Current Concepts in Imaging Diagnosis and Screening of Blunt Cerebrovascular Injuries

Abstract

Blunt cerebrovascular injury (BCVI) is an often underrecognized injury occurring in the carotid or vertebral arteries, associated with a risk of ischemic stroke and potential for poor neurological outcome or death. Computed tomographic angiography (CTA) is the most common modality for initial screening and diagnosis. Vessel wall intimal injuries, intraluminal thrombus, dissection, intramural hematoma, pseudoaneurysm, vessel transection, and arteriovenous fistula, are potential findings to be considered in approach to imaging. Identification of high-risk trauma patients based on clinical and radiological risk factors can determine patients at risk of BCVI for targeted screening.

Keywords: blunt cerebrovascular injury; carotid arteries; neck injuries; stroke; vertebral arteries.

Figure 1

Right internal carotid artery (ICA) injury in a 73-year-old male involved in a motor vehicle accident. (a) Axial and (b) sagittal oblique multiplanar reformatted multidetector CT angiographic images show a small raised intimal flap in the proximal right ICA.

Figure 2

72-year-old male involved in a motor vehicle accident. Axial multidetector CT angiographic image shows a thin linear raised intimal flap in the left common carotid artery.

Figure 3

BCVI in a 71-year-old male driver of a motor vehicle accident. (a) Axial multidetector CT angiographic image shows a raised intimal flap in the distal left common carotid artery with focal circumferential wall thickening representing blood dissected into the arterial wall. (b) Coronal multiplanar reformatted CT angiographic images show blood in the arterial wall at the site of injury, leading to focal luminal narrowing without occlusion.

Figure 4

Right common carotid artery injury in a 71-year-old male who presented following a motor vehicle accident. Axial multidetector CT angiographic image shows dissection in the distal right common carotid artery. The located true lumen is moderately narrowed by the false lumen but remains patent.

Figure 5

68-year-old male with bilateral BCVI and major thoracic injuries following a motor vehicle accident. Axial multidetector CT angiographic image shows bilateral distal cervical internal carotid artery dissection.

Figure 6

49-year-old male with left internal carotid injury and ischemic stroke (a) Axial T1-weighted magnetic resonance (MR) image shows crescentic T1 hyperintensity in the proximal left internal carotid artery compatible with acute intramural hematoma and dissection. There is increased external diameter of the left ICA with severe eccentric luminal narrowing. (b) Diffusion-weighted magnetic resonance (MR) image obtained the two days afterwards shows left middle cerebral artery territory stroke. The patient had developed right-sided weakness.

Figure 7

40-year-old female with right vertebral artery intramural hematoma. Axial image multidetector CT angiographic image shows right vertebral artery mural thickening consistent with intramural hematoma with moderate luminal narrowing.

Figure 8

42-year-old male with left vertebral artery injury. Axial image multidetector CT angiographic image shows eccentric left vertebral artery intramural hematoma causing moderate eccentric narrowing of the arterial lumen.

Figure 9

59-year-old male with left vertebral artery injury. Axial multidetector CT angiographic image shows severe eccentric crescentic left vertebral artery narrowing from dissection.

Figure 10

43-year-old male who presented following motor vehicle accident with multiple vertebral fractures and right vertebral artery injury. Axial multidetector CT angiographic image shows occlusion of the right vertebral artery.

Figure 11

Long segment left internal artery occlusion in a 70-year-old male patient brought in by ambulance with multiple injuries following a motor vehicle accident. Coronal multidetector CT angiographic image shows tapering occlusion of the left internal carotid artery.

Figure 12

Left vertebral artery occlusion in a 77-year-old male patient involved in a motor vehicle accident. (a) Coronal multidetector CT angiographic image shows occlusion of the left vertebral artery with abrupt cut off. (b) Three-Dimensional Time-of-Flight MR Angiography of the Circle of Willis shows the long segment left vertebral artery occlusion extended to the intracranial segments.

Figure 13

40-year-old male with suicide attempt and fall from height sustaining severe facial and skull base fractures. Diagnostic angiogram showed a large pseudoaneurysm arising from the cavernous left internal carotid artery (arrow) and carotid-cavernous fistula.

Figure 14

Treatment algorithm based on grade of BCVI.