A Pain in the Neck

A 60yo M presents to the trauma centre after his 4WD vehicle collided with a semi-trailer at 90km/hr. He was entrapped in the vehicle for more than 1 hour. At scene he has an unrecordable blood pressure and has had bilateral finger thoracostomies. He has received 4 units of blood en-route. On arrival to the ED he has suspected chest and head injuries and a large bore MAC line is inserted into his left subclavian vein, a massive transfusion protocol is commenced, chest drains inserted and upon stabilisation he is intubated for transfer to CT for a pan scan. En-route the ED registrar asks if we should image his carotid arteries to exclude a carotid injury?

Having recently completed a senior registrar rotation through the Alfred Trauma service, Dr Barry Cunningham presented this lightning learning on BCVI to our registrars at their weekly teaching session.

Blunt Cerebrovascular Injury (BCVI) is a non-penetrating injury to the carotid and/or the vertebral arteries. Motor vehicle accidents are the most common cause however we do see patients with BCVIs who fall, have sports related injuries or strangulations. It is caused by either a stretching or impingement of the vessel wall with forceful movements of the head and neck during an acute injury. This can be from a direct blow, hyperextension with rotation, skull base fracture involving the carotid canal or blunt intra-oral trauma.  An intimal tear is formed with exposure of the sub-intimal layers to blood products and either a thrombus, pseudoaneurysm, wall haematoma or vessel occlusion can occur. 

Figure: Traumatic cerebrovascular injuries. A, Intimal disruption. B, Intimal disruption with thrombus formation. C, Elastic laminae disruption allowing traumatic aneurysm formation (arrows). D, Hematoma within the artery wall with luminal stenosis. (Harrigan et al (2020)) 

BCVI is associated with poorer predicted outcomes and higher morbidity and mortality in trauma patients. A significant number of patients go onto suffer strokes during their inpatient stay or have a stroke pre-hospital. It is a commonly missed injury as it typically has a latent period between the time of injury and onset of symptoms.

CT angiography of the neck is the current imaging modality of choice

Key References:

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;67:1150–53 doi:10.1097/TA.0b013e3181c1c1d6 PMID:20009659

Kim DY, Biffl W, Bokhari F, Brakenridge S, Chao E, Claridge JA, Fraser D, Jawa R, Kasotakis G, Kerwin A, Khan U, Kurek S, Plurad D, Robinson BRH, Stassen N, Tesoriero R, Yorkgitis B, Como JJ. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. (2020) The journal of trauma and acute care surgery. 88 (6): 875-887. doi:10.1097/TA.0000000000002668 – Pubmed

Cothren CC, Moore EE, Ray CE, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. (2007) Surgery. 141 (1): 76-82. doi:10.1016/j.surg.2006.04.005 – Pubmed

Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. (2012) The journal of trauma and acute care surgery. 72 (2): 330-5; discussion 336-7, quiz 539. doi:10.1097/TA.0b013e31823de8a0 – Pubmed

Brommeland, T., Helseth, E., Aarhus, M. et al. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 26, 90 (2018). https://doi.org/10.1186/s13049-018-0559-1

Alfred Guidelines for the Investigation and Management of BCVIs (2019)

Harrigan MR. Ischemic Stroke due to Blunt Traumatic Cerebrovascular Injury. Stroke. 2020 Jan;51(1):353-360. doi: 10.1161/STROKEAHA.119.026810. Epub 2019 Dec 11. PMID: 31822250.