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AngiographicEvaluationandTreatmentforHeadandNeckVascular Injury
JulieBykowski,MD,WadeWong,DO,FACR,FAOCR ApplRadiol.201241(3):1016.

AbstractandIntroduction
Abstract

Avarietyofheadandneckvascularemergencies,suchasnosebleedsorneoplastichemorrhages,canoccurspontaneously orresultfrombluntorpenetratingtrauma.Asmosttraumaticvenousbleedingcanberesolvedwithdirectpressure,themain focusisonarterialinjury.Theroleofcatheterangiographyintheacutetraumasettinghasshiftedoverthepast15years,with theconcomitantadvancesincomputedtomography(CT)angiographyfordiagnosis,anddevelopmentofmicrocathetersand embolicagentsfortherapy.


Introduction

Avarietyofheadandneckvascularemergencies,suchasnosebleedsorneoplastichemorrhages,canoccurspontaneously orresultfrombluntorpenetratingtrauma.Asmosttraumaticvenousbleedingcanberesolvedwithdirectpressure,themain focusisonarterialinjury.Theroleofcatheterangiographyintheacutetraumasettinghasshiftedoverthepast15years,with theconcomitantadvancesincomputedtomography(CT)angiographyfordiagnosis,anddevelopmentofmicrocathetersand embolicagentsfortherapy. RegionaltraumaassociationshaveproposedalgorithmsforwhichpatientsshouldbeevaluatedbyCTangiographyand/or catheterangiographyfortraumaticheadandneckvascularinjuries.[13]Theseincludehighriskmechanismssuchas:high energycollisions,neckhyperextensioninjury,intraoraltrauma,andnearhangingwithanoxicbraininjury.Additionally,CTor catheterangiographyshouldbeconsideredinpatientswithLeFort/midfacefractures,cervicalspineorbasilarskullfractures, diffuseaxonalinjurywithGlasgowComaScale(GCS)<6,anewfocalneurologicaldeficit,neurologicalexamination incongruouswithheadCTfindings,orimagingevidenceofanewcerebralinfarctinthesettingoftrauma. Clinicallyoccultheadandneckvascularinjuryisrarehowever,aggressiveCTscreeninginasymptomaticpatientshas becomecommonplacegiventhepotentiallydevastatingsequelaeofamisseddiagnosis,[46]combinedwitheaseofaccessto CTangiography.Ongoingdiscussioninthetraumacommunitycontinuesregardingpatientselectioncriteria,giventhe concernsofcosteffectivenessofbroadscreeninginasymptomaticpatientsaswellasminimizingunnecessaryradiation exposure. Thereremaincasesinwhichconventionalangiogramremainsthe'goldstandard.'TheseincludeCTangiogramslimitedby artifactfromdentalimplants/amalgam,frommetalorshrapnel,situationswhereappropriatebolustimingcannotbeachieved, andhemodynamicallyunstablepatientswithahighprobabilityofrequiringendovascularintervention.Diagnosticcatheter angiogramshouldalwaysbeconsideredinapatientwithhighsuspicionforcervicalvascularinjuryinthesettingofanormal CTangiogram,asthisisadynamicdiseaseprocessandcontrastopacificationofavesseloncrosssectionalimagingmay notfullyreflectflowdynamicsandcollateralpathways.

LargeArterialLacerations,Pseudoaneurysms,andArteriovenousFistulae
Damagetothearterialwallcanresultinlifethreateninghemorrhage,andpatientswithlargearteriallacerationsdueto penetratingtraumahavesignificantmortalitybeforereachinghospitalcare.Alternatively,hemorrhagemaybecontainedby developmentofapseudoaneurysmordivertedthroughatraumaticarterialvenousfistula.Indealingwithapatientwitha potentialarteriallaceration,itiscrucialtomaintainhemodynamicandventilatorysupportthroughoutthesearchforand treatmentoftheactivebleedingsite. Explorationofanteriorneckwoundsisusuallydonesurgically,givenadequateexposureanddirectvisualizationofthecarotid arteries.[7]Inpatientswithactivehemorrhagefromacarotidorvertebrallaceration,thereisahighriskofstrokeorevendeath despiteaggressivetreatment,includingsurgicalligationorendovascularembolizationofthevessel.Giventhedifficultsurgical approachtothecarotidarteryattheskullbaseandthevertebralarteries,[8,9]theinterventionalneuroradiologistcanprovide greatsupporttothetraumateamwithanendovascularapproachtotreatmentatthesesites.[10,11,12]Additionally,inpatients withextensivefacialfracturesorpenetratinginjuries,anendovascularapproachtocontrolbleedingispreferred(Figure1).

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Figure1. (A)CTscanofa22yearoldmanwithmassivefacialhemorrhagefollowingagunshotwound.(B)Earlyarterialphaseofleft externalcarotidarteriogramshowsactivecontrastextravasation(arrowhead).(C)Leftexternalcarotidarteriogramafter embolizationwithgelfoamslurryconfirmscessationofextravasation. Pseudoaneurysmsresultfromarterialbleedingintothewallofaninjuredvessel.Thiscanmanifestasafocallyexpanded dissectionwithcontainmentbytheadventitia,orcontainmentofleakageoutsideofthevesselwallbyalayerofclot.While someextremitypseudoaneurysmshavebeenreportedtoresolvespontaneously,[13]asymptomaticpseudoaneurysmsofthe carotidarteriesaregenerallytreatedtoprecludethromboembolicstrokeandreducetheriskofrebleeding.Endovascular embolizationwithcoilsorballoonocclusionisoftenfavoredoverdirectsurgicalexploration[14,15]however,itshouldbedone withcareasrebleedingiscommongiventhefragilityofstructurescontainingthesiteofinjury(Figure2).Insomesituations,a stentmaybesufficienttodivertflow,allowingthepseudoaneurysmtothrombosewithoutcoildeployment.[1618]Some controversypersistsregardingtherisksandbenefitsofstentplacement,withlongtermstentocclusionratesreportedinupto 45%ofpatientsinearlyseries.[19]Discussioncontinuesabouttheidealtimingoftreatment,perceivedbenefitsofdifferent stentfeatures,andoptimalconcomitantantiplatelettherapyinthesepatients.[20]

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Figure2. (A)T1weightedpostcontrastMRimageofa52yearoldmanrevealsenhancingsquamouscellcarcinomaoftheleftsphenoid sinusandcavernoussinus.Massivearterialhemorrhageoccurredafterendoscopicbiopsy.(B)Leftinternalcarotidarteriogram revealsdevelopmentofacavernoussinuspseudoaneurysm.(C)Aftertestballoonocclusion,coilsweredeployedintothe pseudoaneurysm.Notsurprisingly,severalcoilsrupturedbeyondtheencasingthrombus.(D)Theleftinternalcarotidwas thereforesacrificedwithcoilocclusion.Posttreatmentarteriogramconfirmscompleteocclusionoftheleftinternalcarotidwith fillingonlyoftheleftexternalcarotid.Thepatienthadintactcollateralsupplyfromtherightinternalcarotidviatheanterior communicatingartery. Traumaticarteriovenousfistulaecanoccurinthesettingofarterialtransection,withresultingcommunicationbetweenthe injuredarteryandadjacentvein.Mostcommonly,theseoccurinthefacialarterialoratthecavernouscarotidartery,duetothe prevalenceoffacialandskullbaseinjury,respectively. Differentmethodsofembolizationhavebeendescribed,dependingontheflowrate,site,andavailabletechnology.[2123] Smallfistulouscommunicationsmaybeembolizedwithpolyvinylalcoholparticles(Figure3).Inlargerfistulae,deploymentof microcoils,detachableballoonsorliquidembolicagentsthroughthefistulamaybenecessarytoobtaincessationofshunting (Figure4).

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Figure3. (A)38yearoldwomancomplainedof"swooshing"soundafterwhiplashinjury.Rightexternalcarotidarteriogramconfirms arteriovenousfistula,suppliedbysmallbranchesoftherightoccipitalartery.(B)Amicrocatheterwasadvancedintotheright occipitalarteryandsuccessfulembolizationoffeederbrancheswasperformedwith200micronpolyvinylalcohol(PVA) particles.

Figure4. (A)CTscanin18yearoldmanwithfacialtraumarevealedanenlargedleftsuperiorophthalmicvein.(B)Leftinternalcarotid arteriogramconfirmedthepresenceofacarotidcavernousfistula.(C)Arteriogramrepeatedafterdetachableballoonplacement inthesingleholeshuntofthefistulashowsocclusionofthefistula. Insituationswherevesselsacrificeisconsidered,occlusionbyballoonsorcoilsshouldonlybedoneafterathoroughtest balloonocclusiontoensuretherewillnotbeundesired,irreversibleneurologicalsequelae.Unilateralvertebralarteryocclusion isconsideredmoreforgivingaslongasthecontralateral,uninjuredvertebralarteryhasadequatecaliberandtheembolization materialcanbedeployedproximaltotheposteriorinferiorcerebellarartery(PICA),preservingcollateralsupplyonthesideof injury.[24,25]Atypicalballoontestocclusionisperformedbyanticoagulatingthepatientwithheparinandthenadvancingan occlusiveballoonacrossordistaltothesiteofinjury,tocausecessationofbloodflow.Neurologicaltestingforthecarotid arterywouldincludeevaluationofpronatordrift,motor,sensory,andmemoryfunction.Vertebralarteryneurologicaltesting duringballoonocclusionislessreliable,however,andemphasisshouldbeplacedoncoordination,motor,andsensory
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function.Theballoontestocclusionistypicallymaintainedfor30minutesoruntilthepatientfailstheprocedure.

ExtracranialArterialDissectionsandOcclusions
Arterialdissectionsintheheadandneckusuallyareassociatedwithdecelerationandshearinjuries.Theseincludeinjuriesto theproximalcervicalvertebralartery,andthedistalinternalcarotidandvertebralarteriesbelowtheskullbase.Vertebralartery dissectionscanalsooccuratthesitesoftransverseforamenfractures,andtheseareasshouldbecarefullyevaluatedinthe settingofcervicalspinetrauma.[26]Occlusionscanresultfromsluggishflowinthedissectedvessel,compoundedby underlyingatheroscleroticdisease. Intheacutesetting,CTangiographyiscommonlyusedtoevaluateforvesselirregularityandfillingdefects.MRimaging, particularlyT1fatsaturatedsequences,issensitiveforthedetectionofmethemoglobininafalselumenofadissection[27] (Figure5).However,withinthefirst3daysafterthetraumaticevent,thebloodproductsoftenhaveonlyintermediatesignal changes.Diagnosticcatheterangiographymaybeneededinpatientswithartifactfrombulletfragmentsordentalamalgamor difficultevaluationattheskullbase.

Figure5. (A)MRimagingrevealsT1hyperintensemethemoglobin(blackarrowhead)surroundinganarrowedleftinternalcarotidartery, confirmingdissection.(B)Correspondingangiogramconfirmsfocalvesselnarrowingatthepointofdissection(lower arrowhead).Thrombusisalsonoteddistallywithintheleftinternalcarotidartery(upperarrowhead),asanintraluminalfilling defect. Treatmentofcarotidandvertebralarterialdissectionsremainssomewhatcontroversial.[2]Themostconservativeapproach includesmedicalmanagement,withongoingdebateastowhetheranticoagulationwithheparinand/orantiplatelettherapyis moreeffective.[19,26,28,30]Thereremainsconcernabouttheuseoftheseagentsinthesettingofacutemultitrauma,[30] althoughsuccessfultreatmentwithantiplateletagentshasalsobeendescribedinthesettingofpreexistingintracranial hemorrhage.[31]Medicalmanagementhasresultedin50%to70%successfularterialrecanalizationrates.[32,33]However, thesepatientsremainatriskforthromboemboliceventsinthedaystoweeksfollowingthetraumaticevent[34]ordelayed formationofdissectinganeurysms.Muchofthehealingofdissectionsoccurs36monthsaftertheincitingevent.[35,36] Stentshavebeenusedtotreatpatientswhohavecontraindicationstoanticoagulationorantiplatelettherapy,[37]although adjunctiveantiplatelettherapyisoftenusedtoensurelongtermstentpatency.[20]Endovasculartreatmentwithstentshas alsobeendescribedinpatientswhofailmedicalmanagementeitherwithongoingornewneurologicalsymptoms,or enlargementofadissectinganeurysmonfollowupevaluation.[38] Ifanischemicstrokehasoccurred,coordinationwiththestrokeneurologyteamisessential.Brainimaging,includingdiffusion andperfusionweightedimaging,shouldbeaconsideration,understandingthattheremaybetimeconstraintsif
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revascularizationisindicated.Ifimagingsuggestsanembolicmechanismforthestroke,techniquessimilartostroke thrombolysisorthromboembolectomymaybeused.Ifalargevesselocclusionispresent,angioplastyorstentingmaynotbe wiseasthismaycauseareperfusionhemorrhageinthebrain.

BranchVesselArterialLacerations
Traumatotheface,neck,andscalpcanresultindamagetobranchesoftheexternalcarotidarteriesthatcannotbecontrolled bydirectpressurealone.Understandingthetraumamechanismandhavingcrosssectionalimagingoftheheadandneckare helpfulintheacutesettingtotailortheangiogrammostexpeditiouslytoareasofinterest.Oneshouldalwaysconsidertherich collateralsupplytothefaceandneck,andthethyrocervicaltrunk,vertebralartery,andinternalcarotidarterybranchesshould alsobescrutinized(Figure6).

Figure6. (A)Rightcommoncarotidarteriograminpatientwithhematocheziarevealsactiveextravasationfromabranchofrightsuperior thyroidartery(arrowhead).(B)Selectivearteriogramafterembolizationwith200micronPVAparticlesconfirmscessationof flowdistaltothemicrcatheterandabsenceoffurtherextravastionfromtherightsuperiorthyroidartery. Thegoalistodecreasethepressureheadwithintheinjuredvesselwithresultingcessationofbleeding.Generally,itis importanttoplacethetipofthecatheterasclosetothebleedingsiteaspracticaltoavoidocclusionofnormalbranches. Additionally,priortoanyparticleembolization,oneshouldbewellawareofpotentialdangerousanastamoticcollaterals.[39] Theseinclude:distalexternalcarotidarteryethmoidalperforatorstotheophthalmicartery,superficialtemporalarterytothe middlecerebralartery,middlemeningealarterytotheophthalmicartery,andoccipitalarterytothevertebralartery(Figure7). Additionalembolizationhazards,suchasscalpnecrosis,shouldbekeptinmindwhentargetingsitesinthesuperficial temporalandoccipitalarteries.

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Figure7. (A)Retrogradeflowcanbeseenfromtheexternalcarotidintothedistalinternalcarotidviaethmoidalperforatorsandthe ophthalmicarteries(arrowhead).(B)Collateralflowisidentifiedfromtheoccipitalarterybranchoftheexternalcarotidartery,to thevertebralartery(arrowheads).Thiscanpresenthazardsduringembolization. Inareaswherepotentialneurologicaldeficitorcollateralflowwouldbedetrimental,provocativetestingwith2ml1%lidocaine (20mg)withconcomitantneurologicaltestingcanbehelpful.Forexample,provocativetestingcanrevealneurologicaldeficits ofcranialnervesV,VII,andXassociatedwiththeascendingpharyngealarterybeforeembolization,allowingforappropriate changeinthetherapyplan. Temporaryocclusiveagents,suchasgelfoamandparticles,arethepreferredembolizationmaterialinmostsituations,as coils,glue,andballoonsmayprecludeaccessinthesettingofrebleeding.Gelfoamcanbemadeintoaslurrywithcontrast, allowingsafe,targeteddeliverythrougha3or4Frenchcatheter.Particles,suchas200700micronpolyvinylalcohol,are usuallymixedwithIohexol240contrasttocreateanevenlydistributedisobaricsolution.Polyvinylalcoholparticlesare injectedviaamicrocatheterfastenoughtobevisualizedbutnotsofastastocreaterefluxintonormalvessels.Asthe embolizationprogresses,theinjectionratetypicallyslowsuntilstagnationandflowareangiographicallyevident.Theuseof smallerparticlesincreasestheriskofnontargetembolizationbyparticlemigrationviasmallcollateralvessels.

Epistaxis
Nosebleedsarecommonandcanbespontaneous,traumatic,orsecondarytounderlyingtelangiectasia,arteriovenous malformationsorneoplasms,suchasjuvenilenasalangiofibromas.Thefirststepistoidentifythesiteofbleeding. Mostcommonly,thebleedingsiteisanterior,suppliedfromKiesselbachplexus(sphenopalatine,descendingpalatine,superior labialbranchesfromECAandanteriorandposteriorethmoidalarteriesfromtheophthalmicartery).[40,41]Anteriornasal bleedingcanoftenbestoppedwithdirectpressure,packing,orcautery,giventheeaseofaccess.Ifthebleedingsiteis posteriorlylocated,endovascularembolizationispreferredoverarterialligation,asitallowsrepeatedaccessintheeventofre bleedingviacollateralbranches.[42,43]Thisisusuallybestaccomplishedviatheinternalmaxillaryarteries(Figure8),with microcatheterplacementdistaltotheoriginsofthemiddlemeningealandaccessorymeningealarteries.

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Figure8. (A)62yearoldwomanpresentedwithnasalcongestion.CoronalCTscanrevealsarightnasalcavitymass.Extensive uncontrolledhemorrhageoccurredafterbiopsy.(B)Rightexternalcarotidarteriogramrevealsactivecontrastpoolingafterthe arterialstage,indicatingactivebleeding.Thiswassuccessfullytreatedwithmicrocatheterselectionofthedistalinternal maxillaryartery(arrowhead)andembolizationwith300micronPVAparticles. Inallcasesofnasalandfacialembolization,itisessentialtoevaluatecollateralsupplyviatheophthalmicandfacialarteries toavoidundesirablenontargetembolization.[44]Collateralsupplycanoccurviathearteryoftheforamenrotundum,thevidian andascendingpharyngealarteries,aswellascommunicationsbetweenthefacial,sphenopalatineandophthalmicarteries. Preferredtreatmentiswithtemporaryocclusiveagents,suchas200500micronpolyvinylalcoholparticles.Itisimportantto closelymonitortheinjectionrate,toavoidrefluxintootherbranchvessels.Ifsubselectivearterialpositioningcannotbe achievedorthevascularanatomyisalteredbypriorsurgicalintervention,gelfoaminjectionintothelarger,feedingarterymay sufficientlydiminishthepressureandstopthebleeding.Wetypicallyavoidusingcoilstotreatepistaxis,asthesepermanent devicesprecludefutureaccess,ifrebleedingoccurs.Havingtoaccessthebleedviacollateralsourcessuchasthe ophthalmicarterymakestheembolizationproceduremuchmorehazardous.

NeoplasticBleeds
Vascularheadandneckneoplasms,suchasthyroidcancerandparaganglioma,maybleedspontaneouslyandbedifficultto controlexternally.Often,theonlyfindingishypervascularoozing.Insuchcases,partialembolizationofthetumormay sufficientlyshutdownthevascularbed. Morecommonly,headandneckcancerscanerodeintoabloodvesselwallandcausespontaneoushemorrhage.Thesearch forneoplasticbleedingsourcecanbechallenging(Figure9),andsurgicalexplorationcanbedifficultinpatientswithpriorneck dissectionorradiationtherapy.Inthesettingofneoplasticbleeding,onemayseehypervasculartumorblushortheremaybe actualactiveextravasation.[45]Insomecases,suchascarotidblowout,bleedingcanbeprofuseandlifethreatening.Inthis setting,emergentendovasculartherapywithstents,balloonocclusionandliquidgluehavebeenreported,[46,47,48]withthe understandingthattheseareoftenpalliativemeasures.

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Figure9. (A)81yearoldwithmetastaticthyroidcancererodingintotherightmainstembronchus,withintermittenthematochezia.Inthis case,leftsubclavianangiographydemonstratedthattheexpectedthyrocervicalartery(whitearrowhead)wasnottheactual source.(B)Vascularcontributiontothetumormassoriginatedfromtherightsuperiorthyroidartery,demonstratedon subselectivecatheterization.(C)Aftertreatmentwith200micronPVAparticles,rightsuperiorthyroidarteriogramshows successfulembolization.

Conclusion
Catheterangiographycontinuestoservearoleinthediagnosisofheadandneckvasculartrauma,particularlyincaseswith highsuspicionforvascularinjuryorwhereCTangiographyislimitedduetoartifactfromdentalamalgamorgunshotdebris. Theneurointerventionalistcontinuestoplayanincreasingroleintheacutesettingtoidentifyandstopbleeding,withan increasingnumberoftemporaryandpermanentagentswithintheirarmamentarium.Beforeembolization,itiscrucialtoassess collateralvascularsupply,bothtoavoidnontargetembolizationandundesiredpermanentsequelaewhenvesselsacrificeis required.Endovascularprocedurescanalsobeausefuladjunctinpatientswhohavefailedconservativemanagement.The populationofheadandneckvasculartraumaandbleedingisheterogeneousandtechniquescontinuetoadvancetoserve theseuniquecases.
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