Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents

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Object. The authors describe their preliminary clinical experience with the use of endovascular stents in the treatment of traumatic vascular lesions of the skull base region. Because adequate distal exposure and direct surgical repair of these lesions are not often possible, conventional treatment has been deliberate arterial occlusion. The purpose of this report is to demonstrate the safety and efficacy as well as limitations of endovascular stent placement in the management of craniocervical arterial injuries.

Methods. Six patients with vascular injuries were treated using endovascular stents. There were two arteriovenous fistulas and two pseudoaneurysms of the distal extracranial internal carotid or vertebral arteries resulting from penetrating trauma, and two petrous carotid pseudoaneurysms associated with basal skull fractures. In one patient a porous stent placement procedure was undertaken as well as coil occlusion of an aneurysm, whereas in the remaining five patients covered stent grafts were used as definitive treatment.

There were no procedural complications. One patient in whom there was extensive traumatic arterial dissection was found to have asymptomatic stent thrombosis when angiography was repeated 1 week postoperatively. This was the only patient whose associated injuries precluded routine antithrombotic or antiplatelet therapy. Follow-up examinations in the remaining five patients included standard angiography (four patients) or computerized tomography angiography (one patient), which were performed 3 to 6 months postoperatively, and clinical assessments ranging from 3 months to 1 year in duration (mean 9 months). In all five cases the vascular injury was successfully treated and the parent artery remained widely patent. No patient experienced aneurysm recurrence or hemorrhage, and there were no thromboembolic complications.

Conclusions. The authors' experience demonstrates that endovascular treatment of traumatic vascular lesions of the skull base region is both feasible and safe. The advantages of minimally invasive stent placement and parent artery preservation make this procedure for repair of neurovascular injuries a potentially important addition to existing methods.

Article Information

Address reprint requests to: Thomas Marotta, M.D., The Toronto Western Hospital, 399 Bathurst Street, 3 Fell 210, Toronto, Ontario, Canada, M5T 2S8.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. A: Left VA angiogram, anteroposterior view, demonstrating a posttraumatic pseudoaneurysm of the distal extracranial VA. The surgical clips relate to a previous ligation of the ICA. B: Control angiogram obtained 6 weeks after endovascular placement of a porous stent. Arrows indicate the upper and lower stent margins. There has been mild straightening of the vessel, but the pseudoaneurysm remains unchanged. C and D: Angiograms, anteroposterior (C) and lateral (D) views, obtained 6 months after the pseudoaneurysm was packed with GDCs. The VA is patent and the aneurysm has been occluded.

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    Case 4. Left: Right CCA angiogram, early arterial phase, revealing a large pseudoaneurysm extending anterior and posterior to the petrocavernous segment of the ICA. Tapered narrowing of the ICA lumen indicates the extent of arterial dissection. Right: Right ICA angiogram, midarterial phase, demonstrating a small pseudoaneurysm (arrow) of the angular branch of the MCA.

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    Case 4. Upper Left: Photograph showing a representative PTFE-covered coronary stent graft. This example is 12 mm in length. Following balloon delivery, the stent can expand up to 5 mm in diameter. Upper Right: Lateral x-ray film demonstrating the guide wire with its tip in the distal intracranial ICA and the unexpanded stent in position across the level of the pseudoaneurysm. Center Left: Following balloon expansion and stent placement, contrast material stasis is apparent within the pseudoaneurysm. Arrows indicate the proximal and distal margins of the stent. Center Right: Control angiogram obtained after stent placement demonstrating nearly complete occlusion of the pseudoaneurysm, with minimal extravasation of contrast material. The cavernous ICA distal to the stent remains stenotic due to the arterial dissection, which extends beyond the pseudoaneurysm. Lower Left: Right CCA angiogram obtained 1 week after stent placement demonstrating occlusion of the ICA. The MCA pseudoaneurysm was clipped. Lower Right: Left ICA angiogram demonstrating opacification of vessels in the right hemisphere via the anterior communicating artery.

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    Case 5. Upper Left: Initial left ICA angiogram revealing focal dissection of the petrous segment of the ICA with mild pseudoaneurysm formation (large arrow) and embolic occlusion of an MCA branch (small arrow). Upper Right: Repeated angiogram demonstrating significant enlargement of the pseudoaneurysm. Lower Left: Control angiogram obtained after covered stent placement demonstrating elimination of the pseudoaneurysm and a widely patent ICA. Lower Right: Thin-section CT scan revealing the position of the stent (arrows) within the carotid canal.

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    Case 6. Upper Left: Right ICA angiogram, lateral view, revealing a pseudoaneurysm and a high-flow fistula from the ICA to the jugular vein, which were created as a result of a gunshot wound. Upper Right: Left ICA angiogram with right ICA compression demonstrating that the upper extent of the fistulous communication is located just below the entrance to the carotid canal. Center Left: Control angiogram obtained immediately after tandem placement of three 12-mm covered stents. Elimination of the fistula and minimal extravasation of contrast material at the site of the pseudoaneurysm can be observed. Center Right: Repeated angiogram obtained 2 days later revealing complete occlusion of the pseudoaneurysm. Lower Left: A CT scan revealing the position of the stent (arrow) within the carotid canal. Lower Right: Coronal CT scan visualizing the entire length of the stents (arrows). The areas of overlap of the three stents placed in tandem are apparent.

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