Keywords:
Trauma, Embolism / Thrombosis, Aneurysms, Education, Diagnostic procedure, Computer Applications-3D, MR-Angiography, CT-Angiography, CT, Vascular, CNS, Cardiovascular system
Authors:
S. M. Crilly1, E. McElroy2, J. Ryan3, L. Lawler3; 1Perth, WA/AU, 2Perth/AU, 3Dublin/IE
DOI:
10.1594/ecr2018/C-0272
Results
The authors reviewed the literature on blunt force trauma resulting in carotid arterial injury on Pubmed and Embase from 1970 to date in the English language.
Blunt cerebrovascular injury (BCVI) describes a spectrum of carotid arterial intimal injuries.
These may occur as the result of direct trauma or intimal stress from neck rotation.
BCVI occurs in approximately 1%(0.18-2.7%) of blunt trauma cases and may affect multiple vessels (18-23%) with a 70% association with cervical spine fractures.
A review of 82 patients with carotid arterial trauma in 1995 demonstrated mortality and stroke rates of 21% and 41% respectively in patients with internal carotid artery injuries and 11% in those with common carotid arterial injuries.
BCVI may cause dissection of the common carotid artery,
which may evolve into a pseudoaneurysm in up to 30% of patients.
Literature review revealed a total of 42 cases of post traumatic carotid artery pseudoaneurysm formation,
with the common carotid involved in 24% of patients,
and the internal carotid involved in the remaining 76% of cases.
This case was unusual in that it was ‘mixed’ pathogenesis where the blunt trauma had in-fact resulted in a penetrating injury causing the pseudoaneurysm.
BCVI may be delayed with non-specific signs/symptoms including:
Modified Denver Criteria
- Arterial haemorrhage
- Cervical bruit in a patient < 50
- Expanding cervical haematoma
- Focal neurologic deficit
- Neurologic examination incongruous with head CT scan findings
- Stroke on secondary CT scan
The Modified Denver screening criteria was developed to identify patients who should be screened for BCVI,
and the BIFFL scale describes the severity of arterial injury on CT Angiogram or Digital Subtraction Angiography (DSA).
Literature review over the past 45 years revealed three episodes of hyoid bone induced carotid arterial injury.
No cases of carotid injury as a result of thyroid cartilage fracture were identified.
MMA is increasingly popular at amateur and professional levels.
Sadly,
it has resulted in significant morbidity and mortality.
Frequently the 'target' of these fights is the head and neck area.
It is likely that we shall see more of this and it is important to be cognizant that the blunt forces upon which it are based can lead to 'mixed' blunt and penetrating injury patterns.
From a surgical point of view,
we have found that the radiologist can add extra value in specific circumstances where significant carotid trauma is suspected by producing 3 dimensional post processing images (3DCT) for pre-operative planning.
This has not been widely reported for cases of carotid trauma,
however,
it has been studied for pre-operative planning in the case of DIEP flap for breast reconstructive surgery and has been shown to decrease operative times and reduce patient morbidity in cases where such images are acquired pre-operatively.
The use of 3D CT reformating techniques has become more widespread in the surgical literature in the last 15 years,
with particular emphasis on applications for plastic and reconstructive surgical techniques in the pre-operative planning phase,
in the identification of suitable perforator vessels for myocutaneous flap reconstruction techniques.
In this instance,
it has certain benefits over conventional planar CT images.
It is likely that radiologists will become more adept in the production and interpretation of such images in the years to come as the surgical utility of such imaging techniques is fully realised.