent artery preservation for an iatrogenic ICA pseudoaneurysm is undefined. A 40-year-old man was referred to the authors' institution after identification of a pseudoaneurysm of the left ICA following transsphenoidal resection of a pituitary macroadenoma. The pseudoaneurysm was treated via an endovascular approach that included stent-assisted coil embolization of the lesion. Follow-up angiographic studies obtained 1 year later demonstrated complete occlusion of the aneurysm, and the patient remains asymptomatic. Stent-assisted coil embolization of this iatrogenic pseudoaneurysm was successful in achieving complete, angiographically confirmed aneurysm obliteration, with preservation of the ICA and short-term prevention of hemorrhage or carotidcavernous fistula. The endovascular method provided an effective, relatively low-risk treatment for this difficult lesion, and was an excellent alternative to direct surgical repair. Nonetheless, long-term follow-up review is required before definitive treatment recommendations can be made.     

Direct surgery for posttraumatic carotid-cavernous fistula as a result of an intradural pseudoaneurysm: case report

OBJECTIVE AND IMPORTANCE: Traumatic carotid-cavernous fistula (CCF) is currently treated with interventional neuroradiological embolization procedures. A rare case of posttraumatic CCF that resulted from an intradural pseudoaneurysm is presented. The patient was treated by direct surgery because an embolization procedure was not suitable. CLINICAL PRESENTATION: A 16-year-old boy developed chemosis in the right eye 17 days after a traffic accident. Angiography revealed a pseudoaneurysm that arose from the site of origin of the posterior communicating artery, drained directly into the cavernous sinus, and formed a high-flow CCF. INTERVENTION: Direct surgery was performed to repair the arterial laceration at the junction of the internal carotid artery and the posterior communicating artery. A clip was applied along the internal carotid artery. The posterior stump of the damaged posterior communicating artery was also included in the clip. Postoperatively, the CCF and pseudoaneurysm were completely obliterated, and the symptoms were cured. CONCLUSION: Awareness of an unusual intradural origin of a CCF and the possibility of a direct surgical treatment should be kept in mind.     

Therapeutic embolization of an ascending pharyngeal artery-internal jugular vein fistula. Case report

The authors report a case of an arteriovenous fistula between the ascending pharyngeal artery and the internal jugular vein. The importance of an exact diagnosis and some precautions to be taken during therapeutic embolization are emphasized, as well as the need for superselective cannulation of the feeding artery. The problem of differential diagnosis with glomus tumors is discussed, and a brief mention is made of the anatomy of the jugular foramen and embryology of these tumors. Only one similar case treated by embolization with solid particles was found in the literature. To date, embolization using solid particles rather than liquid agents appears to be the best treatment of fistulas of this type.     

Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION: A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION: Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION: We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.     

Transvenous Embolization for Vertebral Arteriovenous Fistula: Report of two Cases and Technical Notes

Summary  Background. Vertebral arteriovenous fistulas are relatively rare. Although the common treatment is transarterial embolization, it may be impossible to pass through the fistula (e.g. a microfistula created by a needle puncture). We report two patients with vertebral arteriovenous fistulas due to penetrating trauma who were successfully treated by transvenous embolization.  Method. We present 2 patients with vertebral arteriovenous fistulas. One patient is presented to demonstrate complications following attempted internal jugular cannulation and the other is presented to demonstrate complications after surgery for a jugular foramen neurinoma. Both patients manifested the sign of a severe bruit.  Findings. To identify the fistula point, simultaneous transarterial and transvenous angiography was performed. Using the transvenous approach, microcoils were applied to the fistula and the bruit completely disappeared. Interpretation. Transvenous embolization is a useful technique and a first-choice strategy to treat patients with the vertebral arteriovenous fistula due to penetrating trauma.