Neck Vascular Injury in Blunt Force Trauma

Aka: Neck Vascular Injury in Blunt Force Trauma, Blunt Traumatic Cervical Vascular Injury, Cerebrovascular Injury, BCVI

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II. Definitions

  1. Blunt Traumatic Cervical Vascular Injury (BCVI, Cerebrovascular Injury)
    1. Blunt neck injury affecting the Vertebral Artery or Carotid Artery

III. Epidemiology

  1. Blunt Traumatic Cervical Vascular Injury (BCVI) Incidence: <3% of U.S. blunt Trauma patients

IV. Pathophysiology

  1. Occult vascular injury (even minimal intimal injury) may result in local thrombus formation
  2. Embolic Cerebrovascular Accident occurs when thrombus dislodges

V. Types

  1. Carotid Artery Injury in Blunt Neck Trauma
  2. Vertebral Artery Injury in Blunt Neck Trauma

VI. Mechanisms

  1. Direct Trauma
  2. High energy injury (excessive cervical motion)

VII. Signs

  1. Normal Neurologic Exam in up to 66% of patients on initial presentation
  2. Suspected arterial Hemorrhage from neck or face
  3. Cervical bruit in age <50 years old
  4. Expanding cervical Hematoma
  5. Focal neurologic deficit suspicious for CNS cause
    1. Transient Ischemic Attack
    2. Hemiparesis
    3. Vertebrobasilar In sufficiency symptoms
    4. Horner Syndrome
  6. Neurologic deficits not consistent with head imaging (or acute CVA on CT or MRI)

VIII. Precautions

  1. Do not allow a normal Neurologic Exam on initial presentation to dissuade from diagnostics when indicated
  2. Cervical Collars may obscure hard signs of Cerebrovascular Injury (e.g. cervical Hematoma, vascular bruit)

IX. Risk factors

  1. Pulsatile bleeding from oropharynx, nose or ear
  2. Expanding cervical Hematoma
  3. Lateralizing neurologic symptoms in a patient <50 years old
    1. Cerebrovascular Accident or TIA symptoms
    2. Hemiparesis
    3. Horner's Syndrome (Miosis, Ptosis and Anhidrosis)
      1. Sympathetic chain follows the the Carotid Artery and may predict carotid injury
  4. Near-Hanging Injury with anoxic brain injury
  5. Clothsline Injury or cervical Seat Belt Sign with swelling, pain or Altered Mental Status
    1. Isolated Seat Belt Sign alone (per West Assoc. Trauma Surgeons)
  6. Scalp Degloving
  7. Severe Traumatic Brain Injury
    1. Glasgow Coma Scale (GCS) <6
    2. Diffuse Axonal Injury
    3. Traumatic Brain Injury AND Thoracic Injury including thoracic vascular injury
  8. Severe Facial Fractures
    1. Displaced Le Fort II and Le Fort III Fractures
    2. MandibleFracture
  9. Complex Skull Fracture
    1. Basilar Skull Fractures (esp. petrous Temporal BoneFractures)
    2. Occipital Condyle Fracture
  10. Cervical Spine Injury
    1. High Cervical Spine Fractures (C1-C3 Fractures)
    2. Cervical Fracture affecting transverse process (contains Vertebral Artery)
    3. Cervical Spine subluxation or dislocation
  11. Upper Rib Fractures
  12. Non-contrast Head CT with Basilar Skull Fracture (esp. if air extending into internal carotid canal)
  13. Blunt cardiac rupture

X. Imaging

  1. CT neck angiography
    1. See Denver Screening Criteria for Blunt Cerebrovascular Injury for Indications (in addition to risk factors above)
    2. May demonstrate dissection flap, abruptly decreased vessel caliber or Occlusion
    3. Accuracy of CT angiography is imperfect
      1. Malhotra (2007) Ann Surg 246(4): 632-43 [PubMed]
  2. MR Angiography
    1. Not validated for Traumatic dissection
    2. Not recommended by East Assoc. Trauma Surgeons (possible reduced accuracy compared with CTA)

XI. Management

  1. Consult neurosurgery, vascular surgery or Trauma surgery
    1. Consider endovascular stenting
  2. Antithrombotic therapy (e.g. Aspirin for >=90 days)
  3. Repeat CT Angiogram in 7 days

XII. Complications

  1. Embolic Cerebrovascular Accident
    1. Patients with normal initial Neurologic Exam, 21.5% progressed to CVA at a mean of 75 hours after injury
      1. Cothren (2009) Arch Surg 144:685-90 [PubMed]
    2. Risk of CVA based on artery
      1. Carotid Artery Injury: 30% CVA risk
      2. Vertebral Artery Injury: 14% CVA risk
      3. Miller (2001) J Trauma 51:279-85 [PubMed]

XIII. References

  1. Broder (2021) Crit Dec Emerg Med 35(8): 10-1
  2. Arora and Menchine in Herbert (2015) EM:Rap 15(3): 8
  3. Spangler and Inaba in Herbert (2015) EM:Rap 15(11): 5-6
  4. Callcut (2012) J Trauma Acute Care Surg 72:338-45 [PubMed]

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