Blunt Cerebrovascular Injury
Other Names
- Blunt cerebrovascular injury (BCVI)
- Traumatic carotid artery injury (TCAI)
- Traumatic vertebral artery injury (TVAI)
- Blunt traumatic cervical vascular injury (BCVI)
- Blunt Carotid Injury (BCI)
- Blunt Vertebral Artery Injury (BVI)
- Traumatic Cervical Arterial Injury
- Blunt Neck Arterial Trauma
Background
- This page covers traumatic cervical vascular injuries in athletes
- This includes blunt and penetrating
- And includes both vertebral and carotid arteries
- Frequently termed traumatic vertebral artery injury (TVAI) and traumatic carotid artery injury (TCAI)
History
- Traumatic vertebral artery injury First described by Matas in 1893[1]
Epidemiology
Introduction
General
- BCVI is characterized by occlusion or insult to the cerebrovascular circulation can occur spontaneously or due to trauma
- Trauma is most commonly blunt, but may also be penetrating
- Blunt cerebrovascular injury (BCVI) includes any form of non-penetrating injury to the internal carotid and vertebral arteries
- Pathology to the artery can include dissection, thrombosis, aneurysms, pseudoaneurysms, arteriovenous fistula formation, transection or vasospasm
Terminology
- Blunt cerebrovascular injury (BCVI): umbrella term for blunt traumatic injury to carotid and vertebral arteries[7]
- Blunt carotid artery injury (BCAI): injuries specific to the carotid arteries
- Blunt vertebral artery injury (BVAI): injuries specific to the vertebral arteries
Blunt Carotid Artery Injury (BCAI)
- Represents about half of all BCVI with the other half being vertebral artery injuries[8]
- Includes dissection (most common), pseudoaneurysm formation, intramural hematoma, thrombotic occlusion, and vessel transection
Blunt Vertebral Artery Injury (BVAI)
- Most commonly seen in young men following blunt trauma including MVC, hanging and sporting injuries
- May be difficult to diagnosis due to high mortality rate and occurrence of other significant injuries
- Literature discusses cervical spine flexion-distraction, flexion-compression, hyperextension, rotation and direct impact as causes of TVAI
- Hyperextension appears to most significantly associated[9]
Pathoanatomy
- Common Carotid Artery
- Branches into Internal Carotid Artery and External Carotid Artery
- Internal branch is responsible for helping form the circle of willis and providing cerebral blood flow
- External branch helps supple blood to the face and neck
- Vertebral Artery
- Branch off the Subclavian Artery and travel to the bran to form the Basilar Artery
- Provides primary circulation to vertebrobasilar system, posterior cerebrum
- Traverses the Cervical Vertebral Bodies
Associated Injuries
- Any cervical spine fracture
- Especially C1-C3
- Up to 24% of patients with cervical spine injury have concomitant vertebral artery injury[10]
- Atlanto Occipital Dissociation
- Concussion
- Traumatic Brain Injury
- Skull Base Fractures
- Skull base fracture is the strongest traumatic risk factor for BCVI overall (OR 3.61)[11]
- Facial Fractures
Risk Factors
- Cervical Spine Fracture (70-78%)[12]
- Sports
- Unknown
- Systemic Illness
- Ankylosing spondylitis
- Diffuse idiopathic skeletal hyperostosis
Differential Diagnosis
Differential Diagnosis Neck Pain
- Fractures
- Subluxations and Dislocations
- Neuropathic
- Muscle and Tendon
- Pediatric/ Congenital
- Other Etiologies
Clinical Features
History
- Nearly universally, patients or observers will describe high energy trauma
- Patients will endorse symptoms attributed to injury of the posterior circulation including[13]
- Headache
- Dizziness
- Nausea
- Vomiting
- Reduced GCS
- Vision or speech disturbance
- Gbnormalities in gait
- Unfortunately, a high percentage of patients are asymptomatic
- Others have delayed presentation or concomitant head injury making diagnosis more challenging
Physical Exam: Physical Exam Neck
- Careful exam looking for evidence of vascular injury and associated trauma patterns
- Careful evaluate for bruit, hematoma, hemorrhage
- Thorough neurological exam
- Examinations should be performed serially
Evaluation
Modified Denver Screening Criteria
- CTA indicated to evaluate for BCVI if individual meets any of the following[16]
- Signs and Symptoms
- Arterial hemorrhage
- Cervical bruit
- Expanding neck hematoma
- Focal neurologic deficit
- Neuro exam inconsistent with head CT
- Stroke on head CT
- Risk Factors
- Midface Fractures (Le Fort II or III)
- Basilar Skull Fracture with carotid canal involvement
- Diffuse axonal injury with GCS<6
- Cervical spine fracture
- Hanging with anoxic brain injury
- Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status
Radiographs
- Standard Cervical Spine Radiographs
- May be indicated in some cases
- However in the setting of high energy trauma, CT should be seriously considered
CT
- Gold standard for cervical spine trauma
- Angiography necessary to visualize vertebral and carotid arteries
- Eastman et al on CTA for BCVI[17]
- Sensitivity: 97.7%
- Specificity: 100%
- PPV: 100%
- NPV: 99.3%
MRA
- MR Angiography represents a strong alternative to CT
- Benefits include lack of contrast, absence of radiation, better evaluation of brain parenchema
- Sensitivity still lacking ranging from 47-75%[18]
Ultrasound
- Not recommended as a screening tool for blunt cerebrovascular injury
- 38% sensitive for detecting BCVI[19]
Other
- Digital subtraction angiography may be an option in select cases
- Largely replaced by CTA and MRA
Classification
| Injury grade | Descriptions | Stroke rate (%) | Mortality rate (%) |
| Grade I | Luminal irregularity with <25% narrowing | 3 | 11 |
| Grade II | Dissection or intramural haematoma with 25% or greater narrowing, intraluminal thrombus or raised intimal flap | 11 | 11 |
| Grade III | Pseudoaneurysm | 33 | 11 |
| Grade IV | Occlusion | 44 | 22 |
| Grade V | Transection with extravasation | 100 | 100 |
Management
General Principles
- Untreated has very high morbidity and mortality rates depending on the grade of injury
- Treatment is directed at reducing the risk of neurological sequela and death[23]
- No high level treatment guidelines
- Management is thus generally controversial and not based on level 1 evidence
Nonoperative
- Management should be made in conjunction with specialists
- May include vascular surgery, neurosurgery, ENT, Interventional Radiology, Neurology
- Anticoagulation & Antiplatelet therapy
- Mainstay treatment of BCVI and should be initiated as early as possible
- Goal is to prevent thrombus formation
- Optimal treatment algorithm is unclear
- In one cohort, treatment with unfractionated heparin reduced stroke rate from 21% to 0.5%[24]
- Antiplatelet and anticoagulation agents were found to be equally effective in preventing stroke
- Stein et al had similar findings[25]
Procedural
- Endovascular therapy
- Indications: unclear
- Options include stent, occlusion of vertebral artery, coil embolization of pseudoaneurysm
- Some studies have reported significant complication rates[26]
Operative
- Surgical access to vertebral artery is challenging and a last resort
Rehabilitation and Return to Play
Rehabilitation
- A graduated rehabilitation protocol should include
- Neurological clearance with documented vessel healing on imaging
- Completion of antithrombotic therapy (minimum 3 months)
- Gradual activity progression under medical supervision, monitoring for symptoms
- Multidisciplinary evaluation involving neurosurgery, sports medicine, and athletic training
Return to Play
- There is no standardized, evidence-based return to play protocol specifically for athletes with blunt cerebrovascular injury (BCVI)
- Return to play decisions must be highly individualized considering:
- Injury grade
- Documented vessel healing on follow-up imaging
- Completion of antithrombotic therapy
- Absence of neurological symptoms
- Based on expert opinion for sport-related structural brain injuries[27]
- Majority of neurosurgeons allow return to high-contact/collision sports at 6-12 months following resolved hemorrhage
- Approximately 80% not endorsing return if persistent vascular abnormalities remain
Prognosis and Complications
Prognosis
- General
- Untreated BCVI has very high morbidity and mortality rates depending on the grade of injury
- Treatment is directed at reducing the risk of neurological sequela and death[28]
- Risk of stroke/ death
- BCVI carries a significant risk of stroke (7.7% overall incidence) and death (12% overall mortality)[29]
- Both risks increasing substantially with higher injury grades
- Untreated BCVI results in stroke in 10-40% of patients
- Untreated carotid and vertebral artery injuries carry mortality rates as high as 38% and 18%, respectively[30]
- Prognostic Factors[31]
- Higher injury grades (III and IV) are associated with significantly increased stroke risk
- Carotid artery injuries carry nearly twice the stroke risk compared to vertebral artery injuries
- Combined carotid and vertebral injuries increase stroke risk
Complications
- Stroke
- Death
- Permanent disability
- Inability to return to work/sport
See Also
Internal
External
- Sports Medicine Review Neck Pain: https://www.sportsmedreview.com/by-joint/neck/
References
- ↑ Matas R. Traumatisms and Traumatic Aneurisms of the Vertebral Artery and Their Surgical Treatment with the Report of a Cured Case. Ann Surg 1893;18:477-521. 10.1097/00000658-189307000-00079
- ↑ Cothren CC, Moore EE, Ray CE, Jr, et al. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. Surgery 2007;141:76-82. 10.1016/j.surg.2006.04.005
- ↑ Bruns BR, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691–5
- ↑ Montoya, F., et al. "Incidence of Blunt Brain and Neck Injury by Blast in Colombian Military Personnel: A Cases Review." J Clin Med Res 4.3 (2022): 1-15.
- ↑ 5.0 5.1 Nagpal, P., et al. "Blunt cerebrovascular injuries: advances in screening, imaging, and management trends." American Journal of Neuroradiology 39.3 (2018): 406-414.
- ↑ De Wilde, David. Wall shear stress metrics and their relation to atherosclerosis: an experimental and computational study in mice. Diss. Ghent University, 2016.
- ↑ Rutman, Aaron M., Justin E. Vranic, and Mahmud Mossa-Basha. "Imaging and management of blunt cerebrovascular injury." Radiographics 38.2 (2018): 542-563.
- ↑ Scott, William W., et al. "Clinical and radiographic outcomes following traumatic Grade 3 and 4 carotid artery injuries: a 10-year retrospective analysis from a Level 1 trauma center. The Parkland Carotid and Vertebral Artery Injury Survey." Journal of neurosurgery 122.3 (2015): 610-615.
- ↑ Nakajima H, Nemoto M, Torio T, et al. Factors associated with blunt cerebrovascular injury in patients with cervical spine injury. Neurol Med Chir (Tokyo) 2014;54:379-86. 10.2176/nmc.oa.2013-0135
- ↑ American College of Surgeons (2022). 2022. Gregory D. Schroeder MD, Alexander R. Vaccaro MD PhD MBA, William C. Welch MD FACS FAANS FICS FAANOS, et al
- ↑ Grigorian, Areg, et al. "Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria." Surgery 164.3 (2018): 494-499.
- ↑ 12.0 12.1 Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg 2000;231:672-81. 10.1097/00000658-200005000-00007
- ↑ deSouza RM, Crocker MJ, Haliasos N, et al. Blunt traumatic vertebral artery injury: a clinical review. Eur Spine J 2011;20:1405-16. 10.1007/s00586-011-1862-y
- ↑ Sliker, Clint W. "Blunt cerebrovascular injuries: imaging with multidetector CT angiography." Radiographics 28.6 (2008): 1689-1708.
- ↑ Avila, Stephanie V., et al. "Bilateral blunt cerebrovascular injury resulting in direct carotid-cavernous fistulae: a case report and review of the literature." Surgical Neurology International 9 (2018): 229.
- ↑ Bromberg, William. et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010.
- ↑ Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma 2006;60:925-9; discussion 9.
- ↑ Shafafy, Roozbeh, et al. "Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence." Journal of Spine Surgery 3.2 (2017): 217.
- ↑ Mutze S, Rademacher G, Matthes G, et al. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology 2005;237:884-92. 10.1148/radiol.2373042189
- ↑ Kim, Michael, et al. "Neuroendovascular surgery applications in craniocervical trauma." Biomedicines 11.9 (2023): 2409.
- ↑ Witt, Cordelie E., and Clay Cothren Burlew. "Evaluation and management of blunt cerebrovascular injury." JAMA surgery 156.2 (2021): 193-194.
- ↑ Brommeland, Tor, et al. "Best practice guidelines for blunt cerebrovascular injury (BCVI)." Scandinavian journal of trauma, resuscitation and emergency medicine 26.1 (2018): 90.
- ↑ DiCocco JM, Fabian TC, Emmett KP, et al. Functional outcomes following blunt cerebrovascular injury. J Trauma Acute Care Surg 2013;74:955-60.
- ↑ Cothren CC, Biffl WL, Moore EE, et al. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg 2009;144:685-90.
- ↑ Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma 2009;66:132-44; discussion 143-4.
- ↑ Cothren CC, Moore EE, Ray CE, et al. Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits. Arch Surg 2005;140:480-5; discussion 5-6.
- ↑ Zuckerman, Scott L., et al. "Sport-related structural brain injury and return to play: systematic review and expert insight." Neurosurgery 88.6 (2021): E495-E504.
- ↑ DiCocco JM, Fabian TC, Emmett KP, et al. Functional outcomes following blunt cerebrovascular injury. J Trauma Acute Care Surg 2013;74:955-60.
- ↑ Russo, Rachel, et al. "Contemporary Outcomes and Management of Blunt Cerebrovascular Injuries: Results from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) Multicenter Registry." Journal of Trauma and Acute Care Surgery (2021).
- ↑ Stone, David K., Vyas T. Viswanathan, and Christina A. Wilson. "Management of blunt cerebrovascular injury." Current neurology and neuroscience reports 18.12 (2018): 98.
- ↑ Tran, Alexandre, et al. "Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis." Injury 55.3 (2024): 111319.