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.

 

Investigations

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

 

BLUNT CEREBROVASCULAR INJURY (BCVI): EXPANDED DENVER CRITERIA RISK FACTORS FOR ADULTS >15 years 

(endorsed by NRTN and Regional Radiology Network June 2026)

 

CT carotid angiogram to be performed within 6 hours for:

• Le Fort II or II displaced midface fracture
• Mandible fracture from high-energy mechanism of injury
• Complex skull fracture
• Base of skull fracture
• Scalp degloving
• Cervical spine fracture, subluxation, or ligamentous injury at any level
• Severe TBI (with GCS < 6)
  • Intracranial haemorrhage, contusion or DAI
• Near hanging with anoxic brain injury
• Clothesline-type injury of seat belt abrasions with significant swelling, pain, or altered mental status
• CT evidence of TBI with thoracic injuries
• Upper rib fractures (ribs 1-3)
• Thoracic vascular injuries

For reference: Denver BCVI grading scale

I    Luminal irregularity or dissection with < 25% stenosis

II   Dissection of intramural hematoma with > 25% stenosis

III  Pseudoaneurysm

IV  Occlusion

V  Transection with extravasation

 

Management

 

 

 

Disposition – interhospital transfer guidelines

 

References

1. http://www.news.com.au/sport/cricket/phillip-hughes-freak-accident-explained/news-story/85b83a32d05e7c3965cb84cec0c13d56
2. 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