Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation
- Walter L Biffl, MD
Walter L Biffl, MD
- Professor and Associate Chair for Research in the Department of Surgery
- John A. Burns School of Medicine, University of Hawaii-Manoa
- Clay Cothren Burlew, MD
Clay Cothren Burlew, MD
- Professor of Surgery
- University of Colorado Denver
- Ernest E Moore, MD
Ernest E Moore, MD
- Vice Chairman for Research
- Professor of Surgery
- University of Colorado Denver
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Blunt carotid and vertebral artery injury, collectively termed blunt cerebrovascular injury, are rare but potentially devastating events. In the past, blunt carotid injury was associated with mortality rates ranging from 23 to 28 percent, with 48 to 58 percent of survivors suffering permanent severe neurologic deficits .
The overall incidence is low in patients sustaining blunt trauma. Clinical studies in the early 1990s suggested that these injuries were being under-diagnosed . Increased recognition through screening (arteriography, computed tomographic angiography) based upon specific clinical criteria has increased the reported incidence to approximately 1 percent in patients with blunt trauma [1,3-5]. When such injury occurs, it is often bilateral.
Injury mechanisms, screening, and diagnosis of blunt cerebrovascular injury will be reviewed here. The treatment of blunt cerebrovascular injury is discussed separately. (See "Blunt cerebrovascular injury: Treatment and outcomes".)
The diagnosis and management of penetrating cerebrovascular injury and spontaneous cerebrovascular dissection are reviewed elsewhere. (See "Penetrating neck injuries: Initial evaluation and management" and "Spontaneous cerebral and cervical artery dissection: Clinical features and diagnosis".)
The vascular supply to the brain is divided into the anterior and posterior circulations originating from the carotid and vertebral arteries, respectively. The circle of Willis connects the anterior and posterior circulations, but is completely intact and symmetric in only approximately 20 percent of individuals . The anatomic variability of the collateral circulation helps explain the clinical presentations of patients with cerebrovascular injuries, and underscores the need for complete imaging of cerebral circulation when injury is suspected. (See 'Imaging evaluation' below.)
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- CEREBROVASCULAR ANATOMY
- Anterior circulation
- - Internal carotid artery segments
- Posterior circulation
- - Vertebral segments
- Site of injury
- MECHANISMS OF INJURY
- TRAUMA EVALUATION
- Associated injuries
- CLINICAL PRESENTATION
- INDICATIONS FOR IMAGING
- IMAGING EVALUATION
- Imaging modalities
- - CT angiography
- - Digital subtraction arteriography
- - MR angiography
- - Duplex ultrasonography
- Choice of imaging
- Injury grading
- Follow-up imaging
- SUMMARY AND RECOMMENDATIONS