Vascular Injuries

Background

Any neurologic abnormality that is unexplained by a diagnosed injury
Blunt trauma patients presenting with epistaxis from a suspected arterial source after trauma

Asymptomatic patients at risk include those with:

Petrous bone fracture
Diffuse axonal injury
Cervical fracture - particularly C1-C3 - or with narrowing of the foramen transversarium
Cervical spine fracture with subluxation or rotation
Le Fort II or III facial fractures

Paediatric trauma patients should be evaluated using the same criteria as the adult population.

Injury mechanism

Severe hyperextension/rotation or hyperflexion particularly with facial fractures or head injury with diffuse axonal injury
Hanging with anoxic brain injury

Physican signs

Belt abrasion / contusion of anterior neck with significant swelling or altered mental status

Fractures close to carotid or vertebral arteries.

Grade 1 and 2 injuries = use antithrombotics - Aspirin or Heparin. If heparin, use without bolus
Grade 3 injuries (pseudoaneurysm): require vasc/neurosurgery/interventional radiology
Neuro deficit and accessible carotid lesion: radiology/neurosurgery/vascular surgery

The expanded Denver screening criteria for blunt cervical vascular injury.
CTA is indicated if at least one criterion ispresent
Signs/ Symptoms of BCVI
Arterial haemorrhage from neck, nose, or mouth
Cervical bruit in patients ages <50 years
Expanding cervical haemoatoma
Focal neurological deficit
Neurological examination incongruous with head CT findings
Stroke on secondary CT scan
Risk factors for BCVI (high energy transfer mechanism with):
Le Fort II or III midface fracture
Mandible fracture
Complex skull fracture, basilar skull fracture or occipital condyle fracture
Severe TBI with GCS score <8
Cervical spine fracture, subluxation, or ligamentous injury at any level
Near hanging with anoxic brain injury
Seat belt abrasion with significant swelling, pain or altered mental status
TBI with thoracic injury
Scalp degloving
Thoracic vascular injury
Blunt Cardiac rupture
Upper rib fracture

ESVS Grade	Description	Carotid artery injury	Vertebral artery injury
General approach to the management of blunt carotid or vertebral artery injuries. Specific management should follow the recommendations above, individualised to the patient, clinical environment and available resource
1	Partial wall injury (intimal tear, dissection, intramural haematoma), normal external wall contour	Single antiplatelet therapy + surveillance	Single antiplatelet therapy + surveillance
2	Complete wall injury (external wall disruption, pseudoaneurysm). Abnormal external wall contour Contained bleeding	Single antiplatelet therapy + surveillance Selective endovascular treatment	Single antiplatelet therapy + surveillance Selective endovascular treatment
3	Complete wall injury Uncontained haemorrhage	Open surgical or endovascular repair	Endovascular embolisation if possible, otherwise open surgical approach
X	Occlusion	No neurological symptoms: single antiplatelet therapy Neurological symptoms: individualised approach	Single antiplatelet therapy