Endovascular Treatment of Traumatic Injuries of the Vertebral Artery

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Endovascular Treatment of Traumatic Injuries of the Vertebral Artery
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  ORIGINALRESEARCH Endovascular Treatment of Traumatic Injuries of the Vertebral Artery D.A. HerreraS.A. VargasA.B. Dublin BACKGROUND AND PURPOSE:  There are a few reports regarding the treatment of traumatic vertebralarteriovenous fistulas and pseudoaneurysms. Our aim was to describe the clinical and angiographicresults of endovascular therapy for traumatic injuries of the vertebral artery. MATERIALS AND METHODS:  The clinical and angiographic features of 18 traumatic injuries of thevertebral artery during an 8-year period were reviewed. There were 14 male (78%) and 4 femalepatients (22%). The average age was 28 years (range, 11–49 years). Of the 18 lesions of the vertebralartery, 17 (95%) were the result of penetrating trauma (gunshot or stab wound injury) and 1 (5%) wasiatrogenic (jugular vein catheter). In 16 (89%) instances, the injury resulted in an arteriovenous fistula,and in the other 2 (11%), in a pseudoaneurysm. All patients were treated with an endovascularapproach by using different techniques (balloon occlusion, coil embolization, and/or stent deployment). RESULTS:  Endovascular therapy resulted in immediate lesion total occlusion in 16 (89%) patients.Delayed total occlusion was demonstrated angiographically during follow-up in the 2 remainingpatients. Clinical improvement was documented in all patients, and there were no clinically symptom-atic complications. CONCLUSION:  In this small series, endovascular techniques were a safe and effective method oftreatment and were not associated with significant morbidity or mortality. V ertebral artery traumatic lesions can be classified either asdissecting, thrombotic, pseudoaneurysm, or arterio-venousfistula(AVF).AVFscompromisingthevertebralartery are rare lesions, defined by the presence of an abnormal shuntbetweentheextracranialvertebralarteryor1ofitsmuscularorradicular branches and an adjacent vein. 1-3 These lesions canbe of traumatic or spontaneous srcin. 1-6 Traumatic fistulasare frequently associated with penetrating neck injuries. 7-8 Less frequent causes include puncture of the vertebral artery after gaining jugular vein access for central line placement,neck surgery, dislocations, and fractures of the cervicalspine. 9-11 Approximately 30% of AVFs can be asymptomatic, 12 dis-covered incidentally after auscultation of a neck bruit. How-ever, these lesions can have ischemic symptoms of vertigo,diplopia, and cephalgia secondary to arterial steal. The pres-ence of myelopathy or cervical neuralgia is rare but can resultafter arterial blood reflux into spinal pial veins or after rootcompression by engorged epidural veins. 2 Closure of the AVF or pseudoaneurysm with preservationof the parent artery is the main goal of treatment, rarely achieved with surgery but frequently attained with an endo-vascular approach. 12 In this article, our purpose was to review ourexperienceinthemanagementoftraumaticinjuriesofthevertebralartery,toevaluatethemorphologiccharacteristicsof this uncommon condition, and to determine the benefits of endovascular treatment on the basis of clinical and angio-graphic results. Materials and Methods Theclinicalrecordsandimagingstudiesofpatientstreatedfortraumaticvertebralarteryinjuriesbetween1997and2005wereretrospectivelyan-alyzed,andendovasculartreatmentwasperformedin18patients(Table1).Thisseriesrepresentsallofthepatientsseenduringtheintervalofourstudy, because all of the vertebral artery lesions were treated with endo-vascular techniques. There were 14 male (77.8%) and 4 female patients(22.2%). The average age was 28 years (range, 11–49 years). Pre- andpostoperative angiographic images were available for review in all pa-tients. The clinical information was introduced into a data base, includ-ingvariablesreferringtotopographyandmorphologyofvertebralartery lesions previously established elsewhere. 3,12 Information about clinicalpresentation, endovascular techniques used, and angiographic and clin-icaloutcomesoftreatmentwasregistered.All procedures were performed with the patient under moderateconscious sedation with neuroleptanalgesia, allowing regular clinicaland neurologic evaluation, except for an 11-year-old patient who re-quired general anesthesia. All patients received 70 U/Kg of heparinafter proximal positioning of a 6 or 7F catheter in the compromisedvertebral artery. According to the particular requirements of eachpatient, diverse materials and techniques were used, including parentartery occlusion or fistula trapping with detachable balloons, stentdelivery, and embolization with coils or liquid agents like  n -butylcyanoacrylate.Whensacrificeofthevertebralarterywasunavoidable,a balloon occlusion test was performed for 20 minutes while evaluat-ing for possible neurologic deficits secondary to posterior circulationischemia. During balloon occlusion, the collateral circulation wasevaluated by injecting the contralateral vertebral artery and both ca-rotid arteries. The balloon was detached if there were no neurologicdeficits and the collateral circulation was judged adequate. In all pa-tients,comparativepre-andpostembolizationimageswereobtained.After the procedure, the patients were taken to the intensive care unitfor neurologic and vital sign monitoring during 24 hours. Results Thecausesoftheinjurieswerethefollowing:gunshotwoundsin 11 patients (61.1%), stab wounds in 5 patients (27.7%), Received January 20, 2008; accepted after revision March 13.From the Department of Radiology (D.A.H., S.A.V.), Neuroradiology Section, Universidad deAntioquia, Hospital Universitario San Vicente de Paul, Medellin, Colombia; and Departmentof Radiology (A.B.D.), Neuroradiology Section, UC Davis Medical Center, Sacramento, Calif.Please address correspondence to Diego A. Herrera, MD, Department of Radiology,Neuroradiology Section, Universidad de Antioquia, Hospital Universitario San Vicente dePaul, Medellin, Colombia; e-mail: herrera.diego@gmail.comDOI 10.3174/ajnr.A1123 I    N T  E  R  V  E  N T  I     O  N A L     O  R   I      G  I     N  A  L    R   E    S   E   A  R    C   H   AJNR Am J Neuroradiol  ● : ●    ●  2008    www.ajnr.org  1   Published May 22, 2008 as 10.3174/ajnr.A1123   Copyright 2008 by American Society of Neuroradiology.  detonation with explosive-propelled fragments penetratingthe neck in 1 patient (5.5%), and an iatrogenic lesion in 1patient secondary to the puncture of the internal jugular veinduring placement of a central line (5.5%).Patients were most commonly asymptomatic ( n    11;61.1%) and had their lesion discovered after auscultation of aneck bruit. The rest of the patients had diverse symptoms,including cephalgia, cervical radiculopathy, subarachnoidhemorrhage and stiff neck, tinnitus, spinal cord symptoms,and vascular dementia syndrome (Table 1).Sixteen patients (88.8%) had vertebral AVFs, of whom 7(43.7%)hadanassociatedpseudoaneurysm.Two(11.1%)pa-tients had pseudoaneurysms without arteriovenous shunt.These lesions were found on the following portions of thevertebralartery:belowC5in5(27.7%),betweenC5andC2in7 (38.8%), and above C2 in 6 (33.3%). Detailed informationabout lesion morphology including arterial feeders, presenceof pseudoaneurysm, and venous drainage is given in Table 2.Endovascular treatment was performed by using balloonocclusionoftheparentvesselandAVFin12patients(66.6%),coil embolization in 2 patients (11.1%), detachable balloonand coil embolization of the AVF in 1 patient (5.5%), balloonocclusion of the AVF in 1 patient (5.5%), stent delivery, andcoil and  n -butyl cyanoacrylate embolization of the AVF in 1patient (5.5%) (Table 1). One patient with an AVF diagnosedby CT angiography experienced occlusion of the shunt by spontaneous dissection of the vertebral artery demonstratedduring conventional angiography.Immediate angiographic occlusion after endovasculartreatmentwasdocumentedin16patients(88.9%),andpartialocclusion, in 2 patients (11.1%). In the 2 patients with only partial endovascular occlusion, complete closure of the fistula Table 1: Angiographic and clinical results after endovascular treatment of traumatic lesions of the vertebral artery PatientNo.Sex/Age(yr) Clinical Presentation Cause Topography TreatmentOcclusionGrade Clinical Outcome 1 M/18 Neck bruit Gunshot Above C2, left Coiling Total Asymptomatic2 M/28 Neck bruit Gunshot C5-C2, left Balloon occlusion (trapping technique) Total Asymptomatic3 M/18 Neck bruit, cephalgia Gunshot Below C5, left Balloon occlusion (parent artery sacrifice) Total Asymptomatic4 M/26 Spinal cord symptoms Stab wound Below C5, right Stent, coils,  n  -butyl cyanoacrylate Partial* Asymptomatic5 M/35 Neck bruit Gunshot Below C5, left Balloon occlusion (trapping technique) Total Asymptomatic6 M/27 Neck bruit Gunshot C5-C2, right Balloon occlusion (trapping technique) Total Asymptomatic7 M/35 Neck bruit, cephalgia Gunshot Above C2, left Ballon occlusion and coiling of the AVF Partial* Asymptomatic8 M/42 Neck bruit Gunshot Above C2, left Coiling Total Asymptomatic9 M/26 Brain infarcts Stab wound Below C5, right Balloon occlusion (parent artery sacrifice) Total Partial improvement10 M/36 Neck bruit Stab wound C5-C2, left Balloon occlusion (parent artery sacrifice) Total Asymptomatic11 F/11 Radiculopathy Jugular catheter C5-C2, right Balloon occlusion (trapping technique) Total Asymptomatic12 M/19 Neck bruit Gunshot Below C5, right Balloon occlusion (trapping technique) Total Asymptomatic13 F/21 Neck bruit Gunshot Above C2, right Balloon occlusion (trapping technique) Total Asymptomatic14 M/25 Neck bruit Stab wound C5-C2, right Spontaneous occlusion Total Asymptomatic15 M/23 Tinnitus Gunshot Above C2, left Balloon occlusion (trapping technique) Total Asymptomatic16 F/43 Neck bruit Stab wound C5-C2, right Balloon occlusion (parent artery sacrifice) Total Asymptomatic17 F/49 Bruit, arm weakness, SAH Detonation C5-C2, left Balloon occlusion (trapping technique) Total Asymptomatic18 M/27 Neck bruit Gunshot Above C2, left Balloon occlusion of the AVF Total Asymptomatic Note: —SAH indicates subarachnoid hemorrhage; AVF, arteriovenous fistula.* Initially partial angiographic occlusion, total occlusion during follow-up. Fig 1.  Schematic representation of a vertebral arteriovenous fistula with steal phenomenon. Arrows represent blood-flow direction.  A , Blood flow from both vertebral arteries is directedto the fistula site ( double thin arrows  ).  B  , Trapping technique with positioning of detachable balloons ( arrowheads  ) proximal and distal to the arteriovenous communication re-establishesnormal flow through the basilar artery. 2  Herrera    AJNR  ●    ●  2008    www.ajnr.org  was demonstrated at 24-month follow-up. In 17 of the 18study patients (94.5%), the objective and subjective findingsdisappeared. Only 1 patient (5.5%) had partial clinical im-provement (this individual presented with dementia second-ary to emboli from a pseudoaneurysm of the vertebral artery producing cerebellar, occipital, and bithalamic infarcts).There were no clinically symptomatic complications in any of the patients treated. Discussion Vertebral arteriovenous fistulas are an uncommon pathology,either spontaneous or traumatic in srcin. Our series differsfromthatofBeaujeuxetal 12 becausemostofthearteriovenousfistulas in their patients were spontaneous (59%), whereas allof our patients had traumatic lesions. This difference may bedue to the fact that our institution is a regional referral centerfor trauma patients.In our series, we also found differences in the location of the lesions compared with other studies. 4-7,12 Although theliterature reports a preponderance of involvement of the ver-tebralarterybelowC5,wefoundagreaterfrequencyoflesionsbetween C2 and C5 (38.8%). This finding reflects the fact thattraumatic lesions tend to occur in zone II of the neck (zone IIlies between the cricoid and the angle of the mandible), inconcordance with results reported in a study with similar de-mographic characteristics compared with our patientpopulation. 13 Clinical symptoms produced by arteriovenous vertebral Fig 2.  Traumatic arteriovenous fistula caused by detonation with propelled metal fragments ( asterisks  ) penetrating the neck.  A , Left vertebral arteriovenous fistula is identified with bothascending and descending venous drainage.  B  , There is steal phenomenon represented by filling of the fistula through the right vertebral artery.  C  , Fistula trapping has been performedwith proximal ( arrows  ) and distal ( circle  ) balloon detachment. Note occlusion of the fistula with re-establishment of normal flow in the right vertebral artery. Table 2: Angiographic features of traumatic lesions of the vertebral artery PatientNo. Type Arterial feeders Venous Drainage 1 AVF  pseudoaneurysm Left vertebral, ECA Vertebral vein, IJV; Asc, Desc2 AVF Left vertebral Epidural plexus; Asc, Desc3 AVF Left vertebral Vertebral vein; Desc4 AVF  pseudoaneurysm Right vertebral Perimedullary plexus; Asc, Desc5 AVF  pseudoaneurysm Left vertebral IJV; Asc, Desc6 AVF Right vertebral Vertebral vein, IJV; Desc7 AVF  pseudoaneurysm Left vertebral, ECA IJV; Asc8 AVF  pseudoaneurysm Left vertebral Vertebral vein, IJV; Asc, Desc9 Pseudoaneurysm Right vertebral None10 AVF  pseudoaneurysm Left vertebral, muscular branch Vertebral vein; Asc11 Pseudoaneurysm Right vertebral None12 AVF Right vertebral Vertebral vein, IJV, epidural plexus; Desc13 AVF Right vertebral IJV, perimedullary plexus; Asc, Desc14 AVF Right vertebral Vertebral vein; Desc15 AVF Left vertebral Vertebral vein; Asc, Desc16 AVF Right vertebral, thyrocervical trunk Perimedullary plexus; Asc, Desc17 AVF Left vertebral IJV, epidural plexus; Desc18 AVF  pseudoaneurysm Left vertebral Perimedullary plexus, dural sinus; Asc Note: —ECA indicates external carotid artery; IJV, internal jugular vein; Asc, ascending; Desc, Descending; AVF, arteriovenous fistula. AJNR Am J Neuroradiol  ● : ●    ●  2008    www.ajnr.org  3  fistulas are related to the flow velocity in the shunt, venousdrainage pattern, and lesion chronicity. These factors can af-fect neighboring structures by means of steal phenomenon orvenous hypertension. 7 Most of our patients were asymptom-atic at diagnosis, probably because they presented during theacutephaseofthefistulawhenaneckbruitwasfoundatphys-ical examination in the emergency department. Ischemic in- jury resulting in dementia syndrome can result after clot em-bolization from a pseudoaneurysm, as described in 1 of ourpatients. Symptomatic thromboembolism was seen in only 1patient in our series, despite the high incidence of pseudoan-eurysm(43.7%),probablybecauseofaprotectingeffectoftheshunt into the venous side of the fistula.CT angiography has a preponderant role in the evaluationof vascular neck trauma. 13 However, we think that conven-tional angiography remains the study of choice for treatmentplanningbecauseitevaluatescollateralcirculationanddetectsvenous hypertension. It is also helpful to differentiate between asmall hole in the vessel wall or complete transection. It is very important that the examination include catheterization of theexternalcarotidarteryandthethyrocervicaltrunk, 4 because2of ourpatientshadadditionalshuntsurgeryfromthosevessels.Because in most penetrating injuries of the vertebral artery,thereisextensivedamageofthevesselwall,possiblywithtransec-tion, a reconstructive endovascular approach is not possible andvascularsacrificemaybenecessary.Thistechniqueoftreatmentissafe whenever the contralateral vessel is adequate to supply bothintracranialvertebralcirculations.Parentarteryocclusioncanbeperformed if posterior inferior cerebellar artery patency is dem-onstratedandtheballoonocclusiontestisnegativeforvertebro-basilar ischemic symptoms. This is supported in our series withthe occlusion of the vertebral artery in 13 patients, without any immediate or delayed ischemic complications. Because the pos-sibilityofstealphenomenafromthecontralateralvertebralartery exists,itisimportanttoperformatrappingtechnique(Figs1,2),occluding both the proximal and distal aspects of the fistula by usingdetachableballoonsorcoils. 14 Whenever the dominant vertebral artery was injured, a re- Fig 3.  Right vertebral arteriovenous fistula after a stab wound injury of the neck.  A , Prominent ascending and descending venous drainage with the presence of pseudoaneurysm ( arrow  )is noted.  B  , Uncovered stent deployment with coiling ( arrowheads  ) was performed. There is partial occlusion of the pseudoaneurysm and reduction in venous drainage in the immediatepostreatment angiographic images.  C  , Angiographic control image 18 months after treatment shows normal flow through the right vertebral artery without evidence of fistula orpseudoaneurysm.  D  , Reconstructive endovascular approach by using a stent ( double arrows  ) and coils ( arrowhead  ) was accomplished.  E  , Transverse T1-weighted MR image demonstratesthe right vertebral AVF compressing the cervical spinal cord ( arrow  ).  F  , MR control image 18 months after treatment shows AVF thrombosis ( arrow  ) and patency of the right vertebral artery( arrowhead  ). 4  Herrera    AJNR  ●    ●  2008    www.ajnr.org  constructive endovascular approach by using a stent and coilswas accomplished (Fig 3). However, there are other possiblesources of collateral supply in addition to the contralateralvertebralartery,includingtheposteriorcommunicatingarter-ies or anastomosis between the external carotid and the verte-bralarterythatcouldbeidentifiedduringaballoontestocclu-sion, allowing parent vessel sacrifice.Initial total occlusion of the vertebral artery lesions wasachieved in 89% of patients; nearly identical with that in thestudy of Beaujeux et al, 12 who reported immediate occlusionin 91% of lesions. In our series, both patients with immediatepartial occlusion had delayed total occlusion, during fol-low-upin1patient(Fig3)andafteranewsessionoftreatmentintheother.Wealsoobservedspontaneousocclusionwithouttreatment of an AVF. This circumstance is similar to the oc-clusion of the fistula after selective catheterization reported in1 study  12 and the spontaneous closure of the shunt withoutintervention mentioned by another author. 15 Seventeen patients (94.5%) had clinical resolution of symptoms after embolotherapy. One patient who presentedwith incomplete improvement had dementia syndrome, andthough improvement in mentation was difficult to quantify,some objective change was observed.Although ischemic events, contrast media reactions, andclinical deterioration have been described after treatment of AVFs, 3,16-19 theabsenceofcomplicationsinourseriesandthatof Beaujeux et al 12 shows that this technique can be a safemethod of management for this pathology. Conclusions Inthissmallseries,endovasculartechniquesforocclusionofver-tebralarterylesionsweresafeandeffectivemethodsoftreatment.Theywerenotassociatedwithsignificantmorbidityormortality and could be the methods of choice for the treatment of mostvertebral artery traumatic lesions, reserving surgery only for pa-tientswithseverebleedingorafterfailedembolization. 20 References 1. NagashimaC,IwasakiT,KawanumaS,etal. Traumaticarteriovenousfistulaof the vertebral artery with spinal cord symptoms.  J Neurosurg   1977;46:681–872. De Bray JM, Bertrand P, Bertrand F, et al.  Spontaneous arteriovenous fistulasofthevertebralartery:aproposofacase—reviewoftheliterature [inFrench]. Rev Med Interne  1986;7:133–393. Halbach VV, Higashida RT, Hieshima GB.  Treatment of vertebral arterio- venous fistulas.  AJR Am J Roentgenol   1988;150:405–124. Merland JJ, Reizine D, Riche MC, et al.  Endovascular treatment of vertebralarteriovenous fistulas in twenty-two patients.  Ann Vasc Surg   1986;1:73–785. Hieshima GB, Cahan LD, Mehringer CM, et al.  Spontaneous arteriovenousfistulas of cerebral vessels in association with fibromuscular dysplasia.  Neu-rosurgery   1986;18:454–586. Deans WR, Block S, Leibrock L, et al.  Arteriovenous fistula in patients withneurofibromatosis.  Radiology   1982;144:103–077. Reizine D, Laouiti M, Guimaraens L, et al.  Vertebral arteriovenous fistulas:clinical presentation, angiographical appearance and endovascular treat-ment—a review of twenty-five cases  [in English, French].  Ann Radiol (Paris) 1985;28:425–388. Hayward R, Swanton H, Treasure T.  Acquiredarteriovenouscommunication:complication of cannulation of internal jugular vein.  Br Med J (Clin Ed) 1984;288:1195–969. Verrie`res D, Bernard C, Dacheux J, et al.  Cervical arteriovenous fistulas afterinternal jugular catheterization.  Ann Fr Anesth Reanim  1986;5:162–6410. Johnson CE, Russell EJ, Huckman MS.  Resolution of spinal epidural vascularpseudotumor following balloon occlusion of a postoperative vertebral arte-riovenous fistula.  Neuroradiology   1990;31:529–3211. Olson RW, Baker HL Jr, Svien HJ.  Arterio-venous fistula: a complication of  vertebral angiography—a report of a case.  Neurosurg   1963;20:73–7512. BeaujeuxRL,ReizineDC,CasascoA,etal. Endovasculartreatmentofvertebralarteriovenous fistula.  Radiology   1992;183:361–6713. Mu´nera F, Soto JA, Palacio DM, et al.  Penetrating neck injuries: helical CTangiography for initial evaluation.  Radiology   2002;224:366–7214. Connors JJ, Wojak JC.  Interventional Neuroradiology: Strategies and Techniques. Philadelphia: Saunders; 199915. Kubota M, Watanabe O, Takase M, et al.  Spontaneous disappearance of arte-riovenous fistula between the vertebral artery and deep cervical vein: casereport.  Neurol Med Chir (Tokyo)  1992;32:84–8716. Halbach VV, Higashida RT, Hieshima GB, et al.  Normal perfusion pressurebreakthrough occurring during treatment of carotid and vertebral fistulas.  AJNR Am J Neuroradiol   1987;8:751–5617. Higashida RT, Halbach VV, Tsai FY, et al.  Interventional neurovascular treat-ment of traumatic carotid and vertebral artery lesions: results in 234 cases.  AJR Am J Roentgenol   1989;153:577–8218. Spetzler RF, Wilson CB, Weinstein P, et al.  Normal perfusion pressure break-through theory.  Clin Neurosurg   1978;25:651–7219. Kondoh T, Tamaki N, Takeda N, et al.  Fatal intracranial hemorrhage afterballoon occlusion of an extracranial vertebral arteriovenous fistula.  J Neuro-surg   1988;69:945–4820. Demetriades D, Theodorou D, Asensio J, et al.  Management options in verte-bral artery injuries.  Br J Surg   2005;83:83–86 AJNR Am J Neuroradiol  ● : ●    ●  2008    www.ajnr.org  5
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