Multiple intracranial carotid injuries: pitfalls in diagnosis by angiography and principles of endovascular treatment.

BACKGROUND

Simultaneous multiple intracranial carotid injuries (ICIs) after head trauma are rarely referred for treatment and are often times fatal. The purpose of this study was to describe the potential angiographic pitfalls in diagnosis of multiple ICIs and to report the principles of endovascular management in 15 patients with 34 ICIs.

METHODS

A 12-year study of the 15 patients (8 men and 7 women) with 34 ICIs was completed, and patients were managed by endovascular treatment. Of the 34 ICIs, there were 22 traumatic carotid-cavernous fistulas (TCCFs), 6 traumatic carotid aneurysms, 5 meningeal arteriovenous fistulas, and 1 traumatic occlusion of carotid artery. Transarterial endovascular embolization was performed in 32 ICIs.

RESULTS

Four traumatic carotid aneurysms, four meningeal arteriovenous fistulas, and a second hole of the TCCF were missed in early detection by initial cerebral angiograms. The causes of missed early detection of ICIs in angiograms were attributed to occur with TCCFs in the ipsilateral internal carotid artery territory due to overlooking (n = 4), overlap with nearby carotid artery and/or fistula drains of TCCFs (n = 2), steal phenomenon (n = 2), and a latent period of ICI (n = 1). Successful occlusion of 32 ICIs was achieved. On the modified Rankin scale applied in follow-up, 14 patients were assessed as stable clinical status.

CONCLUSIONS

Early initial detection of ICIs in cerebral angiograms may be difficult if ICIs occur in the same carotid artery, particularly when they coexist with TCCF. However, as soon as TCCFs are occluded, postembolization angiograms should be scrutinized to find the potential associating ICIs, and endovascular management should be performed promptly.