Blunt neck (cerebrovascular) trauma

Blunt cerebrovascular injuries (BCVI – injuries to the carotid or vertebral arteries) are rare but can have devastating consequences. Due to the nature of the pathology, there is frequently a delay (hours to days) between the injury and development of stroke symptoms, leading to increased morbidity and mortality from delayed treatment. A high index of suspicion is therefore required.

Mechanisms of injury

  • Hyperextension and contralateral rotation of neck causing stretch of the vessels against the cervical vertebra
    • Most commonly from RTCs
  • Direct force to neck
    • Hanging/strangulation
    • Seat belt injuries
    • Direct blows (eg: cricket ball vs neck1)
  • Intraoral trauma
    • Eg: child falling with a spoon in their mouth
  • Base of skull fractures through carotid canal

The common pathology is an injury to the intima of the artery which can lead to dissection, occlusion or pseudoaneurysm formation.

 

Indications for investigation of BCVI

Certain clinical findings and risk factors are associated with a higher incidence of BCVI, and should therefore prompt further investigations.2

risk factors bcvi

 

signs BCVI

 

Investigations

The best initial investigation for BCVI is a CT angiogram study.

The gold standard test for detecting BCVI is formal angiography, but this is very rarely performed due to the significant risk of complications and poor accessibility at most centres.

Ultrasound has moderate sensitivity for carotid injuries (up to 86%), but detects vertebral artery injuries poorly.

MRA might be useful as a further investigation in some patients.

 

Management

The mainstay of treatment for BCVI is antithrombotic treatment (eg: heparin). Clearly this will be challenging if the patient has other significant injuries.

Some patients might have surgically accessible lesions amenable to operative management. Endovascular techniques may have a role in some patients.

No treatment should be commenced until the patient has been discussed with the vascular service

 

Disposition – interhospital transfer guidelines

BCVI destination

 

References

  1. http://www.news.com.au/sport/cricket/phillip-hughes-freak-accident-explained/news-story/85b83a32d05e7c3965cb84cec0c13d56

 

  1. Bromberg WJ, Collier BC, Diebel LN, Dwyer KM, Holevar MR, Jacobs DG, Kurek SJ, Schreiber MA, Shapiro ML, Vogel TR. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2010 Feb 1;68(2):471-7