Imaging of blunt cerebrovascular injuries

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European Journal of Radiology 59 (2006) 317–326

Imaging of blunt cerebrovascular injuries

Diego B. Nunez Jr. ∗, Turgut BerkmenDepartment of Radiology, Hospital of St. Raphael, Yale University School of Medicine, 1450 Chapel St., New Haven, CT 06511, United States

Received 12 April 2006; received in revised form 14 April 2006; accepted 14 April 2006

bstract

Arterial dissection, pseudoaneurysm, arteriovenous fistula, arterial laceration and occlusion are uncommon complications of blunt trauma.ngiography has been considered the primary method of evaluation to assess for vascular injuries but, due to the low frequency of these lesions,

ts screening role has been challenged. Non-invasive imaging, particularly CT angiography (CTA), offers definitive advantages and has emerged aspromising diagnostic screening method. Angiography is shifting to a rather therapeutic role and the endovascular management of these lesions

s briefly discussed.2006 Elsevier Ireland Ltd. All rights reserved.

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eywords: Blunt trauma; Vascular injuries; Neck CT angiography

. Introduction

Cerebrovascular trauma comprises a variety of injuries thatnclude dissection, aneurysms, arteriovenous fistula and occlu-ions. The overall prevalence of these injuries due to a bluntechanism is low but its recognition is of paramount impor-

ance because of their potential for catastrophic consequencesn trauma patients. Unfortunately, these lesions are often underiagnosed [1–4]. The detection of blunt cerebrovascular injuriesBCVI) is frequently delayed because of the presence of multi-ystem injury, the inherent late appearance of symptom man-festation or simply by failure to suspect an injury caused by

inor trauma. Increased awareness and appropriate screeningre necessary to improve our detection and treatment of theseesions. The article reviews the current trends in imaging diag-osis of BCVI and the emerging screening role of computedomography angiography (CTA). The relevant imaging featuresf blunt traumatic carotid, vertebral and venous sinuses injuriesre discussed, as well as the scope of endovascular interventionalechniques used for appropriate treatment.

. Imaging

The management of traumatic neck injuries has been a sub-ect of controversy in recent years, and diagnostic imaging has

∗ Corresponding author. Tel.: +1 203 789 36 27; fax: +1 203 789 40 04.E-mail address: [email protected] (D.B. Nunez Jr.).

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720-048X/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.ejrad.2006.04.023

een playing an increasing role in the initial assessment ofhese patients [5–7]. Catheter angiography has been accepted ashe gold standard for evaluating the neck vessels and has beenhe preferred initial imaging examination requested by clini-ians when cervical vascular injuries are suspected [8–10]. Inecent years, with the improvement and increasing utilizationf non-invasive imaging techniques, there has been growingnterest in the application and potential role of these modal-ties for the screening of vascular injuries. Specifically, CTAas become an increasingly accessible examination in emer-ency departments, with the ability for faster scanning timesnd increased resolution. Unlike catheter angiography, CTA cane performed within minutes of patient arrival to the hospital.urther developments in image reconstruction has allowed foreamless generation of 3D volume rendered images that helphe referring physician/surgeon with images that are similaro conventional angiography. The applicability and practical-ty of angiography as the screening method of choice for bluntervical vascular injuries has been challenged in recent years.specially for a typically silent clinical entity such as BCVI,ffective screening becomes very important and others factorseyond accuracy need to be considered. The modality shoulde easy to perform, readily available, relatively inexpensive anddeally should also have a low rate of complications. MR and
uplex ultrasonography (DUS) have potential advantages ason-invasive screening techniques but also have limiting short-omings. MR is not universally available in the acute traumaetting and MR scanners limit the accommodation of monitor-
mailto:[email protected]

dx.doi.org/10.1016/j.ejrad.2006.04.023

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ng devices and ventilatory equipments often needed in traumaatients. In addition, reported sensitivity has been low [9] partic-larly if performed with flow dependant time of flight technique.US has also been tested but is very operator dependant and

imited accuracy is found for diagnosing lesions near the skullase, a frequent location for BCVI. In addition, the evalua-ion of the vertebral arteries within the neck is obscured byhe osseous protection of the cervical vertebral canal [11]. CTAas emerged as a test that could fulfill most of the screeningequirements. However, reports dealing with the accuracy ofTA for screening BCVI have been contradictory [5–10,12,13].ne of the important factors contributing to disappointing and

nconsistent results is the lack of uniformity of the scanningnd reconstruction parameters. It is certainly likely that morencouraging results are obtained when using the modern multi-hannel CT technology that allows narrower collimation andaster processing for improved resolution and 3D display. Twoecent reports [5,7] claim acceptable accuracy using 4 and 16hannel scanners. Furthermore, an increasing number of injuriesere detected when using exclusively the 16 multi-detector-row

canner [5]. Of note, these authors have also found a reductionn the mortality rate from BCVI related to the prompt screen-ng provided by CTA. Other factors confounding the reliabilityf screening is the appropriate identification of the patient pop-lation at high risk for BCVI. In that regard, the results of aultivariate analysis reported that skull base fractures, facial

njury, neck and thoracic injury, and abdominal injury are allignificant predictors for high risk [14]. Aggressive screeningf asymptomatic patients have also been proposed, even usingrteriography [8–10], to institute appropriate early treatmentith anticoagulation. This approach has been recently chal-

enged by Mayberry et al. [15] who concluded on the uncertaintyf widespread screening based on questionable improvementn outcome and the dubious cost effectiveness of such prac-ice.

In our institution, CTA is used as the initial method of eval-ation in patients considered at high risk and is done either athe same setting of other CT exams or right after the initial sta-ilization of the multi-trauma patient. Alternatively, it can alsoe performed as part of a dedicated cervical spine examina-ion. Whether using the 4 or the 16 channel scanner design, ourcanning protocol for cervical CTA uses a narrow effective col-imation of 1 or 1.5 mm covering from the thoracic inlet to thekull base. Intravenous contrast material is administered at a ratef 3 ml/s with a 25 s delay. The axial images are reconstructedt 1.5 mm slice thickness with 0.75 mm increments to generatemages for multi-planar display including maximum intensityrojection (MIP) and volume 3D rendering.

. Injury types

.1. Dissections

An arterial dissection is regarded as a hematoma within theedia of the vessel wall that can result in stenosis, occlusion

r aneurysm formation secondary to weakening of the vascu-ar wall. They occur by disruption of the small arterial plexus

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nal of Radiology 59 (2006) 317–326

ithin the wall of the vessel and can be divided into two cate-ories, spontaneous or traumatic. Traumatic dissections can behe result of blunt or penetrating injury whereas spontaneous dis-ections typically occur without an identifiable traumatic event.t times, a history of minor trauma, coughing, sudden neck

orsion or vigorous sport activity is elicited. Dissection of theervical vessels is a rare event and accounts only for 1% oferebrovascular accidents. However, it is estimated that they areesponsible for 20% of all strokes in young adults [16].

Carotid dissections occur in young adults and associated clin-cal findings usually include focal neurological deficit, cerebralnfarction, transient ischemic attacks, bruit and neck pain. It isrequent, however, to have carotid dissection without symptomsr any evidence of ischemia leaving the clinician unable to pre-ict the presence of a vascular injury. In general, blunt injuryo the carotid artery can occur by direct blow to the neck or byervical hyperextension, and the fact remains that devastatingomplications such as stroke can occur if the injury is not recog-ized and treated. Blunt carotid injuries most commonly involvehe internal carotid artery near the base of the skull and threeypes of injuries are recognized depending on the mechanismf injury [16]. Type I injuries occur secondary to tearing of thentima secondary to traction or rotational forces with subsequentntramural dissection. Type II injuries are the result of compres-ion of the internal carotid artery, usually occurring between theransverse processes of the upper cervical spine and the angle ofhe mandible. This type of injury can also occur at the junctionf the internal carotid artery and the skull base where stretchingnd distortion of the vessel occurs against the adjacent osseoustructures. Type III injuries result from crushing of the arteryrom a direct blow to the neck leading to thrombosis and/oristal embolism.

It is estimated that 52% of patients with carotid injuries aresymptomatic at the time of presentation and they have beenistorically regarded as an uncommon complication of bluntrauma, occurring in only 0.1% of all patients admitted to majorrauma centers [8]. However, the true incidence of blunt vascularrauma may be greater than previously suspected.

Recent publications from institutions that developed screen-ng programs with more liberal utilization of digital subtractionngiography reported a higher frequency of vascular injuriesccurring in up to 1.03% of blunt trauma admissions [8,9]. Dis-ections of the cervical carotid artery usually start approximatelycm above the bifurcation and approximately 70% of the dis-

ections involve both the cervical and petrous segments of thertery [16]. Imaging features of dissection include swelling ofhe vessel wall with narrowing of the lumen that can be iden-ified on axial CT/CTA images. More specific findings suchs hematoma of the vessel wall can be shown using MR T1eighted fat suppressed axial images. Ultimately, angiographyrovides confirmatory diagnosis of dissection disclosing irregu-ar vessel narrowing with marginal filling defects and decreasedow through the affected vessel (Fig. 1). Pseudoaneurysms can
e a frequent complication of traumatic dissection, occurringypically near the distal end of the dissection. Carotid occlusionsccur in approximately 20% of cases of dissections. A gradingystem for blunt carotid injury has been proposed by Biffl et

D.B. Nunez Jr., T. Berkmen / European Journal of Radiology 59 (2006) 317–326 319

Fig. 1. Images of a 27-year-old patient who sustained a whiplash injury with severe neck hyperextension. (a) Initial CT reveals a small dense dot projected in ther dle cec m revw

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ight Sylvian fissure (arrow) consistent with a dense insular segment of the miderebral artery sign with an established infarct. (c) Digital subtraction angiograith dissection as the source of distal clot migration to the MCA.

l. [17] and correlation has been found between the grade of
he lesion and the frequency of associated complications suchs pseudoaneurysms and occlusions. Lesions with more than5% of luminal narrowing have a worse prognosis, and moreggressive treatment is recommended. Dissections of the ver-
atti

rebral artery. (b) Follow-up CT obtained 15 h later shows a dense right middleeals irregular narrowing of the proximal right internal carotid artery consistent

ebral artery are less common than carotid dissections and can
lso be spontaneous or traumatic. Vertebral dissections withinhe mid cervical region are usually associated with major bluntrauma. There is a higher incidence of vertebral artery injuriesn patients with fractures of the foramen transversaria (Fig. 2)

320 D.B. Nunez Jr., T. Berkmen / European Journal of Radiology 59 (2006) 317–326

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ig. 2. Axial CT (a) and sagittal reformatted image (b) reveal evidence of a flexf C7. Note extension of fractured fragment to the right foramen transversariumertebral artery at the injury site with distal retrograde filling (arrows).

nd it has also been noted that vertebral artery occlusions occurith higher frequency in patients with facet dislocations, locked

acets and various distracting cervical spine injuries [4]. Addi-ional reports have suggested that vertebral artery injuries have

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ear drop fracture of C6 with associated axial loading and fracture/compressionw). Coronal reformatted CTA (c) image shows proximal occlusion of the right

o association with specific cervical spine injury and a rec-mmendation for screening of all patients with cervical spinenjury has been proposed [10]. The imaging features of verte-ral artery injury are similar to those seen in cervical carotid

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njuries and include caliber changes, pseudoaneurysm forma-ion, intimal flaps and occlusions.

.2. Traumatic intracranial aneurysms

Traumatic intracranial aneurysms are also rare lesions thatccount for only 1% of all intracranial aneurysms [16]. Theyan be the result of penetrating injuries but the majority occursfter closed head injury. Traumatic aneurysms of the cavernousnternal carotid artery are commonly associated with skull baseractures and/or penetrating osseous fragments (Fig. 3). Theevelopment of a cavernous sinus syndrome and carotid cav-rnous fistula are known complications of traumatic carotidneurysms. Epistaxis and ipsilateral blindness are also com-on complications. Less frequently, the middle and the anterior

erebral arteries can also be involved secondary to shearing orompressive forces resulting from closed head trauma. Intrac-rebral arteries that are adjacent to relatively thick structures likehe falx and the tentorium, are more prone to the development ofraumatic aneurysms. Such is the case of the pericallosal arter-es and the posterior cerebral arteries. Fractures of the calvariuman also result in meningeal artery aneurysms.

There is usually a time interval between the time of the initialrauma and the development and presentation of the traumaticntracranial aneurysm. The reported average time between injurynd rupture is 21 days [16]. Diagnosis with CTA, MRA orngiography should be considered if there is intracranial hem-rrhage suggestive of an underlying vascular lesion, delayedevelopment of cranial nerve deficit, signs of cavernous sinusyndrome and/or ipsilateral blindness.

.3. Traumatic carotid cavernous fistula

The majority of post traumatic carotid cavernous fistulae areaused by laceration of the cavernous internal carotid resulting inhe development of a high flow fistula [16]. The clinical presen-ation will depend on the amount of shunting and the directionf the venous blood flow. For example, venous flow towards theeripheral pial veins can result in cortical edema, seizures andubarachnoid hemorrhage. Likewise, pulsatile exophtalmos andecreased visual acuity can present if the venous flow is directedowards the orbit. In general, patients frequently present witheadaches and ophtalmoplegia secondary to cranial nerve com-ression at the cavernous sinus. Angiography is the proceduref choice both for the diagnosis and treatment of these lesions.

.4. Venous sinus thrombosis

Cerebral venous sinus thrombosis (VST) is a relativelyncommon condition but carries significant complications thatan lead to venous infarction, focal neurologic deficit, seizuresnd death. Most cases of VST are related to non traumatic med-cal conditions such as dehydration, oral contraceptives, coag-
lopathies and connective tissue disorders. The majority of theeported traumatic occlusions of the venous sinuses occur in theagittal sinus, related to adjacent skull fractures, and less com-only in the transverse sinuses [18]. Cerebral angiography, CT
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nal of Radiology 59 (2006) 317–326 321

enography and MR venography can be used for diagnosis. Inhe non traumatic patient with suspected VST, MR venographyas gained acceptance as an accurate method that is performedn conjunction with the standard MR examination of the brainFig. 4). Because of the recognized shortcomings of MR in thecute trauma setting CT venography can be used in the initialvaluation of these patients. Three-dimensional display and MIPmages generated from data acquired during the venous phasef intracerebral enhancement aid in the angiographic assessmentST (Fig. 5). A higher index of suspicion should be kept in brain

rauma patients with skull fractures and hematomas near the tra-ectory of the venous sinuses.

. Endovascular treatment of blunt cerebrovascularnjuries

Dissections of the internal carotid artery can result in a vari-ble length of stenosis. Some lesions heal spontaneously butthers lead to long-term sequelae including thromboembolicvents, complete vessel occlusion or pseudoaneurysm formationesulting in stroke, hemorrhage or the development of arteriove-ous fistulae.

Endovascular treatment of dissections is generally reservedor patients who are symptomatic or for those who are foundo have a pseudoaneurysm on follow-up examinations. Also,reatment is indicated when the setting of trauma precludes anti-oagulation. Asymptomatic patients are usually treated onlyith anticoagulation and it has been reported that 62% ofon-occlusive dissections resolve with anticoagulation [19]. Onhe other hand, 29% of patients with dissection will developseudoaneurysms. Surgical treatment of these lesions can behallenging. Frequently, the dissection or the resulting pseu-oaneurysm lies too cephalad in the internal carotid, limit-ng surgical access. The endovascular approach has rapidlyained momentum in the treatment of these lesions. There haveeen scattered reports of stent or stent graft placement for thereatment of dissections and complicating pseudoaneurysms19–21]. Carotid stenting for lesions that are too high for sur-ical access has recently been approved by the FDA. There areo large series reported with long-term follow-up on patientsho have been treated with a stent or stent graft for carotidissection. However, the few published case reports suggest aavorable clinical outcome [20,21].

Endovascular treatment strategies for pseudoaneurysmsesulting from carotid dissections mostly depend on the loca-ion of the lesion and the complexity of the patient’s anatomy.esions that are in the straight segment of the cervical ICA cansually be safely and effectively treated with a stent graft place-ent. However, the devices are usually more rigid and require

arger delivery sheaths resulting in difficulty to negotiate tortu-us anatomy. In such cases, delivery of a regular stent followedy coil embolization of the pseudoaneurysm, through or along-ide the stent, can be performed with microcatheters [22].

Endovascular management of intracranial aneurysms thatesult from BCDI usually requires the standard coil embolizationechniques with or without stent placement to preserve the par-nt vessel. Liquid agents such as NBCA (Cordis, Miami Lakes,


Fig. 3. (a) Admission CT image of patient with facial injury after motorcycle accident shows evidence of pneumocephalus and subarachnoid hemorrhage in theanterior cranial fossa. Axial image using bone algorithm (b) shows fracture of the nasoethmoidal complex with displaced osseous fragment off the left anterior clinoidprocess (arrow). (c) Two weeks follow-up unenhanced CT reveals left juxta-clinoid high density suspicious for complicating pseudoaneurysm. (d) T2 weighted MRaxial image confirms the presence of a post traumatic left parasellar internal carotid pseudoaneurysm.


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ig. 4. CT axial images using bone (a) and soft tissue (b) algorithm of patientid frontal calvarium fracture (arrow) and adjacent high density suspicious fo

enography (d) reveal midline epidural hematoma with compression and narrow

L) or Onyx HD 500 (MicroTherapeutics, Irvine, CA) have alsoeen used in selected cases [23].

The treatment of carotid cavernous fistulas has dramati-
ally changed over the last decade. Initially, occlusion of thestula with one or more detachable balloons used to be the
reatment of choice. However, with the advances in technol-gy, coil embolization with or without stent placement has

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eceived a strong impact to the top of the skull from falling heavy object. Noteural hematoma (arrow). Coronal MR T2 weighted image (c) and MR sagittalf the sagittal venous sinus (arrow).

ecome increasingly accepted. There have also been scatteredeports on the use of liquid agents like NBCA in conjunc-ion with coils for the treatment of carotid cavernous fistulas
24]. The development of stent grafts that can be deliveredhrough smaller and more compliant catheters may revolu-ionize the treatment of carotid cavernous fistulas in the nearuture.


Fig. 5. High resolution CT image of the skull base of patient involved in severe motor vehicle collision. (a) A fracture through the jugular canal (arrow) and opacityo sigmo sion

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f the mastoid air cells is noted. (b) Air is seen within the jugular canal and thef enhancement of the right sigmoid sinus (c) secondary to post traumatic occlu

In some cases, these endovascular strategies may fail to effec-ively treat the lesion or it may not be possible to preserve thearent artery. In these situations one may have to perform carotidacrifice. It is important to trap the fistula from both sides asollaterals may reconstitute the lesion which may still rupture,ause hemorrhage, or fistulae formation.

Therapeutic occlusion of the parent vessel is also an option forissections and lacerations of the vertebral arteries. Preserved
ow through to the posterior fossa can be maintained by theninvolved contralateral artery. In cases of active extravasation,ndovascular occlusion may be necessary even if the contralat-ral vertebral artery flow is compromised (Fig. 6).
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oid sinus (arrows). Coronal reformatted image of CT venography reveals lack(arrow).

Endovascular treatment of cerebral venous sinus thrombo-is is controversial. Most treatment options involve infusion ofhrombolytics which is usually contraindicated in the settingf trauma and may increase the risk of a parenchymal hem-rrhage. The tools available for mechanical thrombolysis areery limited and are difficult to advance through tortuous venousnatomy.

Overall, recent advances in endovascular devices and tech-
iques have allowed the interventional radiologist to treat lesionshat traditionally have been very difficult or impossible to treat.hese non-invasive techniques will continue to play a major role
n the treatment of BCVI.


Fig. 6. Images of patient who was broadsided in motor vehicle collision. (a) Lateral radiograph reveals significant cervical soft tissue swelling consistent with clinicalevidence of enlarging hematoma. Selective vertebral angiograms showed laceration of the right vertebral artery with contrast material extravasation (b) and left-sidedtraumatic vertebral artery occlusion at a comparable level (c). Despite evidence of a left vertebral occlusion, therapeutic coil occlusion of the right vertebral arterywas undertaken to preclude life-threatening exsanguination (d). (e) Right common carotid arteriogram performed after occlusion of the right vertebral artery revealedretrograde filling of the basilar artery and the posterior fossa circulation through competent posterior communicating supply. There was no significant residualneurologic deficit.

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. Conclusion

Imaging plays a major role in the initial evaluation of sus-ected BCVI and the information provided is critical for patientanagement. The diagnosis of these injuries is quite chal-

enging because of the relatively low prevalence of the dis-ase and the delay appearance of clinical manifestation. Aigh index of suspicion is required, as well as familiarityith the screening capabilities of noninvasive imaging tech-iques, particularly CTA. The role of angiography, althoughstablished as a diagnostic gold standard, is shifting towards aore therapeutic function as an effective alternative to surgical

reatment.

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Imaging of blunt cerebrovascular injuries