Background
High risk for Blunt Cerebro-Vascular Injuries (BCVI)
- 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.
Imaging (Biffl) criteria
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.
- Base of skull involving carotid canal
- Cervical vertebral body fractures with narrowing of the foramen transversarium
Investigations
- 4 vessel cerebral angiography is the "gold standard"
- CTA may be considered as screening prior to angiography
Management
- 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
Denver criteria for blunt cervical vascular injury
CTA is indicated if at least one criterion is present.
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 exam. incongruous with head CT findings
- Stroke on secondary CT scan
Risk factors for BCVI (high energy mechanism with):
- Le Fort II or III midface fracture
- Mandible fracture
- Complex skull fracture, BOS#, occipital condyle #
- Severe TBI with GCS <8
- Cervical spine #, subluxation, or lig. injury (any level)
- Near hanging with anoxic brain injury
- Seat belt inj. w. significant swelling, pain or Δ mentation
- TBI with thoracic injury
- Scalp degloving
- Thoracic vascular injury
- Blunt Cardiac rupture
- Upper rib fracture
| 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 | |||
| ESVS Grade | Description | Carotid artery injury | Vertebral artery injury |
|---|---|---|---|
| 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 |