Chapter 181 - Head + Neck Vascular Trauma Flashcards
Penetrating injury to carotid stroke and mortality
Stroke 7-27% Mortality 7-50%
Zones of neck injury
Zone 1: below cricoid cartilage - proximal control in chest Zone 2: between cricoid and angle of mandible - proximal and distal control in neck Zone 3: above angel of mandible
Rate of different zones of neck injury
Zone II 47% Zone III 19% Zone I 18%
Hard signs of vascular injury in neck
1) Shock 2) Refractory hypotension 3) Pulsatile bleed 4) Bruit 5) enlarging hematoma 6) Loss of pulses with stable evolving neurologic deficit PPV 97%
Soft signs of vascular injury in neck
1) history of bleeding at scene of injury 2) stable hematoma 3) nerve injury 4) proximity of injury track 5) unequal UE BP PPV 3%
Gunshot chance of neck vascular injury vs stabs
27% gun 15% stab
Associated injuries to neck penetrating injury
Trachea Esophagus Spine 1-7%
Normal physical exam negative predictive value in neck injury ? vascular
90-100%
Treatment of carotid thrombosis with stroke and coma
Revascularization Benefit within 24 hours of injury
Using platysma penetration as indicator for neck vascular injury
50-90% negative exploratory rate
CTA to diagnose neck vascular injury SEN/SPE
90% sensitivity 100% specificity for injuries that require treatment
Surgical option for neck vascular injuries
1) ligate 2) repair 3) temporary shunt
Vessels in neck that can be ligated
External carotid Internal jugular
Ligation of ICA
45% mortality
Blunt cerebrovascular injuries incidence
<1% of all trauma
Stroke and death after blunt cerebrovascular injuries
Stroke 25-58% Death 31-59%
Mechanism of blunt cerebrovascular injury
1) extreme hyperextension and rotation 2) direct blow to vessel 3) vessel laceration by adjacent bone fractures Most common: hyperextension of carotid over lateral articular processes C1-C3
Associated injury after blunt cerebrovascular injuries
1) close head injury 2) facial # 3) cervical spine # 4) thoracic injuries
Signs/symptoms of carotid cavernous fistula
1) orbital pain 2) proptosis 3) hyperemia 4) cerebral swelling 5) seizure
Screens for blunt cerebrovascular injuries
1) Denver Health Medical Center 2) Memphis Criteria Any criteria met = 4 vessel angiogram indicated
Diagnostic tool for blunt cerebrovascular injury
Duplex - not great Sen 38-86% DSA - gold standard Early generation CTA - new gold standard; sen 47-68%; spe 67-99% Multidetector (4-8 slices) - sen 83-92%; spe 88-98% DSA = CTA 16 slices MRI poor sen 50-95%
Medical treatment after blunt cerebrovascular injury
Antithrombotic therapy no RCT’s done first line = anticoagulation
Vertebral injury incidence
0.2-0.77%
Isolated vertebral injury mortality
4%
Most common mechanism of vertebral injury
Fracture of transverse foramen C2-C6
Unilateral vertebral injury consequences and associations
80% asymptomatic Associated with 25% bilateral 33% carotid injury
Symptoms of vertebral injury
1) Subtle neck pain 2) posterior headache 3) vertebrobasilar insufficiencies
Diagnostic evaluation of vertebral injury
Hard signs of bleed or tracheal injury –> skip further investigation CTA sen 40-60; spe 90-97
Medical treatment of vertebral injury
No evidence Symptomatic patients without contraindication = 3-6 months of anticoagulation Asymptomatic patients = 3-6 months anticoag or DAPT
Types of complication of anticoagulation in trauma and overall rate
1) intracranial 2) GI 3) retroperitoneal 4) solid organ 5) surgical wound Rate 16%
Rate eligible for anticoagulation post blunt cerebrovascular injury
14%
Standard heparin PTT target
50-60seconds
Natural history of blunt cerebrovascular injury by grades at 3 months
Gr 1: 72% heal Gr 2: 1//3 improve; 1/3 stable; 1/3 progress to pseudoaneurysm Gr 3: 50% unchange; 40% enlarge Gr 4: do not improve
Endovascular treatment vertebral injury
Bare stents adequate to cover pseudoaneurysm +/- coils Need long term follow up because risk of kinking
Surgical treatment of vertebral injury
zone 2 Risk of stroke and CN neurapraxia only do in active bleed at time of exploration Unilateral ligation = stroke in 3-5% vertebral
Subclavian artery injury mortality
50-80% in hospital during treatment mortality 15%
Associated injuries with subclavian artery injury
Vein 50% Cervical 70%
Blunt subclavian artery injury associated with
1) Clavicular # 2) Mediastinal injury 3) pulmonary contusion rare overall
Medical management in blunt subclavian artery injury
For intimal disruption, dissection that are not flow limiting Antiplatelet or anticoagulation
Endovascular treatment in blunt subclavian artery injury
appropriate in 42-50% of patients Brachial or femoral approach May still need hematomat evacuation for treating mass effect
Open approaches to subclavian artery injury by side
Right subclavian = mid sternotomy Innominate = mid sternotomy Left subclavian = left anterolateral thoracotomy +/- clavicle resection
Cervical venous injury associated with
1) sternal # 2) clavical #
Rate of IJ and subclavian vein injury in associated penetrating arterial injuries
20% IJ 50% subclavian vein
CTA delayed acquisition time for venous phase
30 sec to 3 min
Treatment of venous injuries in neck
1) ligation because time is critical IJ ligation = rare cerebral edema IJ reconstruction has 18 month patency at 64% primary repair venorrhaphy if < 50% involved
Blunt Cerebrovascular Injury Grading Scale
Screening Criteria for Blunt Cerebrovascular Injury
