Identifying and Managing Blunt Cerebrovascular Injury

Show Notes

Overview

• Blunt neck trauma comprises 5% of all neck trauma
• Mortality due to loss of airway more so than hemorrhage

Mechanism

• MVCs with cervical hyperextension, flexion, rotation during rapid deceleration, direct impact  
• Strangulation: hanging, choking, clothesline injury (see section on strangulation in this chapter)
• Direct blows: assault, sports, falls

Initial Management/Primary Survey

• Airway
  • Evaluate for airway distress (stridor, hoarseness, dysphonia, dyspnea) or impending airway compromise
  • Early aggressive airway control: low threshold for intubation if unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
  • Assume a difficult airway 
• Breathing
• • Supplemental oxygen
  • Assess for bilateral breath sounds 
  • Can use bedside US to evaluate for pneumothorax or hemothorax
• Circulation
• • Assess for open wounds, bleeding, hemorrhage 
  • IV access
• Disability
• • Maintain C-spine immobilization 
  • Calculate GCS
  • Look for seatbelt sign

Secondary Survey

• Evaluate for specific signs of vascular, laryngotracheal, pharyngoesophageal, and cervical spinal injuries with inspection, palpation, and auscultation
• Perform extremely thorough exam to evaluate for any concomitant injuries (e.g. stab wounds, gunshot wounds, intoxications/ ingestions, etc.)

Types of Injuries

• Vascular injury

• • Overview

• • • Carotid arteries (internal, external, common carotid) and vertebral arteries injured
    • Mortality rate ~60% for symptomatic blunt cerebral vascular injury
  • Mechanism
    • Hyperextension and lateral rotation of the neck, direct blunt force, strangulation, seat belt injuries, and chiropractic manipulation
    • Morbidity due to intimal dissections, thromboses, pseudoaneurysms, fistulas, and transections
  • Clinical Features
    • Most patients are asymptomatic and do not develop focal neurological deficits for days
    • if Horner’s syndrome, suspect disruption of thoracic sympathetic chain (wraps around carotid artery)
    • specific screening criteria are used to detect blunt cerebrovascular injury in asymptomatic patients (see below)

Tintinalli 2016

• Diagnostic Testing
  • Gold standard for blunt cerebral vascular injury = MDCTA (multidetector four-vessel CT angiography)
    • <80% sensitive but 97% specific
    • Also images aerodigestive tracts and C-spine (unlike angiography)
  • Followed by Digital Subtraction Angiography (DSA) for positive results or high suspicion 
    • Angiography is invasive, expensive, resource-intensive, and carries a high contrast load
• Management
  • Antithrombotics vs. interventional repair based on BCVI grading system
  • Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology
  • All patients with blunt cerebral vascular injury will require admission

Tintinalli 2018

• Pharyngoesophageal injury  
• • • Overview
      • Rare in blunt neck trauma
      • Includes hematomas and perforations of both pharynx and esophagus
    • Mechanism
      • Sudden acceleration or deceleration with hyperextension of the neck
      • Esophagus is thus forced against the spine
    • Clinical Features
      • Dysphagia, odynophagia, hematemesis, spitting up blood
      • Tenderness to palpation
      • SC emphysema
      • Neurological deficits (delayed presentation)
      • Infectious symptoms (delayed presentation)
    • Diagnostic Testing
      • Esophagography with water-soluble contrast (e.g. Gastrograffin)
      • If negative contrast esophagography, obtain flexible endoscopy (most sensitive)
        • Combination of contrast esophagography + esophagoscopy has sensitivity close to 100%
      • Swallow studies with water-soluble agent
      • MDCTA
      • Plain films of neck and chest 
        • Findings such as pneumomediastinum, hydrothorax, or retropharyngeal air may suggest perforation but are not sensitive
    • Management
      • All pharyngoesophageal injuries receive IV antibiotics with anaerobic coverage
      • Parenteral/ enteral nutrition
      • NGT should only be placed under endoscopic guidance to avoid further injury
      • Medical management vs. surgical repair depending on extent of injury
        • Surgical repair for esophageal perforations or pharyngeal perforations >2cm
      • Involve consultants early: trauma surgery, vascular surgery, otolaryngology, gastroenterology
      • All patients with blunt cerebral vascular injury will require admission
• Laryngotracheal injury  
• • Overview
    • Occurs in >0.5% of blunt neck trauma
    • Includes hyoid fractures, thyroid/ cricoid cartilage damage, cricotracheal separation, vocal cord disruption, tracheal hematoma or transection
  • Mechanism
    • Assault, clothesline injuries, direct blunt force from MVCs compressing the larynx between a fixed object and the spine
  • Clinical Features
    • Patients are often asymptomatic at first and then develop airway edema and/or hematoma resulting in airway obstruction
    • Children are at higher risk for airway compromise due to less cartilage calcifications
  • Diagnostic Testing
    • Flexible fiberoptic laryngoscopy (FFL) to assess airway patency and extent of intraluminal injury
    • MDCTA
      • Obtain 1-mm cuts of larynx and perform multiplanar reconstructions 
    • Consider POCUS to detect laryngotracheal separation
  • Plain films of neck and chest
  • Poor sensitivity for penetrating neck trauma injuries
  • Can show extraluminal air, fracture or disruption of cartilaginous (e.g. larynx) structures 
  • Management
    • When securing airway, use an ETT that is one size smaller due to likelihood of airway edema
    • Conservative management (IV antibiotics, steroids, observation) vs. surgical repair
      • Grades III, IV, and V laryngotracheal injuries as defined by Schaefer and Brown’s classification system require OR

Tintinalli 2018

• • • • Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology 
• Cervical spine/ spinal cord injury  
• • See chapter for spinal trauma

Disposition

• Admit symptomatic patients to monitored setting
• Given delayed symptoms, consider monitoring patients who are asymptomatic on arrival
  • Serial exams for worsening dyspnea, dysphonia, stridor, drooling, bruits, focal neuro deficits
  • Only discharge after ruling out airway threat, neurological deficit, vascular injury, or suicidal/ homicidal ideation
  • Monitor asymptomatic patients on home anticoagulation in ED for at least 6 hours from trauma to rule out delayed neck hematoma
• Social work and/or psychiatry for patients in whom you suspect suicide risk or domestric violence, look for other signs of self harm

Take Home Points

• Aggressive early airway management for unconscious patient, evidence of airway compromise including voice change, dyspnea, neurological changes, or pulmonary edema
• Involve consultants early: trauma surgery, neurosurgery, vascular surgery, neurology, otolaryngology 
• Victims of blunt cerebral vascular injury may present completely asymptomatic but develop delayed neurological symptoms; close observation and monitoring is recommended especially for patients on home anticoagulation
• Remember to evaluate for concomitant injuries
• Psychiatric evaluation for all attempted suicides

References

• Bromberg, William. et al. Blunt Cerebrovascular Injury Practice Management Guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 68 (2): 471-7, Feb 2010. 
• Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540–545; discussion 545–546.
• Joshua AA.  Neck Trauma, Blunt, Anterior.  In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P.  Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edition. Philadelphia, PA: Wolters Kluwer; 2015; 738-739.
• Tintinalli, J., Stapczynski, J. Stephan, editor, Ma, O. John, editor, Yealy, Donald M., editor, Meckler, Garth D., editor, & Cline, David, editor. (2018). Tintinalli’s emergency medicine : A comprehensive study guide (9th ed.).
• Walls, R., Hockberger, Robert S., editor, & Gausche-Hill, Marianne, editor. (2018). Rosen’s emergency medicine : Concepts and clinical practice (Ninth ed.).
• Advanced trauma life support. (2018). 10th ed. Chicago, IL: American College of Surgeons.

Special thanks to Sana Maheshwari, MD 

NYU Bellevue Emergency Medicine Residency PGY3