II. Epidemiology
- Traumatic Carotid Dissections are rare, but potentially devastating
- Traumatic Carotid Dissections are most common in children
- Children (esp. age <6 years old) account for 73% of Traumatic Carotid Dissections
- However occur in only 0.03% Pediatric Trauma patients
III. Pathophysiology
- Predisposing factors in adults
- Carotid Atherosclerosis increases risk of carotid dissection with direct Trauma
- Predisposing factors in children (higher risk than adults)
- Intimal tear risk at ICA as it enters skull base at carotid canal
- Children at risk for carotid overstretching due to excessive neck hyperextension and rotation
- Large head to body ratio,
- Cranial cervical instability (weak neck muscles, ligamentous instability risk)
IV. Background
- Blunt neck injury may result in occult and initially masked major neck vascular injury
- Risk of Carotid Artery Dissection and thrombosis
- May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
- Children are particularly high risk for missed injury (asymptomatic without initial neurologic signs)
V. Risk factors
- Pulsatile bleeding from oropharynx, nose or ear
- Expanding cervical hematoma
- Lateralizing neurologic symptoms in a patient <50 years old
- Cerebrovascular Accident or TIA symptoms
- Hemiparesis
- Horner's Syndrome (Miosis, Ptosis and Anhidrosis)
- Sympathetic chain follows the the Carotid Artery and may predict carotid injury
- Hanging injuries or "closelining" injuries
- Basilar Skull Fractures (esp. petrous Temporal BoneFractures)
- Low GCS with Diffuse Axonal Injury
- Severe Facial Fractures (e.g. Le Fort II and Le Fort III Fractures)
- High Cervical Spine Fractures (C1-C3 Fractures)
- Isolated Seat Belt Sign (per West Assoc. Trauma Surgeons)
- Non-contrast Head CT with Basilar Skull Fracture (esp. if air extending into internal carotid canal)
VI. Imaging
- CT neck angiography
- See Denver Screening Criteria for Blunt Cerebrovascular Injury for Indications (in addition to risk factors above)
- Accuracy of CT angiography is imperfect
- MR Angiography
VII. Management
- Consult neurosurgery, vascular surgery or Trauma surgery
- Anticoagulation
VIII. References
- Arora and Menchine in Herbert (2015) EM:Rap 15(3): 8
- Spangler and Inaba in Herbert (2015) EM:Rap 15(11): 5-6