A 30 year old male is brought into ED following an attempted hanging with a rope. 
On examination, he has a hoarse voice and a ligature mark in zone 1 of the neck. Neurological examination is normal.
CT angiogram of the neck reveals a dissection of the carotid artery.

Picture
Right Carotid Artery Dissection with true lumen demonstrated with contrast.
Basic information about traumatic carotid artery dissection;
  • The incidence of blunt carotid injuries is 1-2% in patients screened for the disease.
  • Most patients are asymptomatic initially with development of symptoms on average 24 hours after injury.
  • Untreated, morbidity is 80% in survivors, and mortality rates are 30%.
  • 90% of infarcts are thromboembolic in origin, and this is why anticoagulation is used to prevent stroke.


When should you consider screening for blunt carotid trauma?
  • Unexplained neurological findings not explained by CT Brain.
  • Blunt trauma with epistaxis thought to be arterial in origin.
  • Expanding cervical haematoma
  • Cervical Bruit 
  • Severe cervical hyperextension or rotation injury.
  • Fracture C1-3 and fractures extending through foramen transversarium
  • Basilar skull fracture
  • DAI
  • GCS < 8
  • Le Fort II and III fractures.
  • Near-hanging
  • Clothesline injury to neck


What screening test should you consider?
  • Doppler ultrasound is not sensitive enough as a screening tool.
  • Multi-slice helical CTA is as effective as four vessel cerebral angiogram for diagnosis.


How are injuries graded?
  • Grade 1 - < 25% narrowing of lumen
  • Grade 2 - > 25% narrowing of lumen
  • Grade 3 - pseudoaneurysm
  • Grade 4 - thrombosis
  • Grade 5 - transection with extravasation


How are injuries managed?
  • Grade 1 and 2 injuries should be managed with anticoagulation (aspirin or heparin). Heparin should be started without a bolus, infusion run at 10 U/kg/hr with an APTT of
  • Grade 1 & 2 injuries should be treated with 3-6 months of warfarin.
  • Grade 1 & 2 injuries are repaired if there is a contraindication to anticoagulation.
  • Grade 1 & 2 injuries should have a progress CTA at 7-10 days as there is a high incidence of progression to pseudoaneurysm.
  • Pseudoaneurysms rarely resolve and usually need invasive therapy.
  • High grade dissections or those with early neurological symptoms should be considered as candidates for open surgical repair or endovascular stenting.
  • The mortality rate for sugical repair is 22% compared to the mortality rate for endovascular repair of 0.9%.
  • Stroke rates following operate and endovascular repair are similar at 3.5%.
  • Patients undergoing stenting should be treated with clopidogrel for 8-12 weeks, and then be placed on aspirin indefinitely.


References
  1. Cohen JE et al.Sinlge-centre experience on endovascular reconstruction of traumatic internal carotid artery dissections.J Trauma. 2012;72; 216-221
  2. Biffl W et al. Western trauma association critical decisions in trauma: Screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2009; 67; 1150-1153
  3. Bromberg WJ et al. Blunt cerebrovascular injury practice management guidelines: The eastern association for the surgery of trauma. J Trauma. 2010; 68; 471-477
  4. DuBose J et al. Endovascular stenting for the treatment of traumatic internal carotid injuries: Expanding experience. J Trauma. 2008; 65; 1561-1566
 


Comments


Comments are closed.