{"id":5434,"date":"2011-07-14T20:26:30","date_gmt":"2011-07-15T00:26:30","guid":{"rendered":"http:\/\/crashtext.org\/misc\/blunt-cerebral-vascular-injuries.htm\/"},"modified":"2015-04-17T19:03:34","modified_gmt":"2015-04-17T23:03:34","slug":"blunt-cerebral-vascular-injuries","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/system\/blunt-cerebral-vascular-injuries.htm\/","title":{"rendered":"Blunt Cerebral Vascular Injuries"},"content":{"rendered":"

West Guidelines<\/a><\/p>\n

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Screen basilar skull fx, c-spine fx, facial fx, gcs < 8, lateralizing facial neurodeficits<\/p>\n

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Antiplatelet both vertebral and carotid injuries<\/p>\n

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Other Injuries Associated with Cervical Spine Trauma<\/strong><\/p>\n

Vertebral artery injury<\/em> This injury is seen in up to 11% of cervical blunt trauma populations and presents as an expanding cervical hematoma, a bruit in patients under 50 years of age, an infarct seen on CT, significant facial hemorrhage from ears, nose or face, or symptoms consistent with a posterior circulation stroke (13, 14).\u00a0 In such patients, MRA or angiography is recommended to evaluate the possibility of vertebral artery injury (VAI).\u00a0 Patients with vertebral subluxation, facet dislocations, or foramen transversarium fractures are at increased risk for VAI and probably should undergo imaging studies as well (15).\u00a0 Injury types are shown in table I. Symptoms of VAI reflect a posterior circulation stroke and range from ataxia, vertigo, or blindness, to focal deficits or complete cord injury.\u00a0 Treatment options are observation versus heparin.\u00a0 Regardless of the type of injury (except grade V), heparin has been shown to be of modest benefit in symptomatic patients (14).\u00a0 Due to the risk of anticoagulation in the blunt trauma patient, it should only be considered in conjunction with neurosurgery and trauma surgery consultation.<\/p>\n

Table I: Grading of VAI (I) Dissection < 25% (II) Dissection > 25% (III) Pseudo-aneurysm (IV) Complete arterial occlusion (V) Transection<\/p>\n

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Landmark Article: Annals of Surgery Volume 223(5) May 1996 pp 513-525 Blunt Carotid Injury: Importance of Early Diagnosis and Anticoagulant Fabian, Timothy<\/p>\n

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Most common sites of injury<\/p>\n

Carotid 2 cm distal to bifurcation<\/p>\n

Vertebral between C2 and the skull base<\/p>\n

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Dissection of the internal carotid artery is the creation of a channel within the wall of the vessel resulting from disruption of the intima. It is manifested angiographically by 1. a narrowing of the “true” lumen flow of blood throug a disrupted intima associated with 2. a linear lucent line representing the intima\/media component that has been dissected by the “intramural” hematoma.Dissection in normal healthy vessels is uncommonly seen. it is far more likely to result from vessels with medial degeneration. I have seen three unquestionable dissections after trauma proven by angiography. Two were blunt, an abdominal aortic injury, and a subclavian artery injury. Both were in elderly men. The third was a young man who sustained a gunshot wound of the axillary artery. This was proven to be a dissection when the guidewire entered the false lumen. The imaging appearance of dissections is much more readily evident on MR and CTA because those cross sectional imaging techniques allow us to see the soft tissue of the wall. It is possible to identify dissections as high attenuation signals (representing clotted hematoma) on CT within the wall. MR can also delineate such wall abnormalites. Angiographic diagnosis of ICA “dissections” is most difficult because many injuries of the ICA, especially intimal trauma, result in spasm which can resemble a dissected vessel. Thrombosis will also give such an appearance that is presumed to be a dissection. but that is unproven. . intimal flaps, which are represented as short linear radiolucencies in the contrast column, are a much more common sequellae of trauma and are often erroneously labeled as dissections by BOTH SURGEONS AND RADIOLOGISTS.<\/p>\n

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Others say evaluation for this injury is futile 11 in 35212 had a stroke (Arch Surg 2004;139:609)<\/p>\n

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Largest series on parameters of multislice CT SENS 97.7 SPEC 100% (J Trauma 2006;60:925)<\/p>\n

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CTA screening protocol (J Trauma 2009;67(3):551)<\/p>\n

they used modified Denver Criteria<\/p>\n

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EAST Recommendations<\/a><\/p>\n

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New Improved Screening Criteria from Fabian’s Group (J Trauma 2011;70:1058)<\/p>\n