Blunt Cerebrovascular Injuries: Diagnosis and Management Outcomes

Abstract

574In recent years, blunt cerebrovascular injury (BCVI) is gaining attention as an important sequela of nonpenetrating trauma to the neck and skull base. Blunt cerebrovascular injury affects approximately 1% of all blunt trauma admissions, and the reported incidence is as high as 2.7% in centres with aggressive screening protocols [1][2][3][4][5][6][7][8] . The pattern of BCVI consists of vascular transection, dissection, thrombosis, and formation of pseudoaneurysm or arteriovenous fistula (AVF) 9,10 . The majority of these injuries occur during motor vehicle accidents, with variable rates of carotid and vertebral artery involvement reported in the literature [11][12][13] . If untreated, BCVI can be fatal and result in devastating neurological sequelae, with mortality and morbidity rates reported up to 38% and 67% respectively 14 .One of the difficulties in initiating treatment for BCVI is related to the variable symptomatology. While approximately ABSTRACT: Background: Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI. Methods: This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed. Results: Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment. Conclusions: BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment. RÉSUMÉ: Diagnostic et résultats du traitement des traumatismes cérébrovasclaires contondants. Contexte :Le traumatisme cérébrovasculaire contondant (TCVC) à la carotide et aux artères vertébrales est une lésion qui peut être dévastatrice chez les patients qui ont subi un traumatisme. Le traitement optimal du TCVC n'a pas été standardisé. Dans notre institutio...

Posterior circulation infarction in patients with traumatic cervical spinal cord injury and its relationship to vertebral artery injury

“…15 Multidetector CT continues to improve in accuracy and currently its ability to assess VAI lies somewhere between catheter angiography and TOF MRA. 16 Many previous studies have examined VAI in the context of acute or subacute trauma. A single study 4 looked at follow-up imaging and noted recanalisation in previously occluded arteries.…”

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options

“…Injuries involving traumatic rotation of the cervical vertebrae include atlantoaxial rotatory fixation (presenting with an inability to return the head to anatomical baseline), traumatic isolation of the articular pillar, and unilateral dislocation [23]. Severe injuries of this nature demonstrate a rotation of C1-C2 of greater than 45 degrees, or a widening of the atlanto-dens interval of greater than 3 mm [24]. In some blunt traumas involving rotational forces, these signs may be absent if a portion of the force is translated into a fracture of the vertebrae; thus, less displacement can be expected if an articular mass fracture is present.…”

“…Endovascular treatment methods may be employed when antiplatelet or anticoagulation methods are contraindicated [11,24,33]. Endovascular treatment of spontaneous VA dissections has been extensively studied, but not so in traumatic injuries.…”

“…The natural history of traumatic VAI is that over 90% of stenotic dissections resolve within several months and over half of occluded vessels recanalize [24,26]. This trend toward spontaneous vessel healing has promoted a culture of conservative management of traumatic VAIs in the acute setting, as opposed to aggressive surgical correction.…”

Modern Advances in Vascular Trauma

“…4,12 For example, even in patients aggressively screened for injury, approximately 25% to 40% have a concomitant hemorrhagic injury that has traditionally been considered a contraindication to therapy. 4,12,20 These competing injuries typically include TBIs and spinal cord injury (SCI) or traumatic neurologic injuries (TNI).…”