Traumatic aneurysms and arteriovenous fistulas of the extracranial vessels in war injuries

BACKGROUND Extracranial vessel injuries are potentially devastating complications of penetrating head and neck wounds associated with war conflicts. These vasculopathies may be occlusive or they may lead to formation of traumatic aneurysms (TA) and arteriovenous fistulae (AVF). Even though these penetrating injuries are usually clinically silent and often appear only as small superficial wounds, they may lead to catastrophic hemorrhage or vascular insult. In this study, we attempted to elucidate signs, symptoms and circumstances present in these victims who are at risk of harboring an occult vasculopathy, excluding the occlusive ones and concentrating primarily on TAs and AVFs. MATERIALS AND METHODS In a prospective study conducted during 8 years of war between Iran and Iraq, we encountered 13 cases of traumatic vasculopathies of the extracranial carotid and vertebral arteries. The type and number of injuries were: carotid-jugular fistula (CJF) 3, carotid trunk or branch aneurysm (CA) 2, superficial temporal artery aneurysm (STA) 3, vertebral artery aneurysm (VA) 2, vertebral arteriovenous fistula (VAVF) 1, ophthalmic artery aneurysm (Oph. An.) 1, and lingual artery aneurysm (Lin. An.) 1. Angiography was performed between the 5th and 30th day after the injury and surgical intervention was performed in all cases. RESULTS The Glasgow outcome scale (GOS) score was 13-15 in all victims at the time of discharge from the base hospital without any additional neurological deficit. The follow-up period varied from 5 to 8 years in all cases in whom no further morbidity or mortality occurred. Single photon emission computed tomography was the noninvasive tool used for measurement of cerebral blood flow in the cases in which a major vessel ligation was performed; no remarkable change in cerebral blood flow was noted. CONCLUSION Early recognition of stigmas suggesting possible formation of extracranial traumatic vasculopathies such as TAs or AVFs in the difficult situation of war frontier hospitals should be highlighted for attending physicians or younger neurosurgeons. Performing angiography promptly in suspected cases can pick up such traumatic vascular lesions earlier. Using simpler surgical techniques in situations in which more sophisticated endovascular equipment is unavailable can be life-saving for these usually young victims. (C) 2000 by Elsevier Science Inc.