Fig. 6.

Biffl grade 5: A 23-year-old male sustained a gunshot wound to the head and neck with multiple skull and facial fractures. Computed tomography angiographic demonstrated occlusion of the left cervical internal carotid artery (ICA) and reconstitution of the supraclinoid left ICA (images not shown). Digital subtraction angiographic (DSA) images ( a, c, e —anteroposterior projections; b, d, f —lateral projections) from a left injection demonstrated a Biffl grade 5 injury with extravasation (black arrows) from a transected left cervical ICA ( a, b ). He underwent emergent endovascular coil and glue embolization for sacrifice of the proximal left ICA stump ( c, d ). DSA images from a right injection demonstrated continued extravasation due to retrograde filling of the distal end of the transected left ICA via collateral flow ( e ). This was treated with coil occlusion of the left ICA distal to the transection ( f ) via retrograde access from the right ICA across the anterior communicating artery. There is also early venous drainage (gray arrowheads) indicative of an arteriovenous fistula ( a, b, e, f ).