Blunt Carotid Injury Research Articles

口腔内外傷後に続発した内頸動脈閉塞症例

Internal carotid artery obstruction due to oropharyngeal trauma was originally reported by Caldwell in 1936. And the number of reports has been limited to seven in the Japanese literature. We report the case of a two-year-old girl who sustained oropharyngeal wall trauma from a tooth brush. After the characteristic period of several hours, hemiplegia developed on her left side. MRA revealed obstruction of the internal carotid and middle cerebral arteries on her right side. Although pediatric oropharyngeal trauma is a common injury, it is important to consider traumatic blunt carotid injury, even if there are initially no neurologic findings. Therefore, informed consent and careful observation are clinically significant in oropharyngeal trauma cases.

Tension Pneumopericardium: A Case Report and a Review of the Literature

Pneumopericardium, or air within the pericardial sack, generally occurs after high-speed blunt deceleration injuries. Although it is generally relatively benign, in rare instances, it can become hemodynamically significant. The diagnosis is easily made on plain chest radiography. More recently, chest computed tomography has been helpful in making the diagnosis. Injury to vital structures such as the tracheobronchial tree or esophageal tears require operative fixation. However, in most instances, pneumopericardium is secondary to dissection of air through the adjacent structures to the pericardial space. The air is trapped as a one-way valve. The pneumopericardium is usually self-limited, requiring no specific therapy. In patients where there is a concomitant pneumothorax, chest tube drainage suffices. We present a case of hemodynamically significant tension pneumopericardium that occurred in association with blunt carotid injury and aortic

Blunt carotid injury

Blunt carotid injury (BCI) is an uncommon disorder, occurring in trauma patients as a result of cervical hyperextension, hyperflexion, or direct blow. BCI is commonly present in initially asymptomatic patients who subsequently develop devastating thromboembolic complications of their injury. Although clinical predictors of injury have been developed, they are of limited accuracy. Nevertheless, employment of clinical screening criteria is of value in identifying at-risk patients in need of diagnostic testing. Liberalized screening of these trauma patients with angiography or the latest generation (64-multidetector) CT angiography facilitates early diagnosis and provides opportunity for timely intervention in asymptomatic victims. Anticoagulation and/or antithrombotic therapy in specific categories of these patients reduces neurologic morbidity and mortality. Endovascular stenting shows promise as a treatment modality for specific subsets of individuals with BCI. Surgery remains a therapeutic option for some surgically accessible lesions.

Internal Carotid Artery Stenosis Due to Atherosclerotic Plaque Damage after Whiplash Injury

Blunt traumatic occlusion or stenosis of the internal carotid artery is a rare complication of whiplash injury and may not be recognized until the onset of neurological symptoms. The clinical course can vary considerably, with regard to both the symptoms and the interval between injury and manifestation. A dissecting aneurysm and intimal tear are usually observed after blunt internal carotid artery injury. Atherosclerotic plaque is often observed in the cervical internal carotid artery and carotid bifurcation, but involvement of plaque has been confirmed in relatively few cases of blunt traumatic internal carotid injury. We describe a 58-year-old man who developed cerebral embolism due to intraplaque thrombus after a minor whiplash injury and was successfully treated with carotid endarterectomy. Because thrombosis occurred within the atherosclerotic plaque, we named the mechanism of this case "plaque injury".

Anticoagulation Is the Gold Standard Therapy for Blunt Carotid Injuries to Reduce Stroke Rate

Anticoagulation Is the Gold Standard Therapy for Blunt Carotid Injuries to Reduce Stroke Rate

Screening for blunt cerebrovascular injuries is cost-effective

Background Recent reports have argued that screening for blunt carotid injury is futile and have called for a cost analysis. Our data previously supported screening asymptomatic trauma patients for blunt cerebrovascular injury (BCVI) to prevent associated neurologic sequelae. Our hypothesis is that aggressive angiographic screening for BCVI based on a patient’s injury pattern and symptoms allows for early diagnosis and treatment and is cost-effective because it prevents ischemic neurological events (INEs). Methods Beginning in January 1996, we began comprehensive screening using 4-vessel cerebrovascular angiography based on injury patterns; these patients have been followed-up prospectively. Patients without contraindications received antithrombotic therapy immediately for documented BCVI. Results From January 1996 through June 2004, there were 15,767 blunt-trauma patient admissions to our state-designated level I urban trauma center, of which 727 patients underwent screening angiography. Twenty-one patients presented with signs or symptoms of neurologic ischemia before diagnosis. BCVI was identified in 244 patients (34% screening yield); the majority were men (68%) with a mean age of 35 ± 3.7 years and mean Injury Severity Score of 28 ± 3.8. Asymptomatic patients (n = 187) were treated (heparin in 117, low molecular–weight heparin in 11, and antiplatelet in 59); 1 patient had a stroke (0.5%). Using estimated stroke rate by grade of injury, we averted neurologic events in 32 asymptomatic patients with antithrombotic treatment. Of the 48 asymptomatic patients who did not receive adequate anticoagulation, 10 (21%) had an INE. Patients with BCVI-related neurologic events had a statistically higher percentage requiring discharge to rehabilitation facilities (50% vs. 77% for carotid artery injury [CAI]), a higher percentage requiring rehabilitation for BCVI-related stroke (0% vs. 55% for CAI), and a higher stroke-related mortality rate (0% vs. 21% for CAI and 0% vs. 17% for vertebral artery injury) than those without neurologic events. Conclusions The cost of long-term rehabilitation care and human life after BCVI-associated neurologic events is substantial. Surgeons caring for the multiply injured should screen for carotid and vertebral artery injuries in high-risk patients.

Case Report

A potentially serious consequence associated with blunt force trauma to the neck is an injury to the carotid artery. Initially the blunt carotid injury may be missed or it may be delayed in presentation; therefore one must have a heightened index of suspicion when considering the patient's mechanism of injury. The purpose of this article is to present a case report of blunt carotid injury and implications for healthcare workers.

Blunt carotid injury outcomes: results of long-term follow-up

RESULTS: 93 patients with a mean age of 37 years were diagnosed with 112 injuries. 72(77%) patients survived to discharge; 6 of 21 deaths were attributable to BCI. Post-discharge follow-up was available on 54(75%) patients. 52 surviving patients had a mean follow-up of 31.1 months(1-109 months). 34(65%) patients had follow-up arteriograms; 32(94%) demonstrated improvement or no change. All except 4(7%) of patients were discharged on anticoagulation therapy. At last follow-up, 80% were ambulatory, 76% performed ADLs, and 59% lived independently. 14 patients with BCI also received endovascular stent therapy; 10 had pseudoaneurysms, 4 had severe narrowing and/or contralateral injuries. Eleven stent patients were alive with a mean follow-up of 29 months(3-69 months) demonstrating no adverse outcomes.

Pediatric Blunt Carotid Injury from Low-Impact Trauma: A Case Report and Review of the Literature

Pediatric Blunt Carotid Injury from Low-Impact Trauma: A Case Report and Review of the Literature

Operative Treatment of a Pseudoaneurysm of the Internal Carotid Artery in a 9-Year-Old Boy

Blunt carotid injuries may causenot only spasm, intimal rupture or mural contusion,but they can also lead to more serious lesions suchas dissection resulting in a pseudoaneurysm, orocclusion of the involved carotid artery. The mostcommonly affected site is the internal carotid artery(ICA) directly distal to the bifurcation, whereas thedistal portion of the ICA is less commonly injured.

Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate.

Aggressive screening, early angiographic diagnosis, and prompt anticoagulation for blunt carotid artery injuries (CAIs) improves neurologic outcome. From January 1, 1996, through December 31, 2002, there were 13 280 blunt trauma admissions to our level I center, of which 643 underwent screening angiography for blunt CAI on the basis of a protocol including injury patterns and symptoms. Patients without contraindications underwent anticoagulation immediately for documented lesions. A state-designated, level I urban trauma center. Of the 643 patients undergoing screening angiography, 114 (18%) had confirmed CAI. Early angiographic diagnosis and prompt anticoagulation. Diagnosis, stroke rate, and complications stratified by method of intervention. A CAI was identified in 114 patients during the 7-year study period; the majority were men (71%), with a mean +/- SD age of 34 +/- 1.3 years and a mean +/- SD Injury Severity Score of 29 +/- 1.5. Seventy-three patients underwent anticoagulation after diagnosis (heparin in 54, low-molecular-weight heparin in 2, antiplatelet agents in 17); none had a stroke. Of the 41 patients who did not receive anticoagulation (because of a contraindication in 27, symptoms before diagnosis in 9, and carotid coil or stent in 5), 19 patients (46%) developed neurologic ischemia. Ischemic neurologic events occurred in 100% of patients who presented with symptoms before angiographic diagnosis and those receiving a carotid coil or stent without anticoagulation. Our prospective evaluation of blunt CAIs suggests that early diagnosis and prompt anticoagulation reduce ischemic neurologic events and their disability. The optimal anticoagulation regimen, however, remains to be established.

Suspected blunt carotid injury in a 54-year-old woman after a motor vehicle crash: A brief review

A 54-year-old female restrained driver was involved in a broadside motor vehicle crash. Her air bag deployed during the crash. During her examination in the emergency department, she was noted to have a large seat belt mark on her neck and across her chest. She was neurologically intact. All results of her workup, which included radiographs of her chest and c-spine and a computed tomography (CT) scan of her head and abdomen, were normal. The team then elected to do a carotid angiography to rule out injury to the carotid artery.

Blunt carotid artery injury.

Blunt carotid artery injury is an uncommon injury with a potentially devastating outcome. Although treatment is often unhelpful for an established neurologic deficit, there is frequently a delay between the episode of trauma and the onset of neurology. This delay provides a window of opportunity where early detection and intervention may significantly improve outcome and prevent lifelong morbidity in a generally young trauma patient population. This paper will review the literature regarding incidence, outcome, treatment options and optimal methods of diagnosis for this lesion. The following synopsis of a case seen at Royal Perth Hospital Emergency Department illustrates several of the classical features of blunt carotid injury, including delayed presentation and pattern of associated injuries. The patient, a 19-year-old female, presented following a single vehicle motor crash. On arrival she had a Glasgow Coma Scale (GCS) of 14 with no focal neurologic deficit. Multiple injuries were identified, including a large scalp laceration, a compound fracture of the mandible, pneumothorax, sternal fracture, subcapsular haematoma of the liver, and a knee laceration. Initial computed tomography (CT) scan of the head was normal. Twenty hours after the motor vehicle accident the patient's conscious state deteriorated to GCS 9. Repeat CT head demonstrated changes consistent with a left middle cerebral artery infarct. Cerebral angiography revealed traumatic dissection of the left internal carotid artery with complete occlusion of the lumen just distal to its origin. After 13 days in the intensive care unit and 2.5 months in the rehabilitation unit, she was discharged with a persistent severe receptive and expressive aphasia, as well as a dense right hemiparesis. She is now living at home with community supports.

Identifying patients at risk for intracranial and extracranial blunt carotid injuries

Blunt carotid injuries are rare, often occult, and potentially devastating. Angiographic screening programs have detected this injury in up to 1% of blunt trauma patients. Implementing a liberal angiographic screening program at our hospital is impractical and we want to identify a high-risk group to target for screening. We hypothesize that intracranial and extracranial carotid injuries have different risks, presentations, and outcomes. Patients with intracranial and extracranial carotid injuries were identified from the British Columbia trauma registry. Presentation and outcome were reviewed. To facilitate statistical modeling the analysis was done by matching cases to 5 randomly selected controls. Risk factors for injury were evaluated by univariate and multiple logistic regression. A total of 35 carotid injuries were identified. Thirteen intracranial injuries were identified in 10 patients. Twenty-two extracranial injuries were identified in 18 patients. Sixty-seven percent of patients with intracranial injuries and 31% of those with extracranial injuries died (P = 0.11). Eleven percent of intracranial injuries and 56% of extracranial injuries were occult (P = 0.04). Glasgow outcome scores were 2.04 intracranial and 3.12 extracranial (P = 0.18). For intracranial injuries the multiple variable predictive model had two predictors: Glasgow Coma Score </=8 and facial fractures. For extracranial the predictors were GCS < or =8 and thoracic injury (Abbreviated Injury Score > or =3). Intracranial injuries were frequently detected on initial investigations and have very poor outcomes. Extracranial injuries were more frequently occult and stand to benefit from early detection by screening programs. As independent risk factors for these two injuries differ, limited screening resources should focus on risk factors for occult extracranial injury: namely, low GCS and significant thoracic injury.

Antiplatelet therapy: an alternative to heparin for blunt carotid injury.

Blunt carotid injuries (BCIs) are uncommon. Most single-center studies are small and highlight the use of anticoagulation for treatment. In a retrospective review, we identified 22 patients who presented with BCI and assessed neurologic and survival outcomes on the basis of injury grade and treatment with anticoagulation or antiplatelet therapy. Patient demographics were identified using the trauma registry at a single Level I trauma center. Chart reviews assessed neurologic function, modalities used for diagnosis, and treatment. Neurologic outcomes were graded good (minimal to no deficit), fair (moderate deficit needing some assistance), poor (requiring institutionalization), and dead. Twenty-two adult trauma patients were diagnosed with BCI, for an incidence of 0.45% in the 8-year study period. All BCI patients underwent head computed tomography and four-vessel cerebral arteriography. Eight patients were not anticoagulated, five because of intracranial injuries, two who had surgical CCA repairs, and one with an aortic injury. Full anticoagulation with heparin was attempted in seven patients, with four major bleeding complications requiring cessation of heparin and blood transfusions. Seven patients received antiplatelet therapy. No difference in neurologic outcome was observed between those receiving anticoagulation and those receiving antiplatelet therapy. Bleeding complications from full anticoagulation were higher than with antiplatelet agents (p = 0.05). Contrary to previous reports, we did not observe improved outcomes with full anticoagulation compared with antiplatelet therapy. Anticoagulation was associated with increased extracranial bleeding complications. The risks and possible benefits, as well as timing, of anticoagulation or antiplatelet therapy for BCI should be carefully weighed by the major care providers of the patient with multiple injuries.

Liberalized screening for blunt carotid and vertebral artery injuries is justified.

Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols

Background: Blunt cerebrovascular injuries are rare injuries causing substantial morbidity and mortality. The appropriate screening methods and treatment options for these injuries are controversial. We examined our experience with these injuries at a community Level I Trauma center over a 51 month period. Study Design: A retrospective review and analysis was done of all patients with the diagnosis of a blunt cerebrovascular injury during this period. Results: Fourteen patients had blunt carotid injury (0.40%) and three had blunt vertebral injury (0.09%) out of 3,480 total blunt admissions. The overall incidence of blunt cerebrovascular injury was 0.49%. The most common associated injuries were to the head (59%) and chest (47%) regions. The overall mortality rate was 59% (10 of 17), with death occurring in 8 of 14 (57%) blunt carotid injury patients and 2 of 3 (67%) blunt vertebral injury patients. Eight of ten (80%) deaths were directly attributable to the blunt cerebrovascular injury. Median time until diagnosis was 12.5 h (range 1–336 h) for the entire group and 19.5 h for nonsurvivors. Diagnosis was delayed > 24 h in 7 patients and > 48 h in 5 patients. All five patients whose diagnoses were delayed > 48 h developed complications, and four (80%) of these patients died. Conclusions: Blunt cerebrovascular injury is uncommon, but lethal; particularly when the diagnosis is delayed. Aggressive screening protocols based on mechanism of injury, associated injuries, and physical findings are justified to minimize morbidity and mortality. Head and chest injuries may serve as markers for blunt cerebrovascular injury. Most deaths are directly attributable to the blunt cerebrovascular injury and not to associated injuries.

Identifying the Asymptomatic Patient with Blunt Carotid Arterial Injury

The Journal of Trauma: Injury, Infection, and Critical Care: December 1999 - Volume 47 - Issue 6 - p 1163

Diagnosis, treatment, and outcome of blunt carotid arterial injuries

Background: Blunt carotid injuries are rare, and present late with devastating strokes. A sizeable single-institution descriptive report could help characterize the injury and its diagnosis and treatment. Methods: We performed a retrospective review of blunt carotid artery injuries from May 1988 to December 1997 at a level I trauma center. Chart review consisted of demographics, mechanism of injury, associated injuries, diagnostic modalities, initial neurologic status, treatment, and outcome. Discharge outcome was classified as “good” (normal-mild deficit), “fair” (needing daily assistance), “poor” (institutionalized), or “dead.” Results: During the study period 16 patients sustained a carotid artery injury. Mean age was 35 years and 63% were female. Vehicular trauma was the most common mechanism of injury (81%), followed by assaults (13%). Dissection was the most common injury (75%), with one quarter having an associated pseudoaneurysm. Initial neurologic presentation was normal in 31% and Glasgow Coma Score was <13 in 31% (including 13% in coma). Eventual hemispheric symptoms developed in 81%. Associated injuries were present in 94%, commonly head (44%) and chest (50%). Duplex ultrasound accurately identified the injury in all patients (5 of 5) when used. Anticoagulation (88%) had no complications. Observation and therapeutic embolization each resulted in 1 fatal stroke. A third patient, with worsening deficits on heparin, died after carotid ligation, for an overall mortality of 19%. There were no deaths in the 13 patients treated by anticoagulation alone. Six patients (38%) had a “good” neurologic outcome, five (31%) “fair,” and two (13%) “poor.” Initial neurologic presentation, associated injuries, and mechanism of injury did not appear to correlate with these outcome categories. Conclusions: These uncommon injuries should be suspected in the presence of head and/or chest injuries, basilar skull fracture, or coma (particularly if the computed tomography scan is unremarkable). Presentation may be varied, but most patients eventually develop hemispheric symptoms. Duplex ultrasound detects many of these injuries, but this study does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome than expectant or occlusive therapy.

Blunt carotid injury: a review.

HomeRadiologyVol. 207, No. 3 PreviousNext Blunt carotid injury: a review.J P Mulloy, P A Flick, R E GoldJ P Mulloy, P A Flick, R E GoldJ P MulloyP A FlickR E GoldPublished Online:Jun 1 1998https://doi.org/10.1148/radiology.207.3.9609876MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Article HistoryPublished in print: 1998 FiguresReferencesRelatedDetailsCited ByJournal of Craniofacial Surgery, Vol. 33, No. 4Imaging and Management of Blunt Cerebrovascular InjuryAaron M. Rutman, Justin E. Vranic, Mahmud Mossa-Basha, 12 March 2018 | RadioGraphics, Vol. 38, No. 2Current Trauma Reports, Vol. 4, No. 3Journal of the American College of Surgeons, Vol. 226, No. 1Seminars in Roentgenology, Vol. 51, No. 3Annals of Vascular Surgery, Vol. 29, No. 7Journal of Thrombosis and Thrombolysis, Vol. 38, No. 3Neuroimaging Clinics of North America, Vol. 24, No. 3European Radiology, Vol. 22, No. 9Journal of Vascular Surgery, Vol. 53, No. 2Neurosurgery, Vol. 68, No. 2Emergency Radiology, Vol. 17, No. 2Current Treatment Options in Neurology, Vol. 12, No. 2Blunt Cerebrovascular Injuries: Imaging with Multidetector CT Angiography1Clint W. Sliker, 1 October 2008 | RadioGraphics, Vol. 28, No. 6Journal of Trauma: Injury, Infection & Critical Care, Vol. 64, No. 2Le bilan d’imagerie dans les traumatismes récents du rachisRevue de Chirurgie Orthopédique et Réparatrice de l'Appareil Moteur, Vol. 93, No. 7Imagerie des traumatismes rachidiensEMC - Radiologie et imagerie médicale - Musculosquelettique - Neurologique - Maxillofaciale, Vol. 2, No. 1European Journal of Radiology, Vol. 62, No. 3Journal of the Neurological Sciences, Vol. 256, No. 1-2Vascular Injuries of the Neck and Thoracic Inlet: Helical CT–Angiographic Correlation1Diego B. Núñez, Jr, , Mario Torres-León, , and Felipe Múnera, 1 July 2004 | RadioGraphics, Vol. 24, No. 4La Revue de Médecine Interne, Vol. 24, No. 7The American Journal of Forensic Medicine and Pathology, Vol. 24, No. 1Neuroimaging Clinics of North America, Vol. 12, No. 2Anales de Pediatría, Vol. 56, No. 2The Journal of Trauma: Injury, Infection, and Critical Care, Vol. 52, No. 6Journal of the American College of Surgeons, Vol. 192, No. 3Acta Radiologica, Vol. 42, No. 3The Journal of Trauma: Injury, Infection, and Critical Care, Vol. 50, No. 1Journal of Trauma and Acute Care Surgery, Vol. 51, No. 6Korean Journal of Radiology, Vol. 2, No. 1Journal of Neurosurgery, Vol. 92, No. 3American Journal of Roentgenology, Vol. 174, No. 5Radiologic Clinics of North America, Vol. 37, No. 3The Lancet, Vol. 353, No. 9161Neurosurgery, Vol. 44, No. 4Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 207, No. 3 Metrics Altmetric Score PDF download