We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Cervical Vascular Injuries
From WikiSM
Contents
Other Names
- Blunt cerebrovascular injury (BCVI)
- Traumatic carotid artery injury (TCAI)
- Traumatic vertebral artery injury (TVAI)
- Blunt traumatic cervical vascular injury (BCVI)
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
- TVAI
- First described by Matas in 1893[1]
Epidemiology
Pathophysiology
- 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
TVAI
- 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[4]
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
- Atlanto Occipital Dissociation
Risk Factors
- Cervical Spine Fracture (70-78%)[5]
- Sports
- Needs to be updated
- Systemic Illness
- Ankylosing spondylitis
- Diffuse idiopathic skeletal hyperostosis
Differential Diagnosis
- Fractures
- Subluxations and Dislocations
- Neuropathic
- Muscle and Tendon
- Pediatric/ Congenital
- Other Etiologies
Clinical Features
- General: Physical Exam Neck
- History
- Nearly universally, patients or observers will describe high energy trauma
- Patients will endorse symptoms attributed to injury of the posterior circulation including: headache, dizziness, nausea, vomiting, reduced GCS, vision or speech disturbance and abnormalities in gait[6]
- Unfortunately, a high percentage of patients are asymptomatic
- Others have delayed presentation or concomitant head injury making diagnosis more challenging
- Physical Exam
- Careful evaluate for bruit, hematoma, hemorrhage
- Thorough neurological exam
- Examinations should be performed serially
- Special Tests
Evaluation
Modified Denver Screening Criteria
- CTA indicated to evaluate for BCVI if individual meets any of the following[7]
- 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[8]
- 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%[9]
Ultrasound
- Not recommended as a screening tool for blunt cerebrovascular injury
- 38% sensitive for detecting BCVI[10]
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
Traumatic vertebral artery injury (TVAI)
Prognosis
- 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[11]
- 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
- 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%[12]
- Antiplatelet and anticoagulation agents were found to be equally effective in preventing stroke
- Stein et al had similar findings[13]
- Endovascular therapy
- Indications: unclear
- Options include stent, occlusion of vertebral artery, coil embolization of pseudoaneurysm
- Some studies have reported significant complication rates[14]
Operative
- Surgical access to vertebral artery is challenging and a last resort
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Stroke
- Death
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
- ↑ 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
- ↑ 5.0 5.1 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
- ↑ 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
- ↑ 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.