Incidence of traumatic carotid and vertebral artery dissections: results of cervical vessel computed tomography angiogram as a mandatory scan component in severely injured patients

Abstract

PurposeThe aim of this study was to evaluate the true incidence of cervical artery dissections (CeADs) in trauma patients with an Injury Severity Score (ISS) of ≥16, since head-and-neck computed tomography angiogram (CTA) is not a compulsory component of whole-body trauma computed tomography (CT) protocols.Patients and methodsA total of 230 consecutive trauma patients with an ISS of ≥16 admitted to our Level I trauma center during a 24-month period were prospectively included. Standardized whole-body CT in a 256-detector row scanner included a head-and-neck CTA. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed retrospectively in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD).ResultsOf the 230 patients included, 6.5% had a CeAD, 5.2% had a CAD, and 1.7% had a VAD. One patient had both CAD and VAD. For both, CAD and VAD, mortality is 25%. One death was caused by fatal cerebral ischemia due to high-grade CAD. A total of 41.6% of the patients with traumatic CAD and 25% of the patients with VAD had neurological sequelae.ConclusionMandatory head-and-neck CTA yields higher CeAD incidence than reported before. We highly recommend the compulsory inclusion of a head-and-neck CTA to whole-body CT routines for severely injured patients.

Best practice guidelines for blunt cerebrovascular injury (BCVI)

“…In some instances this process develops into a pseudoaneurysm [ 1 ]. BCVI has been given considerable attention in the literature for the past 30 years [ 2 – 5 ]. It was earlier considered to be a very rare injury but recent publications show an incidence of 1–2% in the in-hospital trauma population and 9% in patients with severe head injury [ 6 , 7 ].…”

“…There seem to be a higher risk of ischemic events with injury to the carotid than the vertebral artery [ 19 , 20 ]. BCVI is an independent predictor for poor outcome with higher morbidity and mortality rates in trauma patients with this injury, reported as high as 25–50% for those suffering a stroke [ 5 , 19 ].Unfortunately, a substantial number of patients with this injury arrive at the hospital with a stroke in progress [ 6 ]. Treating the remaining asymptomatic patients with BCVI in order to avoid an ischemic insult is controversial [ 17 , 21 , 22 ].…”

Critical Care Management of Acute Spinal Cord Injury—Part II: Intensive Care to Rehabilitation

“…In patients with traumatic SCI, concomitant blunt cerebrovascular injury (BCVI) is an independent risk factor for increased morbidity and mortality. [49][50][51] Cervical SCI is highly associated with extracranial carotid and vertebral artery injury. Forceful neck flexion, hyperextension, and rotation during motor vehicle crashes account for almost one-half of BCVI.…”

Early Management of Acute Spinal Cord Injury—Part I: Initial Injury to Surgery

“…39 Among traumatic SCI patients, this blunt cerebrovascular injury (BCVI) is an independent risk factor for increased morbidity and mortality. [39][40][41] Patients benefit from screening with CT angiography (CTA) if they have signs or symptoms of BCVI, such as expanding hematoma, bruits, or neurologic symptoms of posterior circulation insufficiency. 42,43 Some argue for screening of all trauma patients with cervical SCI regardless of the presence of symptoms since there is often a latent, asymptomatic period before the natural pathology of carotid or vertebral artery injury leads to neurologic ischemic events.…”