II. Epidemiology

  1. Traumatic Carotid Dissections are rare, but potentially devastating
  2. Traumatic Carotid Dissections are most common in children
    1. Children (esp. age <6 years old) account for 73% of Traumatic Carotid Dissections
    2. However occur in only 0.03% Pediatric Trauma patients

III. Pathophysiology

  1. Predisposing factors in adults
    1. Carotid Atherosclerosis increases risk of carotid dissection with direct Trauma
  2. Predisposing factors in children (higher risk than adults)
    1. Intimal tear risk at ICA as it enters skull base at carotid canal
    2. Children at risk for carotid overstretching due to excessive neck hyperextension and rotation
      1. Large head to body ratio,
      2. Cranial cervical instability (weak neck muscles, ligamentous instability risk)

IV. Background

  1. Blunt neck injury may result in occult and initially masked major neck vascular injury
  2. Risk of Carotid Artery Dissection and thrombosis
  3. May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
    1. Children are particularly high risk for missed injury (asymptomatic without initial neurologic signs)

V. 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. Hanging injuries or "closelining" injuries
  5. Basilar Skull Fractures (esp. petrous Temporal BoneFractures)
  6. Low GCS with Diffuse Axonal Injury
  7. Severe Facial Fractures (e.g. Le Fort II and Le Fort III Fractures)
  8. High Cervical Spine Fractures (C1-C3 Fractures)
  9. Isolated Seat Belt Sign (per West Assoc. Trauma Surgeons)
  10. Non-contrast Head CT with Basilar Skull Fracture (esp. if air extending into internal carotid canal)

VI. Imaging

  1. CT neck angiography
    1. See Denver Screening Criteria for Blunt Cerebrovascular Injury for Indications (in addition to risk factors above)
    2. 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)

VII. Management

  1. Consult neurosurgery, vascular surgery or Trauma surgery
  2. Anticoagulation

VIII. References

  1. Arora and Menchine in Herbert (2015) EM:Rap 15(3): 8
  2. Spangler and Inaba in Herbert (2015) EM:Rap 15(11): 5-6

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