Imaging and Management of Blunt Cerebrovascular Injury

Abstract

Blunt cerebrovascular injury (BCVI) is a relatively rare but potentially devastating finding in patients with high-energy blunt force trauma or direct cervical and/or craniofacial injury. The radiologist plays an essential role in identifying and grading the various types of vascular injury, including minimal intimal injury, dissection with raised intimal flap or intraluminal thrombus, intramural hematoma, pseudoaneurysm, occlusion, transection, and arteriovenous fistula. Early identification of BCVI is important, as treatment with antithrombotic therapy has been shown to reduce the incidence of postinjury ischemic stroke. Patients with specific mechanisms of injury, particular imaging findings, or certain clinical signs and symptoms have been identified as appropriate and cost-effective for BCVI screening. Although digital subtraction angiography was previously considered the standard examination for screening, technologic improvements have led to its replacement with computed tomographic angiography. Of note, although not appropriate for screening, improvements in magnetic resonance angiography with vessel wall imaging hold promise as supplemental imaging studies that may improve diagnostic specificity for vessel wall injuries. Understanding the screening criteria, imaging modalities of choice, imaging appearances, and grading of BCVI is essential for the radiologist to ensure fast and appropriate diagnosis and treatment. This article details the imaging evaluation of BCVI and discusses the clinical and follow-up imaging implications of specific injury findings. RSNA, 2018.

Vascular Trauma

“…Additional wound packing may also be helpful. In our opinion every penetrating vascular injury of the neck should be surgically explored in order to prevent a secondary damage as uncontrolled hematoma expansion leading to neurological and respiratory deficits which is supported by the data from the literature [36,37]. The unstable patients are qualified to immediate surgery, while the stable ones after fast-track imaging in order to localize the exact lesion location should also undergo surgical exploration (Figure 7).…”

Spinal Trauma and Spinal Cord Injury (SCI)

“…These include fractures located at the upper cervical spine (C1-C3), subluxation, or involvement of the transverse foramina [45]. In the context of a carotid artery injury, it is thought that cervical hyperextension and contralateral rotation lead to stretching of the internal carotid artery (ICA) over the C1-C3 transverse processes, precipitating a vessel wall injury [46]. Nearly all VAIs are associated with cervical spine subluxations and fractures involving the transverse foramen [47].…”

“…According to the Denver criteria and Western Trauma Association (WTA) guidelines, radiologic risk factors associated with BCVI include high-energy injury mechanisms with Le Fort II or III fracture patterns; basilar skull fracture with carotid canal involvement; cervical vertebral body or transverse foramen fracture, subluxation, or ligamentous injury; any fracture at C1-C3; closed head injuries with diffuse axonal injury and a Glasgow Coma Score of <6; clothesline-type injuries with associated swelling and/ or pain; or near-hanging with anoxia. Urgent screening for BCVI should be performed in these patients that may be still neurologically asymptomatic at this time [46].…”

“…With the widespread use of multi-detector CT scanners, CT angiography (CTA) has emerged as the first-line screening modality for BCVI. CTA is a cost-effective screening tool in high-risk populations, ultimately preventing the most strokes at a reasonable cost [46].…”

“…Grade IV injury represents a complete vessel occlusion, usually tapering in the CA and quite abrupt in the VA. Vessel transection represents a grade V injury, observed as free contrast extravasation into the surrounding tissues, or into the adjacent vein in the form of an arteriovenous fistula (AVF) [46,47].…”