Blunt Carotid Trauma
Dr Jessica Savage
Dr Ben McGuiness
Outline
“In the neck” :
Blunt Carotid trauma
Dr Jessica Savage, Surg Reg
Dr Ben McGuiness, Radiologist
ADHB Trauma Forum April 2011
Introduction
Blunt carotid trauma accounts for <1% of all blunt traumas
Currently many debates exist:
– Who to suspect BCI in (Screening)
– How to diagnose (Imaging)
– How/ when to intervene (Treatment options)
– Longer term follow up
Two cases from Auckland
The spectrum of BCI
A broad diagnosis encompassing carotid intimal disruption, dissection and thrombosis.
The Denver “Grading scale”
Blunt carotid injury is
Rare
– Incidence <1% (up to 2% with screening)
Often missed
– 50% of patients asymptomatic at arrival
Potentially lethal
– Mortality rates 20-60%
– Neurological morbidity rates up to 80%
Treatment options for BCI
Case Study 1
Case Study 1
Mechanism:
40yr old motorcyclist, full protective gear and helmet collides at low speed with slow moving car
On Arrival:
Haemodynamically stable and GCS 15/15
Complains of right sided neck pain.
On Examination:
Clinical nasal fracture, Phalynx fracture and right neck bruise.
Initial Investigaton:
CT head and C-spine performed.
– Fractures of C5/6 spinous processes, CT head -NAD
Then…
Whilst in ED developed focal Left Hemiparesis
CTA: Right internal carotid artery occlusion from 3cm above it’s origin, probably due to dissection
MRI 3 hours later (Day 0) : Extensive restricted diffusion within right anterior and middle cerebral artery territories.
Case Study 1
CTA neck: right internal carotid artery occlusion/ dissection from 3cm above origin to cavernous sinus, early ischemic changes noted
MRI head 3hrs later: ischemic changes over the right hemisphere
Admitted to HDU
Lengthy discussions held overnight between Neurology, Neurosurgery, ITU and radiology.
Decision made NOT to proceed with anticoagulation or surgical intervention
CT Head Day 1: Extensive right hemispheric infarct, with midline shift, secondary to right internal carotid occlusion
On day 2 Pt dropped GCS to 12/15
Decompressive craniotomy performed
Extubated on day 3. Responded normally for a brief period then vomited. Dropped GCS to 8 (E1V1M6)
Developed LRTI
Day 5 – Pt Extubated following family discussion
Day 7- Patient died
Discussion:
High index of suspicion
Often BCI patients have a symptom-free period of hours to days after presentation
Early diagnosis may improve survival
(Berne et al time to diagnosis: 12.5 hrs in survivors,19.5 hours in fatalities)
Mechanism
C-spine hyperextension & rotation, hyperflexion or direct blow
Examination
Screening for BCI?
Screening assymptomatic patients is controversial and many people have suggested screening criteria
Could we have detected this earlier?
Recommendations for symptomatic patients:
Patients presenting with any neurologic abnormality that is
unexplained by a diagnosed injury should be evaluated for BCI.
Blunt trauma patients presenting with arterial epistaxis following trauma should be evaluated for BCVI.
The Eastern Association for the Surgery of Trauma
What Imaging to use?
CTA – fast, convenient, and with new detector scanners reliable. Most of the negative literature is on old technology.
MRA – can see the wall, probably not better for lumen, not good for acute/unstable patient
DSA – gold standard for lumen calibre, dynamic (for collateral flow), takes time, risk is minimal
Managing BCI
Grade IV lesions:
Managing this case
Large vessel arterial occlusion has very low rate of recanalisation (<10%) spontaneously or with IV tPA
Large MCA ischemia (clinically or on imaging (DWI/PWI) has dismal outcome
Therefore if acute (say <8hrs) hemispheric neurological signs with a blocked or severely stenosed artery… “nothing to lose, plenty to gain” situation
Emergent stent insertion for acute traumatic and nontraumatic carotid dissection shows favourable results in recent small series
Jeon P et al. AJNR 2010; 31: 1529-31
Major problem with stenting is need for dual antiplatelet agents in the setting trauma and likely bleeding risk.
Time is crucial and therefore rapid MDT weighing of risk is needed
Case Study 2
Fully restrained racing car driver, high speed roll-over, Car bursts into flames, Pt self extricates and extinguishes fire!
Brought by Ambulance to ED. Main complaints right neck pain, transient left arm numbness, swallowing difficulty.
Haemodynamically stable. GCS 14/15 (E4,V4, M6)
CT Head and neck.
– Retropharyngeal haematoma noted, Right, C2 level
CT Head and neck 01.21
CTA: Right ICA pseudo-aneurysm at the level of C2.
Case study 2
Anticoagulated with heparin
No surgical/ endovascular intervention due to the difficulty accessing this lesion
Follow up MRA 24Hrs later, showed no dissection in the vessel wall and a stable pseudoaneurysm.
Remained asymptomatic.
Repeat CT Angiogram a week later prior to discharge showed the lesion unchanged
Discharged with Warfarin. Follow up planned.
Case Discussion
Managing this case
Anticoagulation
Level 3 evidence for antithrombitic therapy
Either heparin or antiplatelet therapy can be used
– Many authors recommend heparin if there is no active bleeding
If heparin is selected for treatment, the infusion should be started without a bolus and titrated to an aPTT of 50-60 sec.
Heparin is then converted to Warfarin, titrating to a PT INR of 2-3, for 3-6 months is recommended
Grade III lesions:
Endovascular Treatment
Indication is if persistent emboli on medical treatment or persistent enlargement of aneurysm
Best done delayed
– can load with antiplatelets
– bleeding risk is minimized
Jail microcatheter in aneurysm, deploy stent to hold coils and then coil aneurysm.
Conclusions
‘Best treatment’ is currently unknown
Most authors seem to agree that:
– Anticoagulation decreases mortality and stroke risk
– Antiplatelet therapy seems as effective at preventing strokes, with a lower haemorrhage risk than anticoagulants.
– Patients with a fixed, dense neurological deficit should be conservatively managed
Multicenter, systematic trials are needed to compare anticoagulation vs invasive intervention, and to recommend antithrombotic regimens
Take home message:
BCI is rare, easily missed and kills
Be suspicious and act early…. Get a CTA and discuss with MDT
Consider Antithrombotic therapy, even in trauma.
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Ministry of Health
