Anticoagulate both vertebral and carotid injuries
Other Injuries Associated with Cervical Spine Trauma
Vertebral artery
injury
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). In
such patients, MRA or angiography is recommended to evaluate the possibility of
vertebral artery injury (VAI). 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). 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. Treatment
options are observation versus heparin. Regardless of the type of injury
(except grade V), heparin has been shown to be of modest benefit in symptomatic
patients (14). Due to the risk of anticoagulation in the blunt trauma patient,
it should only be considered in conjunction with neurosurgery and trauma surgery
consultation.
| Table I: Grading of VAI | |
| (I) | Dissection < 25% |
| (II) | Dissection > 25% |
| (III) | Pseudo-aneurysm |
| (IV) | Complete arterial occlusion |
| (V) | Transection |
Landmark Article: Annals of Surgery Volume 223(5) May 1996
pp 513-525 Blunt Carotid Injury: Importance of Early Diagnosis and
Anticoagulant Fabian, Timothy
Most common sites of injury
Carotid 2 cm distal to bifurcation
Vertebral between C2 and the skull base
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.
Others say evaluation for this injury is futile 11 in 35212 had a stroke (Arch Surg 2004;139:609)
Largest series on parameters of multislice CT SENS 97.7 SPEC 100% (J Trauma 2006;60:925)