Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

: 2012  |  Volume : 22  |  Issue : 4  |  Page : 350--357

Pictorial essay: Vascular interventions in extra cranial head and neck

Suyash S Kulkarni, Nitin S Shetty, Tejas P Dharia, Ashwin M Polnaya 
 Department of Radiodiagnosis, Tata Memorial Centre, Parel, Mumbai, India

Correspondence Address:
Nitin S Shetty
Department of Radiodiagnosis, Tata Memorial Hospital, Parel, Mumbai - 400 012


Medicine is an ever changing field and interventional radiology (IR) procedures are becoming increasingly popular because of high efficacy and its minimally invasive nature of the procedure. Management of disease processes in the extra cranial head and neck (ECHN) has always been a challenge due to the complex anatomy of the region. Cross sectional imaging of the ECHN has grown and evolved tremendously and occupies a pivotal and integral position in the clinical management of variety of head and neck pathologies. Advances in angiographic technologies including flat panel detector systems, biplane, and 3-dimensional rotational angiography have consolidated and expanded the role of IR in the management of various ECHN pathologies. The ECHN is at cross roads between the origins of great vessels and the cerebral vasculature. Thorough knowledge of functional and technical aspects of neuroangiography is essential before embarking on head and neck vascular interventions. The vessels of the head and neck can be involved by infectious and inflammatory conditions, get irradiated during radiotherapy and injured due to trauma or iatrogenic cause. The ECHN is also a common site for various hypervascular neoplasms and vascular malformations, which can be treated with endovascular and percutaneous embolization. This pictorial essay provides a review of variety of ECHN pathologies which were managed by various IR procedures using different approaches.

How to cite this article:
Kulkarni SS, Shetty NS, Dharia TP, Polnaya AM. Pictorial essay: Vascular interventions in extra cranial head and neck.Indian J Radiol Imaging 2012;22:350-357

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Kulkarni SS, Shetty NS, Dharia TP, Polnaya AM. Pictorial essay: Vascular interventions in extra cranial head and neck. Indian J Radiol Imaging [serial online] 2012 [cited 2019 Nov 12 ];22:350-357
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Full Text


Interventional Radiology (IR) has evolved rapidly in past two decades with advancement in imaging technology. There has also been significant improvement and development of more sophisticated hardware with the help of which it is possible to target any vascular territory in the body and carry out therapeutic procedures by minimally invasive technique.

The head and neck region is unique in terms of the critical anatomy and vital neurovascular structures involved. It needs detailed knowledge of the head and neck vascular anatomy and special technique to perform vascular IR procedure in extra cranial head and neck (ECHN). [1]

The pathologies where IR can offer minimally invasive treatment include vascular malformations, tumor embolization, and ECHN bleeding.

Vascular malformations

ECHN vascular malformations usually cause cosmetic as well as functional disability. [2] The slow flow type of venous and lymphatic malformations respond very well to percutaneous sclerotherapy with sclerosing agents like sodium tetradecyl sulfate (STS), polidocanol sulfate, or ethanol [1] [Figure 1]. Other abnormalities like plunging ranula, sialocele, and other benign cysts also respond well to percutaneous sclerotherapy. [3]{Figure 1}

High flow arteriovenous malformations (AVM) of ECHN present with disfigurement or episodes of bleeding. They need to be managed by multi specialty team where IR has an important role to embolize the abnormal vascularity, which can be followed by surgery to completely remove the lesion. [3],[4] When AVM is extensive with involvement of bones and soft tissues, multiple sessions of embolization by transarterial route or direct puncture using liquid embolizing agents like onyx [ev3, Irvine, USA] or n-BCA (n-Butyl-2-Cynoacrylate) glue [Bbraun, Aesculap, Germany] would be required [5] [Figure 2]. In cases where transarterial approach is precluded due to previous surgical ligation of external carotid artery (ECA), percutaneous route is used for embolization. However, transarterial embolization can still be performed by gaining vascular access into one of the superficial ECA branch after surgical dissection [Figure 3].{Figure 2}{Figure 3}

Approximately, 75-95% of patients with low flow venous malformation show good results with ethanol or STS [6],[7] while poor outcome is seen with diffuse AVM. [8]

Tumor embolization

ECHN tumors need embolization procedure for some highly vascular tumors like juvenile nasopharyngeal angiofibroma (JNA) and glomus tumors either preoperatively or to stop an episode of bleeding. Similarly, other tumors like hypervascular metastases, schwannomas, plasmacytomas, chordomas, and hemangiopericytomas may also need preoperative embolization. [1] Benign vascular lesions like hemangiomas can be effectively treated by embolization and surgery may be avoided [Figure 4].{Figure 4}

Preoperative embolization of ECHN tumors is frequently performed by transarterial route. Preoperative embolization helps to prevent blood loss during surgery and provides a clean field for the surgical resection [1] [Figure 5]. During transarterial tumor embolization, the feeders from ECA are super selectively catheterized using micro catheter to prevent nontarget embolization. Commonly used embolizing materials are particulate embolizing agents like polyvinyl alcohol (PVA) particles, [Cook Incorporated, Bloomington, USA], embospheres [Biosphere Medical SA, Paris, France] in the size range of 100-300 microns. The aim of embolization is to inject the particles in the arteriolar capillary bed of tumor parenchyma, so that collateral circulation does not develop rapidly. [9] Coil embolization of feeding arteries is not routinely performed when open surgical resection is planned. However, as endoscopic resection of skull base tumors is being increasingly performed, proximal coil embolization of the feeding artery (e.g., internal maxillary artery coiling in case of JNA) after particulate embolization of tumor bed provides additional protection from possible avulsion of the vessel and intraoperative bleed.{Figure 5}

Tumors involving the skull base frequently derive blood supply from ophthalmic or petrous branches of internal carotid artery (ICA). The ICA branches are often difficult to cannulate and there is considerable risk of reflux of the embolic agent with nontarget embolization if transarterial embolization of the ICA feeders are attempted. The territory supplied by ICA can be then be safely embolized by directly puncturing the tumor and injecting liquid embolizing agents like NBCA glue or onyx [10] [Figure 6]. The approach could be either percutaneous, transnasal, or transoral depending on the location of tumor. Though in most cases preoperative embolization is done electively a day or two prior to surgery, it can also be performed intraoperatively by direct puncture of tumor under vision and embolization under fluoroscopic guidance [Figure 7].{Figure 6}{Figure 7}

Extreme care should be taken to prevent the embolizing agent from entering ophthalmic artery or vital circulation of brain. The interventional radiologist should be aware about the potentially dangerous anastomosis between the ECA and ICA and should carefully watch for opening of these collaterals during ECHN embolization. [11]

In situations where internal carotid artery is encased by the tumor, surgical resection would be difficult with high risk of injury to the artery. In such cases a balloon test occlusion (BTO) is performed to assess the ipsilateral cerebral circulation from opposite carotid or vertebra-basilar circulation. If patient tolerates BTO, the involved carotid artery can be safely occluded using coils or detachable balloons [10],[11] [Figure 8].{Figure 8}

Overall, preoperative embolization is a safe procedure and serious complications occur in less than 2% patients that includes facial numbness, mucosal necrosis, blindness, or cerebrovascular accident. [12],[13] Preoperative embolization is not only cost effective, it reduces the morbidity by reducing blood loss and operative time, shortens the hospital stay while reducing the rate of tumor recurrence. [14]

Management of head and neck bleeding

Bleeding in ECHN manifests as epistaxis, hematemesis, or bleeding from an open wound or ulcer. [15] Various causes of bleed include craniofacial injury, infections, tumors, surgery, and vascular abnormalities while medical causes like hypertension and anticoagulation therapy [Figure 9].{Figure 9}

Treatment is often variable and multidisciplinary approach is required for successful outcome. Preprocedure computed tomography (CT) angiography helps in identifying the likely source and cause of bleed while also exquisitely depicting the anatomy. [16] Subclavian, carotid, and vertebral artery angiograms are obtained to identify and target the culprit vessel. Endovascular treatment is safe and effective option in the management of these patients. [17]

Bleeding from head and neck malignancy

Endovascular treatment is increasingly being preferred in the management of bleeding from ECHN malignancies as compared with traditional open surgical approach and ligation of involved vessels. [18] Difficult postoperative anatomy, radiation effects, infections preclude safe, and effective surgery in these patients. Angioembolization has been proven to be effective with minimal risk of complications in a few reported series. [19] Goal of endovascular therapy is complete devascularization of the tumor by embolizing the tumor bed. This can be achieved by superselective catheterization of target vessels by microcatheter and embolizing with particulate embolic agents (e.g. PVA/embospheres of size 100-300 micron) [Figure 10].{Figure 10}

Carotid artery blow out

Carotid artery in ECHN is vulnerable to rupture by trauma, infection, malignancy, and iatrogenic injury. Radiotherapy to head and neck malignancy increases the risk of carotid blow out by 7.6-fold. [15] Posttraumatic and iatrogenic vascular injuries can be potentially life threatening though carotid injury is seen in less than 1% of blunt head and neck trauma. [20] Carotid blow out patient usually presents with neck swelling or bleed from nose or mouth which could be sentinel or massive. Carotid blow out can be accurately diagnosed by CT angiography and definitive treatment can be planned by knowing the exact size and location. The blow out can be seen in common carotid, internal, or ECA and imaging would reveal either a pseudoaneurysm or an active bleed. [15],[16] The clinical presentation and imaging findings demands the endovascular treatment to be performed on an emergency or semi-emergency basis.

The common carotid and internal carotid artery blow out can be treated by endovascular placement of covered stent [Figure 11] and [Figure 12]. This not only achieves immediate hemostasis but also maintains patency of lumen and blood flow to the brain. [15],[21],[22] Patients requiring stent graft placements need to be administered with antiplatelets before and after the procedure. [15] However, if placement of stent graft becomes technically difficult, the diseased carotid artery can be occluded after confirming adequate cross flow from the contralateral carotid or vertebrobasilar circulation by BTO [15] [Figure 13]. Rarely, in case of uncontrolled massive bleeding after skull base surgery, failed attempt to deploy stent graft mandates immediate occlusion of carotid artery to prevent death from exsanguination [15] [Figure 14].{Figure 11}{Figure 12}{Figure 13}{Figure 14}

Blow out of ECA or its branch is usually treated by embolizing the culprit vessel both proximal and distal to the pseudoaneurysm [Figure 15]. The carotid artery can be permanently occluded using coils or balloons and approximately 15-20% would develop cerebral ischemia. [15]{Figure 15}

At times, penetrating injuries could result in the formation of complex arterio-venous fistulae, which can be effectively treated by minimally invasive endovascular means using balloons and coils for flow modification [23],[24] [Figure 16].{Figure 16}

Overall, IR can provide a wide spectrum of procedures for the effective management of various vascular ailments involving the head and neck region with a minimally invasive approach, where recovery of patient is faster and morbidity significantly less.


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