Wartime traumatic aneurysms

Acute presentation, diagnosis, and multimodal treatment of 64 craniocervical arterial injuries

Randy S. Bell, Alexander Vo, Ryan Roberts, John Wanebo, Rocco A. Armonda

Research output: Contribution to journalArticle

48 Citations (Scopus)

Abstract

OBJECTIVE: Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management. METHODS: A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study. RESULTS: A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically. CONCLUSION: The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve.

Original languageEnglish (US)
Pages (from-to)66-79
Number of pages14
JournalNeurosurgery
Volume66
Issue number1
DOIs
StatePublished - Jan 2010

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Nervous System Trauma
Combined Modality Therapy
Aneurysm
Intracranial Aneurysm
Vascular System Injuries
Penetrating Head Injuries
Closed Head Injuries
2003-2011 Iraq War
Rupture
Arteries
Cerebral Angiography
Arteriovenous Fistula
Wounds and Injuries
Craniocerebral Trauma
Surgical Instruments
Population
Stents
Dissection
Inpatients

Keywords

  • Endovascular occlusion
  • Pseudoaneurysm
  • Traumatic intracranial aneurysms
  • Vascular complications of traumatic brain injury

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Wartime traumatic aneurysms : Acute presentation, diagnosis, and multimodal treatment of 64 craniocervical arterial injuries. / Bell, Randy S.; Vo, Alexander; Roberts, Ryan; Wanebo, John; Armonda, Rocco A.

In: Neurosurgery, Vol. 66, No. 1, 01.2010, p. 66-79.

Research output: Contribution to journalArticle

Bell, Randy S. ; Vo, Alexander ; Roberts, Ryan ; Wanebo, John ; Armonda, Rocco A. / Wartime traumatic aneurysms : Acute presentation, diagnosis, and multimodal treatment of 64 craniocervical arterial injuries. In: Neurosurgery. 2010 ; Vol. 66, No. 1. pp. 66-79.
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N2 - OBJECTIVE: Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management. METHODS: A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study. RESULTS: A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically. CONCLUSION: The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve.

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