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Cervical Vascular Injuries

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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

  • TVAI is more common than TCAI[2]
  • BCVI estimated to occur in 1-2% of all blunt trauma[3]

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

Associated Injuries


Risk Factors

  • Cervical Spine Fracture (70-78%)[5]
  • Sports
    • Needs to be updated
  • Systemic Illness
    • Ankylosing spondylitis
    • Diffuse idiopathic skeletal hyperostosis

Differential Diagnosis


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

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

Cerebrovascular injury grading scale (Biffl et al[5])
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


References


  1. 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
  2. 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
  3. 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
  4. 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. 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
  6. 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
  7. 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.
  8. 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.
  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.
  10. 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
  11. DiCocco JM, Fabian TC, Emmett KP, et al. Functional outcomes following blunt cerebrovascular injury. J Trauma Acute Care Surg 2013;74:955-60.
  12. 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.
  13. Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma 2009;66:132-44; discussion 143-4.
  14. 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.
Created by:
John Kiel on 17 June 2019 14:32:33
Authors:
Last edited:
17 November 2020 17:01:02
Categories:
Trauma | Vascular | Neck | Spine - Cervical | Acute