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