Chapter 181 - Head + Neck Vascular Trauma

Question 1

Penetrating injury to carotid stroke and mortality

Answer 1

Stroke 7-27% Mortality 7-50%

Question 2

Zones of neck injury

Answer 2

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

Question 3

Rate of different zones of neck injury

Answer 3

Zone II 47% Zone III 19% Zone I 18%

Question 4

Hard signs of vascular injury in neck

Answer 4

1) Shock 2) Refractory hypotension 3) Pulsatile bleed 4) Bruit 5) enlarging hematoma 6) Loss of pulses with stable evolving neurologic deficit PPV 97%

Question 5

Soft signs of vascular injury in neck

Answer 5

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%

Question 6

Gunshot chance of neck vascular injury vs stabs

Answer 6

27% gun 15% stab

Question 7

Associated injuries to neck penetrating injury

Answer 7

Trachea Esophagus Spine 1-7%

Question 8

Normal physical exam negative predictive value in neck injury ? vascular

Answer 8

90-100%

Question 9

Treatment of carotid thrombosis with stroke and coma

Answer 9

Revascularization Benefit within 24 hours of injury

Question 10

Using platysma penetration as indicator for neck vascular injury

Answer 10

50-90% negative exploratory rate

Question 11

CTA to diagnose neck vascular injury SEN/SPE

Answer 11

90% sensitivity 100% specificity for injuries that require treatment

Question 12

Surgical option for neck vascular injuries

Answer 12

1) ligate 2) repair 3) temporary shunt

Question 13

Vessels in neck that can be ligated

Answer 13

External carotid Internal jugular

Question 14

Ligation of ICA

Answer 14

45% mortality

Question 15

Blunt cerebrovascular injuries incidence

Answer 15

<1% of all trauma

Question 16

Stroke and death after blunt cerebrovascular injuries

Answer 16

Stroke 25-58% Death 31-59%

Question 17

Mechanism of blunt cerebrovascular injury

Answer 17

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

Question 18

Associated injury after blunt cerebrovascular injuries

Answer 18

1) close head injury 2) facial # 3) cervical spine # 4) thoracic injuries

Question 19

Signs/symptoms of carotid cavernous fistula

Answer 19

1) orbital pain 2) proptosis 3) hyperemia 4) cerebral swelling 5) seizure

Question 20

Screens for blunt cerebrovascular injuries

Answer 20

1) Denver Health Medical Center 2) Memphis Criteria Any criteria met = 4 vessel angiogram indicated

Question 21

Diagnostic tool for blunt cerebrovascular injury

Answer 21

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%

Question 22

Medical treatment after blunt cerebrovascular injury

Answer 22

Antithrombotic therapy no RCT’s done first line = anticoagulation

Question 23

Vertebral injury incidence

Answer 23

0.2-0.77%

Question 24

Isolated vertebral injury mortality

Answer 24

4%

Question 25

Most common mechanism of vertebral injury

Answer 25

Fracture of transverse foramen C2-C6

Question 26

Unilateral vertebral injury consequences and associations

Answer 26

80% asymptomatic Associated with 25% bilateral 33% carotid injury

Question 27

Symptoms of vertebral injury

Answer 27

1) Subtle neck pain 2) posterior headache 3) vertebrobasilar insufficiencies

Question 28

Diagnostic evaluation of vertebral injury

Answer 28

Hard signs of bleed or tracheal injury --\> skip further investigation CTA sen 40-60; spe 90-97

Question 29

Medical treatment of vertebral injury

Answer 29

No evidence Symptomatic patients without contraindication = 3-6 months of anticoagulation Asymptomatic patients = 3-6 months anticoag or DAPT

Question 30

Types of complication of anticoagulation in trauma and overall rate

Answer 30

1) intracranial 2) GI 3) retroperitoneal 4) solid organ 5) surgical wound Rate 16%

Question 31

Rate eligible for anticoagulation post blunt cerebrovascular injury

Answer 31

14%

Question 32

Standard heparin PTT target

Answer 32

50-60seconds

Question 33

Natural history of blunt cerebrovascular injury by grades at 3 months

Answer 33

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

Question 34

Endovascular treatment vertebral injury

Answer 34

Bare stents adequate to cover pseudoaneurysm +/- coils Need long term follow up because risk of kinking

Question 35

Surgical treatment of vertebral injury

Answer 35

zone 2 Risk of stroke and CN neurapraxia only do in active bleed at time of exploration Unilateral ligation = stroke in 3-5% vertebral

Question 36

Subclavian artery injury mortality

Answer 36

50-80% in hospital during treatment mortality 15%

Question 37

Associated injuries with subclavian artery injury

Answer 37

Vein 50% Cervical 70%

Question 38

Blunt subclavian artery injury associated with

Answer 38

1) Clavicular # 2) Mediastinal injury 3) pulmonary contusion rare overall

Question 39

Medical management in blunt subclavian artery injury

Answer 39

For intimal disruption, dissection that are not flow limiting Antiplatelet or anticoagulation

Question 40

Endovascular treatment in blunt subclavian artery injury

Answer 40

appropriate in 42-50% of patients Brachial or femoral approach May still need hematomat evacuation for treating mass effect

Question 41

Open approaches to subclavian artery injury by side

Answer 41

Right subclavian = mid sternotomy Innominate = mid sternotomy Left subclavian = left anterolateral thoracotomy +/- clavicle resection

Question 42

Cervical venous injury associated with

Answer 42

1) sternal # 2) clavical #

Question 43

Rate of IJ and subclavian vein injury in associated penetrating arterial injuries

Answer 43

20% IJ 50% subclavian vein

Question 44

CTA delayed acquisition time for venous phase

Answer 44

30 sec to 3 min

Question 45

Treatment of venous injuries in neck

Answer 45

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

Question 46

Blunt Cerebrovascular Injury Grading Scale

Answer 46

Question 47

Screening Criteria for Blunt Cerebrovascular Injury

Answer 47