Bilateral extracranial internal carotid artery injury due to non-penetrating trauma--report of three cases.

Angiographic features of three patients with bilateral internal carotid artery injury (spasm/dissection/thrombosis) due to non-penetrating trauma are reported. All three patients were involved in motor vehicle accidents. Focal-localizing neurological signs were present and the patients were suspected of having extracerebral haematomas. The diagnosis of traumatic spasm/dissection/thrombosis of the cervical portion of the internal carotid arteries was made following angiography. The need to include views of the cervical carotid arteries in cases of traumatic hemiparesis is stressed and possible effect of cranial CT scanning in these patients on diagnosis of carotid artery injury discussed.     

Carotid and vertebral artery trauma: clinical and angiographic features.

Injury to the carotid or vertebral artery is an important clinical entity that requires angiography for definitive diagnosis and evaluation. The common carotid artery may be injured by penetrating trauma while the internal carotid artery is usually damaged by either trivial or blunt trauma. With trivial trauma extracranial internal carotid artery dissection should be considered if there is unilateral headache, Horner's syndrome or delayed transient ischaemic attack, and intracranial dissection if a profound neurological defect occurs immediately following trauma. Injury to the internal carotid artery following blunt trauma includes dissection of the extracranial internal carotid artery, carotid-cavernous fistula and pseudoaneurysm formation. These should be considered in a patient with delayed neurological deficit, mandibular or skull fracture, a constellation of orbital signs or diffuse subarachnoid haemorrhage, respectively. Vertebral artery injury is less frequent. Dissection typically follows abrupt cervical rotation and occurs at C1-2, whereas penetrating trauma may involve either the proximal or distal vertebral artery and occlusion, arteriovenous fistula or pseudoaneurysm may be found. Endovascular techniques may be used in either the carotid or vertebral artery to close fistulae or occlude an extensively damaged vessel.     

重型口腔颌面部创伤的临床救治

目的通过520例口腔颌面部创伤病例的回顾性临床分析，探讨特殊类型重型颌面部损伤的救治方法。方法选取我科近21年口腔颌面部创伤住院患者病例资料，分析损伤类型、相应救治方法和临床疗效。通过4例典型病例，探讨颈部血管损伤、颅面多发伤、中面部骨折和面神经损伤的救治要点。结果全部患者无一例死亡，均获得良好疗效。结论颈动脉损伤应即刻修复，恢复大脑血供；颅面多发伤应在颅脑伤情稳定后，于伤后7—14d行颌面部骨损伤的确定性治疗；中面部骨折采用骨折开放复位、坚固内固定的手术方法可获更好的治疗效果；面神经损伤应尽可能在伤后30d内行神经修复手术。     

Craniofacial gunshot injuries: an unrecognised risk factor for blunt cervical vascular injuries?

Objectives

To review our institutional experience with cervical arterial injuries remote from the penetrating tract seen in the setting of craniofacial gunshot injuries.

Methods

Institutional Review Board approval was obtained. Our institutional trauma registry was queried over a 5-year period for patients with cervical arterial injuries due to penetrating craniofacial gunshot wounds who underwent CT angiography. Imaging results and clinical notes were reviewed.

Results

A total of 427 patients sustained gunshot wounds to the head, face and/or neck, of whom 222 underwent CT angiography yielding 56 patients with 78 vascular injuries. There were five internal carotid artery injuries remote from the wound tract. The incidence of these “indirect” cervical arterial injuries in our patient population was 1.2%, or 2.8% of patients who underwent CT angiography.

Conclusions

The incidence of “indirect” cervical arterial injuries with craniofacial gunshot wounds is comparable to or slightly higher than those seen in pure blunt trauma. Screening patients with craniofacial gunshot injuries with CT angiography may yield unexpected cervical vascular injuries remote from the penetrating tract. The significance and optimal therapy of these injuries are unknown. Additional experience will be needed to determine the significance of “indirect” cervical arterial injuries in the setting of craniofacial gunshot wounds.

Key Points

? There are several known risk factors for blunt cervical arterial injuries. ? Cervical arterial injuries may occur remote from the wound following craniofacial gunshot wounds. ? Craniofacial gunshot wounds pose a risk for blunt cervical vascular injuries.     

Post-traumatic dissection of the internal carotid artery associated with ipsilateral facial nerve paralysis: Diagnostic and forensic issues

Traumatic internal carotid artery dissection may result from a direct blow to anterolateral aspect of the neck, or an extreme extension and rotation of the neck. Traumas involved are variable ranging from high speed motor vehicle accident to trivial traumas. The most frequent presentations of carotid artery dissection are stroke, Hörner syndrome, and paralysis of a cranial nerve. Time of ischemic signs onset is very variable too, diverging from immediate to several months delay. We report the case of a 60-year-old woman, who was assaulted by a young man. Immediately, she complained of headache and posterior cervical pain. Three months later she developed a left hemifacial paralysis. MRI and MRA showed a dissection of the left internal carotid artery. The causal relationship between the trauma and the carotid artery dissection as well as forensic issues are discussed.     

Delayed traumatic occlusion of the extracranial internal carotid artery after earthquake: report of two cases

We report on two patients with head and neck injuries, who remained asymptomatic after the earthquake for 1 and 2 years, respectively. They developed late transient ischemic neurological signs and eventually presented with complete occlusion of the internal carotid artery. They made a good recovery with medical treatment. Focal cerebral ischemic symptoms may develop months or even years after the head or neck trauma, and internal carotid artery occlusion should be considered in differential diagnosis as a late complication.     

闭合性颈椎创伤伴椎动脉损伤的临床研究

目的　研究椎动脉损伤在闭合性颈椎创伤中的发病率及其与颈椎损伤机制、类型、损伤程度的相关性 ,观察椎动脉损伤后的临床症状、体征 ,探讨早期正确诊断的方法。　方法　于2 0 0 0年 8月～ 2 0 0 2年 2月间 ,利用颈部动脉磁共振血管造影 (MRA)技术 ,连续观察 4 6例闭合性颈椎创伤患者 ,结合颈椎X线、MRI、CT检查及患者的临床症状、体征综合分析。　结果 4 6例闭合性颈椎创伤中 ,12例 (2 6 % )伴椎动脉损伤。其中 7例为双侧损伤 (4例一侧未显影、一侧狭窄 ,3例双侧狭窄 ) ,5例为单侧损伤 (均为一侧狭窄 ) ;10例椎动脉损伤患者无任何症状 ,2例出现眩晕、恶心呕吐、面部麻木、偏盲等症状。椎动脉损伤与屈曲型损伤及颈椎严重不稳定相关 (P <0 .0 5 ) ,与小关节绞锁、横突孔骨折及脊髓完全性损伤明显相关 (P <0 .0 1)。　结论　椎动脉损伤是闭合性颈椎创伤的较常见并发症 ,其临床症状体征缺乏特异性。颈椎创伤中的颈椎严重不稳定、屈曲型损伤、伴有脊髓完全性损伤、小关节绞锁和 (或 )横突孔骨折应高度怀疑椎动脉损伤。临床医师应对此类损伤有较高的警惕性 ,常规进行颈部动脉MRA检查是最有效的早期正确辅助诊断方法。     

Seat belt injuries: radiologic findings and clinical correlation

The seat belt syndrome consists of skeletal, soft-tissue, and visceral injuries associated with use of two- and three-point restraints in patients involved in motor vehicle accidents. Skin abrasions of the neck, chest, and abdomen--the classic seat belt sign--indicate internal injury in 30% of cases. Neck abrasions are associated with injuries to the carotid artery, larynx, and cervical spine; chest abrasions, with fractures of the sternum, ribs, and clavicles and injuries to the heart and thoracic aorta; and abdominal abrasions, with mesenteric tears, bowel perforation and hematoma, Chance fractures, and injuries to the abdominal aorta. The seat belt sign should prompt a diligent search for related injuries.     

Ascending pharyngeal artery collateral circulation simulating internal carotid artery hypoplasia

Summary Complete occlusion of the cervical segment of the internal carotid artery may result in a collateral circuit between an enlarged ascending pharyngeal artery and the intracranial segment of the internal carotid artery. This anastomosis may simulate a severely stenotic or hypoplastic internal carotid artery. Differentiation between these entities is particularly important if carotid endarterectomy for relief of stenosis is contemplated.     

Fatal subarachnoid hemorrhage following traumatic rupture of the internal carotid artery

Traumatic subarachnoid hemorrhage (TSAH) is a life-threatening intracranial bleed often associated with violent assault or motor vehicle accidents. The vast majority of TSAH is associated with rupture of the vertebral artery, although rare cases of traumatic aneurysm of the internal carotid artery (ICA) have been reported. A 27-year-old man was found bleeding and unresponsive following a violent altercation in which he received repeated blows to the head and neck. CT scan showed acute SAH, and death ensued within 24h. Autopsy revealed generalized bruising of the face, a complete midline mandibular fracture, and massive basal SAH resulting from traumatic rupture of the right terminal internal carotid artery at the origin of the middle cerebral artery. Anterior and posterior neck dissection revealed focal hemorrhage associated with the right neural arch of the first cervical vertebra (C1). Autopsy findings were consistent with TSAH resulting from rupture of the ICA following blunt force trauma to the head. The rupture site in TSAH can be difficult to locate, and injury to the ICA may be overlooked if not routinely examined. Dissection of the neck and skull base is required to ensure accurate identification of the site of vascular injury.     

颅外颈内动脉损伤诊治方法的探讨

目的　探讨颅外颈内动脉损伤的早期诊断和治疗方法。方法　 1982～ 2 0 0 2年共收治颅外颈内动脉损伤 8例 ,其中颈内动脉破裂并休克 3例 ,并发栓塞 4例 ,假性动脉瘤 2例。行颈内动脉修补 2例 ,颈内动脉 -颈外动脉端端吻合 1例 ,颅内 -外动脉搭桥 2例 ,手术取栓 1例 ,瘤体切除加动脉修补 2例。结果无死亡 ,4例出现偏瘫失语等神经系统并发症 ,1例经颅内 -外动脉搭桥后完全康复 ,1例经取栓术后改善 ,2例经保守治疗症状轻度改善。余 4例除 1例遗有颈内动脉假性动脉瘤外 ,均痊愈。结论　早期诊断及颈内动脉修复重建是降低死亡率 ,减少神经系统并发症的关键     

Angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector CT

Purpose

Blunt carotid injuries (BCI's) and blunt vertebral artery injuries (BVI's), known jointly as BCVI's, are common in “high risk” patients. The purpose is to evaluate the rate of occurrence of BCI/BVI in patients screened purely by the radiologic criteria of fracture through the carotid canal or vertebral transverse foramina, or significant cervical subluxation, noted by multidetector CT.

Methods

Seventy-one patients with 108 catheterized vessels were included over a 13-month interval. The angiographic examinations were prompted by current hospital protocol, solely by the presence of fractures involving/adjacent to the carotid canal, cervical fractures involving/adjacent to the foramen transversarium, or cervical fractures with significant subluxation. The incidence of each grade of blunt injury was calculated after review of the CT scans and catheter angiograms by two neuroradiologists.

Results

Two thousand and seventy-three total blunt trauma admissions occurred during the time period, with a BCVI rate of 0.92–1.0% (depending on the reviewer), similar to previous studies. Mean time to catheter angiography was 16.6 h. Of the 71 included patients, there were 11–12 BCI's and 10–12 BVI's, an overall rate of 27–30% of BCVI in the patients with foraminal fractures. Interobserver agreement in reviewing the catheter angiograms was excellent (Kappa 0.795). Of note, three internal carotid pseudoaneurysms resolved spontaneously after anticoagulation or aspirin.

Conclusion

This study confirms that there is a high rate of BCVI in the presence of carotid canal or vertebral foramen fractures that are noted by multidetector CT. Utilization of purely radiologic criteria of foraminal involvement may be a significant screening tool in the decision of whether to evaluate these patients acutely by catheter or CT angiography, and for early detection of patients at risk for symptomatology, to initiate prompt, prophylactic treatment.     

Extracranial carotid artery aneurysms following accidental injury: ten years experience

Extracranial carotid artery aneurysms secondary to accidental injury are rare. We have seen eight lesions of this type in the last 10 years. The aneurysm was produced by blunt trauma in four patients, penetrating shrapnel injury in two, stabbing and electrical injury in one each. The left side was involved in seven patients. The internal and common carotid artery were each involved in four patients and the lesion was unilocular in five. These lesions often produce non-specific symptoms and may mimic neoplastic or inflammatory masses: a mistaken diagnosis of tonsillar abscess in one patient resulted in incision and drainage before an intravenous digital subtraction angiogram (IV-DSA) correctly identified the abnormality. IV-DSA is ideal for pre-operative assessment of these patients. Awareness of these lesions is essential since definitive surgical repair is possible. All patients in the present study underwent successful surgical repair.     

Cervical collaterals may protect against stroke after blunt vertebral artery injury

The incidence of ischemic stroke reported after blunt vertebral artery injury is lower than that reported after blunt carotid artery injury. Unlike the carotid arteries, the vertebral arteries receive collateral blood flow through ascending cervical branches in addition to a convergent arterial supply with the contralateral vertebral artery. We hypothesize that the incidence of stroke after vertebral artery injury is less than after carotid artery injury in part because of reconstitution of vertebral arteries by cervical collaterals. A retrospective blinded interpretation of angiographic studies in 46 patients with blunt vertebral injury was performed to assess for presence and grade of vertebral artery injury and for the presence of reconstitution of the vessel via cervical collaterals. Follow-up CT scans from the same patients were evaluated for the presence of posterior circulation strokes. There were 55 injured vertebral arteries in the 46 patients, of whom 8 experienced posterior fossa strokes. Two-tailed Fisher exact probability test evaluating the hypothesis that patients with vertebral artery collaterals were less likely to experience posterior fossa strokes reached significance, p < 0.05. Of patients with occlusive (grades IV and V) injuries, those with collateral vessels were significantly less likely to experience posterior fossa strokes (p < 0.01). This result may be considered when weighing the potential risks and benefits of antiplatelet or anticoagulation therapy in patients with occlusive blunt vertebral artery injury.     

Pseudoaneurysm of the Internal Carotid Artery: Treatment with a Covered Stent

Dissection of the cervical segment of the internal carotid artery may occur spontaneously or after trauma. We report the management of a 53-year-old right-handed man with progressive dizziness and neck pain 6 weeks after a motor vehicle collision. The clinical and neurologic examinations were normal. The CT scan led to the diagnosis of a pseudoaneurysm of the right internal carotid artery near the skull base. We successfully treated this post-traumatic lesion with a covered stent. The patient underwent the endovascular procedure under general anesthesia and transcranial Doppler monitoring. No neurologic event was observed. Obliteration of the pseudoaneurysm with preservation of the carotid artery was achieved. The patient was discharged from the hospital 72 hr later with no complications. Clinical and imaging follow-up at 6 months was unremarkable.     

Can cervical spine injury be correctly diagnosed by postmortem computed tomography?

We discuss the usefulness of postmortem computed tomography (PMCT) by reviewing cases of cervical spine injury. A merit of PMCT is that it can identify injury that cannot be found on autopsy; however, peculiar defects of it may exist. While PMCT can identify bone fractures, it cannot indicate whether the injury was inflicted while the deceased was still alive or not because of its inability to clearly image bleeding around the fracture. Furthermore, CT often misses some types of cervical spine injuries, such as laceration of an intervertebral disk and incomplete fracture of the cervical spine. On the other hand, cervical spine injury on CT images occasionally has an appearance similar to subarachnoid hemorrhage due to rupture of the cerebral artery, indicating that cervical spine injury can be misdiagnosed as a disease by PMCT. When PMCT is used for screening trauma, caution must be observed regarding its limitations. If the possibility of trauma of the neck or head is not completely ruled out from the personal history of the victim, autopsy is strongly recommended, even when PMCT findings indicate that the cause of death may be due to disease, such as subarachnoid hemorrhage.     

Association of internal carotid artery injury with carotid canal fractures in patients with head trauma

OBJECTIVE: The purpose of our study was to determine the degree to which carotid canal fracture and other CT findings are associated with internal carotid artery (ICA) injury in patients with head trauma. MATERIALS AND METHODS: Three neuroradiologists retrospectively evaluated CT scans and cerebral angiograms of 43 patients who underwent cerebral angiography within 7 days after blunt cranial trauma over a 5-year period. Seventeen patients underwent unilateral and 26 had bilateral carotid angiography. Angiograms were evaluated for ICA injury and CT scans were evaluated for carotid canal fracture, brain contusion, subarachnoid hemorrhage, basilar skull fracture, subdural hematoma, soft-tissue swelling, sphenoid sinus air-fluid level, and other skull fracture. We recorded the number of true-positive (+CT, +angiogram), true-negative (-CT, -angiogram), false-positive (+CT, -angiogram), and false-negative (-CT, +angiogram) studies. We determined the sensitivity, specificity, positive predictive value, and negative predictive value for each CT finding. RESULTS: We identified 21 carotid canal fractures in 17 patients. Eleven ICA injuries were seen in 10 patients. Six patients with ICA injury had a carotid canal fracture. The presence of a carotid canal fracture had a sensitivity of 60% and specificity of 67% for detection of injury to the ICA passing through that canal. These values were similar to those for other CT findings. CONCLUSION: Sensitivity, specificity, positive predictive value, and negative predictive value of carotid canal fracture were only moderately good for determining the presence of ICA injury and were similar to other CT findings not typically associated with ICA injury.     

Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?

PURPOSE: To retrospectively determine what information, if any, magnetic resonance (MR) imaging of the cervical spine in obtunded and/or "unreliable" patients with blunt trauma adds to multi-detector row computed tomography (CT) of the entire cervical spine (including routine multiplanar sagittal and coronal reformations) when the CT findings are normal. MATERIALS AND METHODS: The study was HIPAA compliant and institutional review board approved. Informed consent was not required. From April 2001 to November 2003, 1400 trauma patients underwent MR imaging of the cervical spine to evaluate potential cervical spine injuries. Multi-detector row CT of the cervical spine was performed with a four- or 16-detector row scanner. MR imaging of the cervical spine was performed with transverse gradient-echo, sagittal intermediate-weighted, sagittal short inversion time inversion-recovery, and sagittal T1- and T2-weighted fast spin-echo sequences. Many MR examinations were performed to exclude soft-tissue injuries in the cervical spine of obtunded patients with blunt trauma in whom cervical spine injury could not be excluded with physical examination. Complete cervical spine MR studies were obtained to evaluate soft-tissue injuries in 366 obtunded patients with blunt trauma (281 male and 85 female patients; age range, 13-92 years; mean age, 42.1 years). The patients had previously undergone total cervical spine multi-detector row CT with normal findings. The results obtained with these two modalities were compared. RESULTS: MR images were negative for acute injury in 354 of the 366 patients and negative for cervical spine ligamentous injury in 362. Seven of the 366 patients had cervical cord contusions, four patients had ligamentous injuries, three patients had intervertebral disk edema, and one patient had a cord contusion, a ligamentous injury, and an intervertebral disk injury. Four patients had ligamentous injuries; however, all of these patients had ligament injuries limited to only one of the three columns of cervical spine ligament support. Multi-detector row CT had negative predictive values of 98.9% (362 of 366 patients) for ligament injury and 100% (366 of 366 patients) for unstable cervical spine injury. CONCLUSION: A normal multi-detector row CT scan of the total cervical spine in obtunded and/or "unreliable" patients with blunt trauma enabled the authors to exclude unstable injuries on the basis of findings at follow-up cervical spine MR imaging.     

Odontoid fractures following blunt trauma

Fractures of the odontoid process typically result from forceful blunt trauma. They often produce instability of the cervical spine, and may be associated with neurologic impairment. This study was designed to examine the epidemiology and demographics of odontoid injuries, including their incidence and prevalence relative to other spine injuries, the prevalence of associated injuries, and the likelihood of neurologic impairment. Of 34,069 enrolled blunt trauma victims, 818 (2.4 %) sustained a cervical spine injury, 94 of whom had a fracture of the odontoid. The relative prevalence of odontoid fractures varied by age, ranging from less than 3 % among individuals under age 20 years, to greater than 20 % in patients over 80 years old. Classification by Anderson–D'Alonzo criteria revealed 6 type I injuries, 60 type II injuries, and 27 type III injuries; one vertical injury could not be categorized. Over half of the odontoid fracture victims sustained additional cervical spine injuries, with 90 % of these injuries involving the atlanto-axial complex. In addition, non-spine-related injuries were found in 52 % of odontoid injury victims, over one-third (34 %) presented with an altered level of alertness, and almost one-quarter (23 %) exhibited some form of focal neurologic deficit associated with their injury. Fractures of the odontoid are among the most frequently encountered cervical spine injuries, and increase in prevalence with increasing patient age. Odontoid fracture victims often have other spine injuries, particularly to the atlanto-axial complex, and may harbor other non-spine-related injuries and neurologic pathology.     

Traumatic internal carotid artery dissection presenting as delayed hemilingual paresis.

A case of internal carotid artery dissection presenting as delayed right hemilingual paresis after blunt craniocervical trauma is presented. Diagnosis is discussed with emphasis on MR and MR angiographic findings. Mechanisms of injury and lower cranial nerve palsy are also briefly discussed.