The role of computed tomography angiography and digital subtraction angiography in the diagnosis and management of gunshot wounds to the head

Introduction: Traumatic intracranial pseudoaneurysms (TICAs) and penetrating cerebrovascular injuries (PCVI) complicate gunshot wounds to the head (GSWH) and other forms of penetrating traumatic brain injury (pTBI). Recent developments in neuroimaging have allowed early detection of these lesions in the minutes and hours following the initial injury. CT angiography (CTA) and digitally subtracted angiography (DSA) have different sensitivity, periprocedural risks, and logistical limitations. Growing evidence is defining their role in clinical practice. Methods: A systematic review of the literature was performed for published articles treating the use of CTA and DSA to diagnose PCVI and TICAs after pTBI and GSWH. Four series, three retrospective and one prospective, were selected for this review. Results: In three retrospective and one prospective series (with a sensitivity of ~70% in the former studies vs 36% in the latter), DSA emerges as the modality of choice to study the intracranial vasculature of patients that suffered pTBI. Nonetheless, the use of CTA in the first hours after the injury can provide a wealth of information in emergent scenarios where TICAs and PCVIs can significantly affect surgical management and risk. Further, a significantly higher incidence of TICAs was reported in the first hours after civilian GSWH via CTA. Conclusions: DSA and CTA emerged as two complementary techniques in the study and management of PCVI and TICA related to pTBI and GSWH. Their integration can provide a safe approach to the emergent surgical management of vascular lesions via CTA, allowing for delayed DSA characterization after neurological and hemodynamical stabilization.