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 Sciences Center - Dallas Campus
- 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 about one 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 about 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.)
- Biffl WL, Moore EE, Ryu RK, et al. The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg 1998; 228:462.
- Cogbill TH, Moore EE, Meissner M, et al. The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma 1994; 37:473.
- Biffl WL, Ray CE Jr, Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg 2002; 235:699.
- Berne JD, Norwood SH, McAuley CE, et al. The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols. J Am Coll Surg 2001; 192:314.
- Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 2002; 236:386.
- Fabian TC. Blunt cerebrovascular injuries: anatomic and pathologic heterogeneity create management enigmas. J Am Coll Surg 2013; 216:873.
- Biffl WL, Moore EE, Elliott JP, et al. Blunt cerebrovascular injuries. Curr Probl Surg 1999; 36:505.
- Cavdar S, Arisan E. Variations in the extracranial origin of the human vertebral artery. Acta Anat (Basel) 1989; 135:236.
- Edwards NM, Fabian TC, Claridge JA, et al. Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: results from longterm followup. J Am Coll Surg 2007; 204:1007.
- Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma 2006; 60:925.
- Goodwin RB, Beery PR 2nd, Dorbish RJ, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. J Trauma 2009; 67:1046.
- Crissey MM, Bernstein EF. Delayed presentation of carotid intimal tear following blunt craniocervical trauma. Surgery 1974; 75:543.
- Zelenock GB, Kazmers A, Whitehouse WM Jr, et al. Extracranial internal carotid artery dissections: noniatrogenic traumatic lesions. Arch Surg 1982; 117:425.
- Mikulaschek A, Hoyt DB. Intraoral blunt carotid injury in an adult: case report and review of the literature. J Trauma 1999; 47:179.
- Carter DA, Mehelas TJ, Savolaine ER, Dougherty LS. Basal skull fracture with traumatic polycranial neuropathy and occluded left carotid artery: significance of fractures along the course of the carotid artery. J Trauma 1998; 44:230.
- Bogousslavsky J, Despland PA, Regli F. Spontaneous carotid dissection with acute stroke. Arch Neurol 1987; 44:137.
- Cook A, Osler T, Gaudet M, et al. Blunt cerebrovascular injury is poorly predicted by modeling with other injuries: analysis of NTDB data. J Trauma 2011; 71:114.
- Franz RW, Willette PA, Wood MJ, et al. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg 2012; 214:313.
- Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999; 178:517.
- Lebl DR, Bono CM, Velmahos G, et al. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine (Phila Pa 1976) 2013; 38:1352.
- Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg 2000; 231:672.
- Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003; 55:811.
- Lockwood MM, Smith GA, Tanenbaum J, et al. Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center. J Neurosurg Spine 2016; 24:490.
- Kopelman TR, Leeds S, Berardoni NE, et al. Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures. Am J Surg 2011; 202:684.
- Fabian TC, George SM Jr, Croce MA, et al. Carotid artery trauma: management based on mechanism of injury. J Trauma 1990; 30:953.
- Cothren CC, Biffl WL, Moore EE, et al. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg 2009; 144:685.
- Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 1999; 47:845.
- Sturzenegger M. Headache and neck pain: the warning symptoms of vertebral artery dissection. Headache 1994; 34:187.
- Sturzenegger M. Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol 1995; 242:231.
- Fabian TC, Patton JH Jr, Croce MA, et al. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 1996; 223:513.
- Kerwin AJ, Bynoe RP, Murray J, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001; 51:308.
- Cothren CC, Moore EE, Ray CE Jr, et al. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg 2005; 190:845.
- Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma 2009; 66:132.
- Mayberry JC, Brown CV, Mullins RJ, Velmahos GC. Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg 2004; 139:609.
- Schneidereit NP, Simons R, Nicolaou S, et al. Utility of screening for blunt vascular neck injuries with computed tomographic angiography. J Trauma 2006; 60:209.
- Berne JD, Reuland KS, Villarreal DH, et al. Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma 2006; 60:1204.
- Bruns BR, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg 2014; 76:691.
- Prall JA, Brega KE, Coldwell DM, Breeze RE. Incidence of unsuspected blunt carotid artery injury. Neurosurgery 1998; 42:495.
- Berne JD, Norwood SH. Blunt vertebral artery injuries in the era of computed tomographic angiographic screening: incidence and outcomes from 8,292 patients. J Trauma 2009; 67:1333.
- Carrillo EH, Osborne DL, Spain DA, et al. Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event. J Trauma 1999; 46:1120.
- Ringer AJ, Matern E, Parikh S, Levine NB. Screening for blunt cerebrovascular injury: selection criteria for use of angiography. J Neurosurg 2010; 112:1146.
- Burlew CC, Biffl WL, Moore EE, et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg 2012; 72:330.
- Emmett KP, Fabian TC, DiCocco JM, et al. Improving the screening criteria for blunt cerebrovascular injury: the appropriate role for computed tomography angiography. J Trauma 2011; 70:1058.
- Biffl WL, Egglin T, Benedetto B, et al. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma 2006; 60:745.
- Jacobson LE, Ziemba-Davis M, Herrera AJ. The limitations of using risk factors to screen for blunt cerebrovascular injuries: the harder you look, the more you find. World J Emerg Surg 2015; 10:46.
- Kaye D, Brasel KJ, Neideen T, Weigelt JA. Screening for blunt cerebrovascular injuries is cost-effective. J Trauma 2011; 70:1051.
- Berne JD, Cook A, Rowe SA, Norwood SH. A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury. J Vasc Surg 2010; 51:57.
- Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma 2009; 67:1150.
- Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma 2010; 68:471.
- Mundinger GS, Dorafshar AH, Gilson MM, et al. Blunt-mechanism facial fracture patterns associated with internal carotid artery injuries: recommendations for additional screening criteria based on analysis of 4,398 patients. J Oral Maxillofac Surg 2013; 71:2092.
- Bub LD, Hollingworth W, Jarvik JG, Hallam DK. Screening for blunt cerebrovascular injury: evaluating the accuracy of multidetector computed tomographic angiography. J Trauma 2005; 59:691.
- Biffl WL, Ray CE Jr, Moore EE, et al. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma 2002; 53:850.
- Paulus EM, Fabian TC, Savage SA, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg 2014; 76:279.
- Utter GH, Hollingworth W, Hallam DK, et al. Sixteen-slice CT angiography in patients with suspected blunt carotid and vertebral artery injuries. J Am Coll Surg 2006; 203:838.
- Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg 2007; 246:632.
- Sliker CW, Shanmuganathan K, Mirvis SE. Diagnosis of blunt cerebrovascular injuries with 16-MDCT: accuracy of whole-body MDCT compared with neck MDCT angiography. AJR Am J Roentgenol 2008; 190:790.
- Roberts DJ, Chaubey VP, Zygun DA, et al. Diagnostic accuracy of computed tomographic angiography for blunt cerebrovascular injury detection in trauma patients: a systematic review and meta-analysis. Ann Surg 2013; 257:621.
- DiCocco JM, Emmett KP, Fabian TC, et al. Blunt cerebrovascular injury screening with 32-channel multidetector computed tomography: more slices still don't cut it. Ann Surg 2011; 253:444.
- Biffl WL, Moore EE. Computed tomographic angiography for blunt cerebrovascular injuries: don't throw out the baby with the bathwater. Ann Surg 2011; 253:451.
- Shahan CP, Magnotti LJ, Stickley SM, et al. A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke. J Trauma Acute Care Surg 2016; 80:915.
- Wang AC, Charters MA, Thawani JP, et al. Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury. J Trauma Acute Care Surg 2012; 72:1601.
- Friedman D, Flanders A, Thomas C, Millar W. Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences. AJR Am J Roentgenol 1995; 164:443.
- Giacobetti FB, Vaccaro AR, Bos-Giacobetti MA, et al. Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis. Spine (Phila Pa 1976) 1997; 22:188.
- Weller SJ, Rossitch E Jr, Malek AM. Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography. J Trauma 1999; 46:660.
- Bok AP, Peter JC. Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis. J Trauma 1996; 40:968.
- Hughes KM, Collier B, Greene KA, Kurek S. Traumatic carotid artery dissection: a significant incidental finding. Am Surg 2000; 66:1023.
- Punjabi AP, Simon J, Plaisier B. Blunt carotid injury. J Trauma 1996; 41:1077.
- Lévy C, Laissy JP, Raveau V, et al. Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology 1994; 190:97.
- Fry WR, Dort JA, Smith RS, et al. Duplex scanning replaces arteriography and operative exploration in the diagnosis of potential cervical vascular injury. Am J Surg 1994; 168:693.
- Mutze S, Rademacher G, Matthes G, et al. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology 2005; 237:884.
- Landwehr P, Schulte O, Voshage G. Ultrasound examination of carotid and vertebral arteries. Eur Radiol 2001; 11:1521.
- Sturzenegger M, Mattle HP, Rivoir A, et al. Ultrasound findings in spontaneous extracranial vertebral artery dissection. Stroke 1993; 24:1910.
- 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