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.