Neurosurgery notes/Trauma/Primary head Injury/Blunt cerebrovascular injury (BCVI)/Carotid artery blunt injuries

Carotid artery blunt injuries

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Blunt cerebrovascular injury (BCVI)

General

  • This section considers blunt (i.e., nonpenetrating) specifically related to ICA dissection.

Mechanism

  • Neck hyperextension with lateral rotation is a common mechanism of injury → stretch the ICA over the transverse processes of the upper cervical spine
  • In posttraumatic dissection, ischemic symptoms are the most common.
  • Most carotid dissections start ≈ 2cm distal to the ICA origin.

Aetiologies

  • RTA: most common
  • Attempted strangulation
  • Spinal manipulation therapy:
    • VA dissections are more common than ICA

Clinical

  • The risk of stroke increases with increasing grade for ICA injuries.
      • Gradeᵃ
      Description
      Stroke risk
      I
      Stenosis < 25%
      3%
      II
      Stenosis > 25%
      11%
      III
      Pseudoaneurysm
      44%
      IV
      Occlusion
      Uniformly lethal
    • ᵃfor grading
    • This is not true for VA injuries.
  • Initially, there may be no neurologic sequelae;
    • However, progressive thrombosis, intramural hemorrhage, or embolic phenomenon may develop in a delayed fashion.
    • Time to presentation after non-penetrating trauma
        • Time
        % of cases
        0–1 hours
        6–10
        1–24 hours
        57–73
        after 24 hours
        17–35
      • The majority are evident within the first 24 hours

Management

  • Same as BCVI

Outcome

  • Natural history is not well known.
  • Many patients with minor symptoms may not present and presumably do well.
  • Hart et al 1983
    • 75% of patients returned to normal
    • 16% had a minor deficit
    • 8% had a major deficit or died
  • Grade I injuries:
    • 70% heal with or without heparin
    • 25% will persist.
    • 4–12% will progress to more severe grade
      • Anticoagulation reduces the risk of progression
  • Grade II:
    • ≈ 70% progress to more severe grade even with heparin therapy.
  • Grades III & IV:
    • Most persist.