Blunt cerebrovascular injuries: diagnosis and treatment

Blunt cerebrovascular injuries (BCVIs), once thought to be rare, have been recognized with increasing frequency in recent years. An incidence of 0.33% for carotid artery injury (CAI) was noted from our institution, with 24% stroke-related mortality. Vertebral artery injury (VAI) has been thought both rare and of questionable significance. Incidence, associated injury patterns, and outcomes were examined during a period of aggressive screening (four-vessel angiography).

Patients with BCVI were identified from the registry of a Level I trauma center over a 5-year period (1995-1999).

One hundred thirty-nine BCVIs were identified in 96 patients: 75 were CAIs (14 bilateral), 64 were VAIs (14 bilateral), and 15 patients had both CAI and VAI. The incidence of CAI was 0.5% of all blunt trauma admissions, significantly higher than our earlier experience (p < 0.0002), whereas that for VAI was 0.4%. Thirty-four percent of CAIs were diagnosed because of ischemic changes and 38% because of injury pattern (neck, Horner syndrome, basilar skull fracture); only 12% of VAIs were diagnosed because of posterior circulation ischemia, with 64% because of injury pattern (cervical spine, soft tissue, facial fracture). Stroke-related mortality for CAI was 13%, and that for VAI was 4%. Forty-three of the 75 CAIs were treated (anticoagulation/antiplatelet) before development of ischemia. Thirty-nine of the 50 VAI patients were treated before development of ischemia. Stroke rate for CAI was 31% (hemiplegia/hemiparesis) and for VAI was 14% (brain stem dysfunction). Stroke rate for treated vessels (heparin, antiplatelet therapy) with CAI was 6.8% compared with 64% in untreated vessels (p < 0.001). Treated patients with VAI had a stroke rate of 2.6%, whereas untreated patients developed stroke 54% of the time.

Increased awareness and aggressive screening have resulted in significantly increased incidence of diagnosis of CAI, with associated lower stroke-related mortality. VAIs have been noted with similar incidence, and though the stroke rate is lower with VAI, stroke outcomes are generally catastrophic. Anticoagulation therapy is effective for both varieties of BCVI.