Penetrating intracranial trauma of two minors treated with endovascular technique with the use of temporary balloon occlusion for proximal arterial control

Abstract

We present two children treated with endovascular techniques to gain proximal arterial control of the internal carotid and vertebral artery prior to removal of penetrating objects from the skull base. Both siblings (8-month-old and 22-month-old boys) were injured by different sharp objects (knife and scissor) by a guardian. They were transported to the emergency room where vascular control, including coil embolisation and internal carotid balloon occlusion, was performed in the neuroendovascular suite for safe removal of penetrating objects. Both minors recovered and were discharged home without any focal neurological deficits. In two children with scissor and knife stab with intracranial penetration, endovascular technique allowed safe removal of objects and ensured proximal arterial control was maintained to control for possible extravasation of blood on removal from the skull base.

Background

Penetrating intracranial trauma in children is extremely rare. Utilisation of temporary balloon occlusion for proximal arterial control to remove penetrating intracranial objects has only been reported once before in the literature.¹ Cunningham et al demonstrated the first successful orbitocranial removal of a penetrating object from the cavernous sinus and orbit utilising temporary balloon occlusion of the cavernous carotid artery.¹ We present the first and second cases reported of successful simultaneous removal of penetrating objects from intracranial, intradural injuries suffered by two children treated with balloon occlusion of the internal carotid and vertebral artery and who both recovered and discharged home.

Case presentation

The two minors presented as trauma alerts via ground transport to a level II trauma centre. Intravenous access and fluids were given. Endotracheal intubation was achieved and central lines were placed by general surgery in the emergency room. The stabilisation of the minors allowed for CT scanning evaluation and endovascular intervention.

Case 1

An 8-month-old boy presented to the emergency department with a scissor stab to the left ear. The scissors entered the left temporal bone and extending to the left petroclival fissure, they entered the posterior fossa and crossed the anterior margin of the foramen magnum near the right vertebral artery.

Case 2

A 22-month-old boy presented to the emergency department with a knife stab to the face, skull base and brain (figure 1).

Figure 1.

AP chest X-ray of presenting trauma (Case 2). AP, anteroposterior position; CSF, cerebrospinal fluid; ENT, otolarynology.

Investigations

Case 1

A CT angiogram confirmed the location of an approximately 6-inch scissor abutting the right vertebral artery and ventral to the brainstem (figures 2 and 3). The patient was transported to the neuroendovascular lab for stabilisation and removal of the scissors. Diagnostic angiogram was performed of the right carotid and vertebral arteries.

Figure 2.

CT angiogram AP view demonstrating scissor abutting right vertebral artery and ventral to the brainstem (Case 1).

Figure 3.

CT angiogram lateral view demonstrating scissor abutting right vertebral artery and ventral to the brainstem (Case 1).

Case 2

The CT scan demonstrated the knife entered beneath the right jaw, traversing the external carotid circulation and retromandibular space, through the skull base, beneath the circle of Willis and into the left middle cerebral artery territory (figure 4). The path of the knife came in close proximity to the intracranial portion of the left internal carotid artery and crossed multiple branches of the right external carotid artery. In the neuroendovascular lab, cerebral angiography was performed of the right vertebral artery, right common carotid artery and left internal carotid artery. The right external carotid artery demonstrated a vascular stump with contrast extravasation.

Figure 4.

3D reconstruction of CT angiogram demonstrating knife crossing the right external carotid artery and entering the left middle cerebral artery territory (Case 2).

Treatment

Case 1

The right vertebral artery (V4 segment) was catheterised and a balloon positioned so that the proximal and distal portions of the balloon extended past the area of penetration of the scissor blade to control for possible extravasation of blood on removal from the skull base (figure 5). Once the balloon was inflated, ENT assisted in removal of the scissor blade and packed the ear to obtain haemostasis of the external canal. An external ventricular drain and later a lumbar drain were placed to treat CSF otorrhea. The CSF fistula continued to leak despite CSF diversion and a direct repair was performed on a delayed basis. Fat and fascial packing of the external auditory canal and skull base was required to stop the cerebrospinal fluid leak.

Figure 5.

Digital subtraction X-ray lateral view demonstrating balloon positioned within the right vertebral artery so that the proximal and distal portions of the balloon extended past the area of penetration of the scissor blade (Case 1).

Case 2

The internal maxillary artery appeared to be severed near the origin of the external carotid artery for which we performed coil embolisation of the internal maxillary artery and lingual artery (figure 6). Postembolisation angiography demonstrated that contrast extravasation of the external carotid artery had stopped. Balloon occlusion of the left internal carotid artery was performed across the petrous and ophthalmic segment of the carotid and provided proximal arterial control. The balloon was deflated with no evidence of contrast extravasation or pseudoaneurysm formation. Neck exploration and ligature of retromandibular vein were performed by ENT directly following knife pull, with the incision closed. A right frontal external ventricular drain was placed to treat the development of hydrocephalus and mild intraventricular haemorrhage.

Figure 6.

CT angiogram demonstrating coil embolisation of the right external carotid artery with a knife tip in the left middle cerebral artery territory (Case 2).

Outcome and follow-up

Case 1

The ventricular drain was eventually removed without further evidence of CSF leak. The patient was later discharged with partial hearing loss in the left ear. No permanent shunt was required. At last follow-up, 3 months following discharge, the boy was doing well and attaining all his milestones.

Case 2

The ventricular drain was later weaned without evidence of CSF fistula. No permanent CSF shunt was required. He had subtle leg weakness but was ambulating with a limp, which wore off throughout the day. The patient has no other lasting deficits, 3 months post discharge.

Discussion

Penetrating intracranial trauma in children is extremely rare. Compared with blunt head trauma, penetrating intracranial injury is more lethal due to the risk of vascular injury leading to intracranial bleeding and death.² Historically, management of penetrating objects focused on surgical removal. Peripheral endovascular treatment may be associated with reduced morbidity and mortality compared with surgical management.³ Endovascular management using balloon occlusion to gain proximal intraluminal control has been in use for over 30 years.⁴ Temporary balloon occlusion is widely used in medicine to gain proximal arterial control in trauma. One report of successful temporary balloon occlusion of the cavernous carotid artery for removal of a penetrating object from the cavernous sinus was found in the literature.¹ Permanent balloon occlusion with parent vessel sacrifice has been reported to treat stab injuries to the vertebral artery.⁵ However, with temporary balloon occlusion, we did not require sacrifice of parent vessel as temporary occlusion allowed for safe removal of the object and once no extravasation was observed, the balloon was deflated. We were prepared to utilise coil embolisation if extravasation occurred and did not cease with extended balloon occlusion. Endovascular techniques for treatment of stab injuries resulting in extracranial carotid artery transection are commonly managed with endovascular coiling.^{6 7} We performed coil embolisation of the internal maxillary and lingual artery prior to knife pull to stop extravasation from the severed vascular tree. This is the first and second cases that temporary balloon occlusion has been used for removal of penetrating intracranial, intradural objects as means for intraluminal control in two children. The treatment of two minors with use of balloon occlusion for proximal arterial control and coil embolisation adds to the body of the literature and provides a guide for future care, especially with regards to penetrating intracranial trauma.

Learning points.

• Temporary balloon occlusion ensured proximal arterial control in penetrating intracranial injury in two minors.

• Coil embolisation and temporary balloon occlusion allowed safe removal of intracranial penetrating objects from the skull base in two children.

• First report of two cases of intracranial, intradural injuries suffered by two children treated with temporary balloon occlusion of internal carotid and vertebral artery who recovered and discharged home.

• Guide for future endovascular care for penetrating intracranial trauma.