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Cervical Internal Carotid Artery Injuries Due to Blunt Trauma

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Cervical Internal Carotid Artery Injuries Due to Blunt Trauma 292 Cervical Internal Carotid Artery Injuries Due to Blunt Trauma Solomon Batnitzky,1 , 2 Hilton I. Price,1 Robert W, Holden,2 and Edmund A. Franken, Jr.2 Blunt or nonpenetrating trauma to the head and neck occa­ th ere was a delay of from 3 hr to 4 days in the onset of neurolopic sionally results in damage to the cervical segment of the internal symptoms after the injury. carotid artery. This may produce neurologic signs and symptoms Pl ain skull films were normal in all 21 patients, Two pati ents had that mimic acute craniocerebral injury. The mortality and mor­ fractures involving the angle of the mandible, and one patient had bidity associated with these injuries are alarmingly high. These a depressed fracture of the sternum. Cranial CT was performed in injuries may be missed if one relies only on computed tomogra­ nine patients on admission to the hospital. It was repeated in five 01 phy. Angiography is still the definitive procedure t o diagnose th ese patients who suffered neurologic deterioration occurri ng 3- these lesions. The clinical and radiographic features as well as 24 hr later. the pathogenesis and mechanism of injury are discussed for 21 In two patients, the initial CT scan demonstrated diffuse bilateral cases of injury to the cervical internal carotid artery due to blunt cerebral edema. The CT scans in the other seven patients and those trauma. five patients who had follow-up CT scans after neurologic deteri o­ ration were normal. Bilateral carotid angiography was performed in all 21 pati ents. Although rare, blunt or nonpenetrating injuries to the head and Bilateral involvement of the cervical ICAs was demonstrated in live neck may result in damage to th e cervical segment of th e internal carotid artery (ICA). This damage may produce neurologic defic its that mimic the signs and symptoms of acute craniocerebral injury. The morbidity and mortality associated with these injuries are alarmingly high. Computed tomography (CT) has virtuall y replaced angiography as the definitive radiologic procedure in the diagnosis and manage­ ment of craniocerebral trauma [1], but because CT is not a partic­ ularly effective imaging mode for vascular sequelae, an arterial injury may go unrecognized because of the failure to suspect it. Physicians dealing with traumatized patients should be aware of this possibility and should not attribute all neurologic signs in the traumatized patient to direct cerebral injury. Angiography is still the procedure of choice to demonstrate the vascular sequelae of head and neck trauma. Materials and Methods We investigated 21 cases of injuries to the cervical segment of the ICA foll owing blunt or non penetrating trauma. The patients were 16 to 57 years old (mean, 28.2 years). There were 12 males and nine females. The sources of trauma were: vehicular accidents, 18; head caught in metal punch press, one; fall on head during seizure, one; and hit on neck by a chair, one. In 15 cases there was evidence of trauma to the forehead and face consisting of abrasions, contusions, and lacerations. In two A B cases th ere was extern al evidence of trauma to the neck, consisting Fig . 1.- Angiograph y in 25-year-old woman after automobile accid(. It. A, of abrasions and contusions. Four patients exhibited no external Left lateral carotid view. Dissecting aneurysm in vo lves cervical seg m' nt of evidence of trauma to the head or neck. ICA. Extensive segment of narrowing and irregularity of lumen. B, S' milar In 11 cases the onset of symptoms was immediate. In 10 cases changes involve cervical seg ment of ri ght ICA. 1 Department of Di ag nostic Radiology, University of Kansas Coll ege of Health Sciences and Hospital, Rai nbow Boulevard at 39th Street, Kansas Cit v, KS 66103. Address reprint requests to S. Batnitzky. 2 Department of Radiology, Indiana University Medical Center, Indianapolis, IN 46202. AJNR 4:292-295, May/ June 1983 0195-6108/ 83/ 0403-0292 $00.00 © American Roentgen Ray Society AJNR:4, May I June 1983 CEREBRAL ANGIOGRAPHY 293 pati ents (figs. 1 and 2 ). Of these five pati ents, four had bilateral dissecti ons but without to tal occlusion of the art ery. The o ther pati ent had a dissecti on on one side and complete occlusion on the oposite side. One of the pati ents with bilateral dissecting aneurysms of the ICA exhibited an asociated traumati c aneurysm on one side (fig. 2A). Fourteen pati ents had complete occlusion of one of their ICAs (figs. 3 and 4), and two patients showed evidence of dissecti on of one of their carotid arteries without to tal occlusion. In th ose cases in whic h complete occlusion o f the cervical ICA was demon­ strated , the site of occlusion occurred within the first 3 c m of the proximal ICA. Results Nine pati ents underwent surgery consisting of arteri o tomy w ith thrombectomy or thromboendarterectomy. Of these nine pati ents, two died shortly after surgery. One pati ent improved without any residual neurologic d efic it. Six pati ents impro ved sli ghtly but still had significant residual neurologic defi c its at the time of discharge, whic h persisted in foll ow-up examinations cond ucted up to 1 year A 8 postinjury. Five of the group of 12 pati ents who did not have any surgery died . Six were left with a moderate to severe neurologic Fig. 2. -A, Left lateral carotid angiography in 40-year-old woman injured defi c it, and one pati ent recovered completely. in automobile accid ent. Progressive intraluminal narrowing of ICA , tapering Autopsies were performed in five o f the patients w ho died . (Fo ur 10 extremely arrow diameter (arrows ) just below ca rotid ca nal. Posteri orl y were from the group who did not have any surgery.) In all fi ve cases, si luated traumatic aneurysm (arrowhead). Right carotid angiography dem­ th ere was evidence o f one or more intimal tears of the cervical ICA onstrated simil ar features of dissectin9 lesion in right side, but without showing traumati c aneurysm. B, Au topsy specimen of left ICA. Di sruption of at the level of C1 and C2 (fig. 28). Extensive intraluminal antemor­ inllma (arrowh eads ) at three levels and area of dissection (arrows ). Traumati c tem thrombus was present in all five cases, and three cases showed aneurysm cannot be seen on this projection . evidence of intramural dissecti on. 3 4 5 6 Fig. 3. -Left lateral carotid angiograph y in 17 -year-old boy aft er motor­ cervica llCA due to dissecting lesion. Li nea r filli ng defect (arrowheads ) wit hin cycle accident. Complete occlu sion of intern al carotid artery 3 cm di stal to its opacified vesse l whi ch represe nts intimal flap. origin. Fi g. 5. -Lateral carotid angiog raphy in 23-year-old man in jured in auto­ Fig. 4. -Left carotid angiog raphy in 57-yea r-old hypertensive and diabeti c mobile accident. Dissecting aneurysm of ce rvica l segm ent of ICA . Character­ man hit on his neck by a chair. Compl ete occlu sion of ICA at its ori gin istic irreg ul arity and na rrowing of lu men of vessel. Dissection ex tends distally (arro wheads ). Athero sc lerotic chang es involve co mm on carot id artery. into petrous and cavern ous seg ments of artery . Spiral filling defect (arrow­ Fig. 5. -Anteroposterior vi ew of ri ght carotid angiograph y in 42-yea r-old heads) wi thin opacified vessel represents intima betwee n false and true man injured in automobile accident. trregular narrowing of lumen of upper lumen of vessel. 294 CEREBRAL ANGIOGRAPHY AJNR:4 , May/ June 1983 Discussion in intramural dissection with a resultant narrowing and compromise of the vascular lumen. The resultant stenosis of the lumen may leM Traumatic tCA occlusion after blunt trauma was first reported by to thrombotic occlusion of the vessel and the complicati ons of Vern euil over a hundred years ago [2]. Reports of posttraumatic emboli. The tendency for thrombus formation is increased by the changes in th ese vessels have been relatively frequent since the presence of perivascular edema or hematoma, vasospasm, hypo­ automobile age [3- 7]. In th e overwhelming majority of cases, trauma tension, and the increased adhesiveness of platelets after major to th e ICA is the result of penetrating injuries to the vessel. Non­ trauma [1 2]. penetrating or blunt injuries of the cervical ICA account for only The most common site of ICA injuries is the upper cerviC81 3%- 10% of all cervical caroti d artery trauma [6, 7]. Nonpenetrating intern al carotid artery at the level of C1 and C2 [4, 10, 11] . •\ or blu nt trauma to th e cervical ICA may result in partial or complete number of reports have suggested that the most frequent site 0f thrombotic occlusion and/ or aneurysm form ati on. These injuries injury is th e cervical ICA 1-3 em above the bifurcati on of the are associated with a high incidence of severe neurologic compli­ common carotid artery [1 2, 17]. However, the proximal propag ation cati on s and significant mortality [4]. of the thrombus from the upper cervical ICA toward the bifurcation of the common carotid artery may lead to the erroneous impression that the site of arterial injury is nearer the bifurcation of the common Pathogenesis and Mechanisms of Injury carotid artery. Cervical ICA aneurysms due to blunt trauma are extremely rare Nonpenetrating or blunt trauma to the cervicallCA may be caused but may occur if there is disruption of the media and / or the by: (1) indirect trauma caused by hyperextension of the neck; (2) adventitia, as well as the intima at the time of injury [11 , 18].
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