Remember the Vessels! Craniofacial Fracture Predicts Risk

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CRANIOMAXILLOFACIAL TRAUMA

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*Consu

Center, U

Helsinki, F

yConsuCenter, U

Helsinki, F

zConsuT€o€ol€o Hos

xRadiolRadiology,

Helsinki U

kConsuUniversity

Finland.

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Remember the Vessels! CraniofacialFracture Predicts Risk for Blunt

Cerebrovascular InjuryElina Varjonen, MD,* Frank Bensch, MD, PhD,y Tuomo Pyh€alt€o, MD, PhD,z

Mika Koivikko, MD, PhD,x and Johanna Sn€all, MD, DDS, PhDk
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Purpose: The risk factors for blunt cerebrovascular injuries (BCVIs) are currently under intensive

research, yet it is still controversial who should be screened. This study aimed to determine whethercraniofacial fractures are associated with BCVI.

Patients andMethods: This retrospective cohort study focused on patients with suspected polytraumaafter whole-body computed tomographic angiography of the cervical arteries. Patients were reviewed for

BCVI and craniofacial fractures. Exclusion criteriawere hanging injury, gunshot injury or other penetrating

injury to the neck, and a cervical fracture on any level. The outcome variable was BCVI, and the main

predictor variable was a craniofacial fracture. A secondary predictor variable was a type of craniofacial

fracture classified as a facial fracture, skull fracture, or a combination of facial and skull fracture. Other

predictor variables were gender, age, and mechanism of injury. In addition, specific craniofacial fractures

were analyzed in more detail. The relevance of associations between BCVI and the predictors underwent

c2 testing. Significance was set at .01.

Results: Four hundred twenty-eight patients 13 to 90 years old during a 12-month period were included

in the analysis. Craniofacial fractures occurred in 75 (17.5%). BCVI occurred significantly more frequentlyin those with than in those without a craniofacial fracture (18.6 vs 7.4%; P = .002). Patients with cranio-

facial fracture had a 4-fold increased risk for BCVI, whereas those 31 to 50 years old had 3.4-fold increased

risk. Type of craniofacial fracture, gender, and mechanism of injury were not associated with BCVI.

Conclusion: Craniofacial fractures are a serious risk factor for BCVI. This research suggests that in

patients with any craniofacial fracture and suspected polytrauma, rigorous imaging of cervical arteries

in search of BCVI is essential.

� 2018 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial

Surgeons

J Oral Maxillofac Surg -:1.e1-1.e9, 2018
93
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9697

Blunt cerebrovascular injury (BCVI) can lead to devas-

tating neurologic sequelae. BCVI occurs in 1 to 2% ofall patients with blunt trauma, and in severely injured

ltant, Department of Radiology, HUS Medical Imaging

niversity of Helsinki and Helsinki University Hospital,

inland.

ltant, Department of Radiology, HUS Medical Imaging

niversity of Helsinki and Helsinki University Hospital,

inland.

ltant, Department of Orthopedics and Traumatology,

pital, Helsinki University Hospital, Helsinki, Finland.

ogist-in-Chief and Adjunct Professor, Department of

HUS Medical Imaging Center, University of Helsinki and

niversity Hospital, Helsinki, Finland.

ltant, Department of Oral and Maxillofacial Diseases,

of Helsinki and Helsinki University Hospital, Helsinki,

1.e1

FLA 5.5.0 DTD � YJOMS58221_proof �

patients, the incidence can be at least twice as high.1-5

Early recognition and prompt initiation of treatment ofthese injuries have resulted in a marked decrease in

Conflict of Interest Disclosures: None of the authors have any

relevant financial relationship(s) with a commercial interest.

Address correspondence and reprint requests to Dr Varjonen:

Department of Radiology, T€o€ol€o Trauma Center, Topeliuksenkatu

5, 00029 HUS, Finland; e-mail: [email protected]

Received January 1 2018

Accepted March 23 2018

� 2018 Published by Elsevier Inc. on behalf of the American Association of Oral

and Maxillofacial Surgeons

0278-2391/18/30293-3

https://doi.org/10.1016/j.joms.2018.03.035

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Delta:1_given name

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Delta:1_given name

Delta:1_surname

Delta:1_given name

mailto:[email protected]

https://doi.org/10.1016/j.joms.2018.03.035

Q2

1.e2 BLUNT CEREBROVASCULAR INJURY Q1

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cerebrovascular ischemic insults from 20 to 31% to 0.5

to 9.6%.3,6-9 If left untreated, mortality associated with

these injuries increases to 9 to 13%.3,4,6

BCVI diagnosis has been facilitated by the wide-

spread adoption of standardized screening protocols

and advances in imaging technology, such as multide-

tector cervical computed tomographic angiography

(CTA). Various screening guidelines are available toidentify patients with risk factors suggestive of a

possible BCVI, such as the evidence-based guidelines

established by the Eastern Association for the Surgery

of Trauma (EAST)10 and the Denver Group guide for

practicing physicians in screening, diagnosing, and

treating BCVI.3,6,8,11

The most common etiology for BCVI is assumed to

be hyperextension of the neck, causing stretching ofthe carotid arteries over the lateral processes of C1

to C3.11,12 Basic screening guidelines, such as the

Denver criteria, include fractures of the upper

cervical spine as an indication for BCVI screening.

Further studies have suggested expanding screening

protocols to include any cervical fracture.13,14

The role of facial fractures in BCVIs is not completely

understood, and BCVIs can be missed when applyinginsufficient screening protocols. Mundinger et al15

investigated 4,398 patients with facial fractures and

found BCVI in 1.2%. They also reported that 20% of

BCVIs would have been missed by the EAST BCVI

screening criteria. Burlew et al11 similarly reported

that one fifth of patients with confirmed BCVI did not

meet the Denver screening criteria, and up to one third

of themhad amandibular fracture. Geddes et al16 imple-mented expanded screening criteria (mandibular frac-

tures, complex skull fractures, traumatic brain injury

with thoracic injuries, scalp degloving, thoracic

vascular injuries, and upper rib fractures) to include

the ‘‘missing’’ 20% of patients with BCVI. They found

that 28% of patients with asymptomatic BCVI were

identified solely by the new screening indications pro-

vided as the expanded criteria. Most current BCVIscreening criteria include only Le Fort pattern fractures

as an indication for imaging, although a systematic

review identified mandibular fractures as the most

commonBCVI-associated craniomaxillofacial pattern.17

A correlation between skull base fractures and BCVI

has been repeatedly reported in previous

studies.1,14,15,18,19 These studies were consistent in

indicating skull base fractures as a risk factor for BCVI,although fracture types varied. Previously, the focus

was on petrous bone fractures and carotid canal

involvement,18-20 whereas more recent investigations

have taken into account other parts of the skull

base13-15 and fronto-orbital area.11 York et al21 reported

BCVI rates for all types of skull fractures.

In bony craniofacial trauma, fracture lines often

continue across facial and cranial bones, so the


craniofacial region can be considered a single unit.

Therefore, in contrast to previous studies, the present

analyses included any type of facial and skull fracture,

with the aim of analyzing possible correlations

between BCVI and craniofacial fractures and evalu-

ating BCVI incidence in different types of craniofacial

fractures. The hypothesis was that there would be an

association between craniofacial fractures and BCVI.Specific aims for the study were to analyze whether

some facial fracture subtypes correlate with an

increased risk for BCVI.

Patients and Methods

STUDY DESIGN

For this retrospective study, the cohort consisted of

patients with suspected blunt high-energy polytrauma

who were admitted to a level 1 trauma center (T€o€ol€oTrauma Center, Helsinki University Hospital, Helsinki,

Finland) in accord with a trauma alarm protocol from

May 2015 through May 2016. These included patients

with a mechanism of injury serious enough to requirecomputed tomography (CT) of the whole body. All

patients were subjected to split-bolus whole-body

64-slice CT (Discovery CT 750 HD, GE Healthcare,

Milwaukee,WI) including angiography (aWBCT),which

includes a continuous scan from the skull base to the

ischium in simultaneous arterial and portal venous

phases. Table 1 presents the imaging protocol. Data for

patients imaged by aWBCT, in addition to their demo-graphic data, clinical findings, and initial reports, were

retrospectively retrieved from the Picture Archiving

and Communications System (Impax 6, Agfa HealthCare

NV, Mortsel, Belgium) and electronic patient files.

Exclusion criteria were hanging injury, gunshot

injury or other penetrating injury to the neck region,

and cervical fracture at any level.

All CT studies were reviewed by 2 board-certifiedradiologists with 12 and 6 years of experience in

trauma radiology, respectively, who were blinded to

the initial reports. Any discrepancies were resolved

by consensus.

STUDY VARIABLES

Themain outcome variable was BCVI. Themain pre-

dictor variable was a craniofacial fracture. A secondary

predictor variable was type of craniofacial fracture

classified as a facial fracture, skull fracture, or a combi-

nation of facial and skull fractures. Other predictor

variables were gender, age, mechanism of injury, andcraniofacial fracture subgroups.

Patients with craniofacial fractures were identified

and their fractures were divided into 4 facial fracture

subgroups and 3 skull fracture subgroups. Facial

fractures consisted of 1) combined facial fractures

18 April 2018 � 2:37 pm � CE AH

Table 1. IMAGING PROTOCOL OF BODY COMPUTEDTOMOGRAPHIC ANGIOGRAPHY OF CERVICALARTERIES

Split-bolus imaging protocol

Scan area

Circle of Willis and ischium (lower extremities on

request)

Contrast enhancement

Cervical spine in arterial phase

Body in simultaneous arterial and venous phases

80 mL+ 50-mL contrast medium bolus (Omnipaque*Q4 350 mg/mL + iohexol) at 22-second interval

Contrast delay

Cervical spine, SmartPrep* with 130-HU threshold

Body, 45-second fixed delay

Image acquisition parameters

Slice thickness, 0.625 mm

Range, 120-700 mA

Pitch, 39.37 mm/rotation

Table feed: neck, 98.4 mm/second; body,

137.5 mm/second

Neck: kV 100, NI 40

Body: kV 120, NI 50

Reformatted series

Axial, coronal, sagittal planes; vascular and bone

windows

Reformatted slice thickness

Cervical spine: axial, 1.25 mm; coronal and sagittal,

1.5 mm

Cervical vessels, 2 mm coronal and sagittal

Body, 3 mm coronal and sagittal

* GE Healthcare Ireland (Cork, Ireland).

Varjonen et al. Blunt Cerebrovascular Injury. J Oral Maxillofac

Surg 2018.

Table 2. DESCRIPTIVE STATISTICS FOR 428 PATIENTSWITH TRAUMA

n %

Gender

Male 304 71.0

Female 124 29.0

Age (yr)

Mean 41.9

Range 13-90

Age groups (yr)

13-30 133 31.1

31-50 156 36.4

51-70 111 25.9

71-90 28 6.5

Mechanism of trauma

Motor vehicle accident 199 46.5

Fall from height 86 20.1

Bicycle accident 35 8.2

Pedestrian traffic injuries 24 5.6

Fall on stairs 19 4.4

Assault 14 3.3

Other 51 11.9

Craniofacial fracture 75 17.5

Facial fracture 42 9.8

Skull fracture 19 4.4

Facial + skull fracture 14 3.4

BCVI 40 9.3

Abbreviation: BCVI, blunt cerebrovascular injury.


Surg 2018.

VARJONEN ET AL 1.e3

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(mandibular and midfacial fractures, midfacial and

upper third fractures, and panfacial fractures extend-

ing to all facial thirds); 2) upper third fractures

(fractures of the frontal sinus, orbital roof, or anterior

skull base); 3) midfacial fractures (multiple midfacial

fractures, Le Fort I to III, naso-orbito-ethmoidal, zygo-

matic, and orbital fractures other than the roof or nasal

fractures); or 4) lower facial fractures (exclusivelymandibular fractures). Skull fractures consisted of 1)

basilar skull fractures (fractures of the sphenoid,

petrous temporal bone, or basilar portion of the occip-

ital bone); 2) other skull fractures; or 3) complex skull

fractures (combination of basilar skull fractures and

other skull fractures). Specific facial fractures and

fractures involving the carotid canal and foramen

magnum were documented separately.

STATISTICAL ANALYSIS

For statistical analysis, SPSS 24.0 (IBM Corp,

Armonk, NY) was used. The relevance of associations

between BCVI and craniofacial fractures, facial and

skull fracture subtypes, gender, age, and mechanism


of traumawas testedwith the c2 test. Significance level

was set at .01. Multivariate logistic regression analysis

was performed to test the relation between BCVI and

the explanatory variables gender, age, mechanism of

injury, and any craniofacial fracture.

ETHICAL APPROVAL

The internal review board of the Division of Muscu-

loskeletal Surgery at the Helsinki University Hospital

approved the study. Patient-informed consent was

waived, because the study was retrospective. The

study followed the principles of the Declaration

of Helsinki.

Results

Of the 465 patients, 7 were excluded for poor image

quality or lack of intravenous contrast media and 30

were excluded for cervical spine fractures. None of

the patients had sustained a hanging, gunshot, or other

penetrating injury to the neck region. Thus, 428patients were accepted for the final analyses.

Table 2 presents descriptive statistics for the 428

patients. Most patients (71%) were male, and mean

18 April 2018 � 2:37 pm � CE AH

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1.e4 BLUNT CEREBROVASCULAR INJURY

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age was 41.9 years. The most common mechanism of

injury was motor vehicle accident (46.5%), followed

by fall from a height (20.1%) and bicycle accident

(8.2%). Other injury mechanisms were pedestrian

traffic injuries (5.6%), a fall on the stairs (4.4%), and

assault (3.3%). The remaining 11.9% fell under other

injury mechanisms, in which the mechanism was un-

known or the trauma was considered of relativelylow energy. Such mechanisms include falls from low

heights or on even on the ground, sports injuries,

and being struck by or crushed between blunt objects.

Craniofacial fractures had occurred in 75 patients

(17.5%), of whom 42 (58.3%) had a facial fracture,

19 (25.3%) had a skull fracture, and 14 (18.7%) had

facial and skull fractures, and 40 (9.3%) had BCVI.

Table 3 presents the association between BCVI andits predictors. BCVI was evident in 18.6% of patients

with craniofacial fracture, reaching significance

(P = .002). BCVI occurred most frequently with skull

fractures (21.1%), followed by facial fractures

(19.0%) and combinations of facial and skull fractures

(14.3%), although the differences among these 3

patient groups were nonsignificant (P = .882). No

meaningful associations emerged between BCVI andgender or mechanism of trauma. Table 4 presents a

logistic regression analysis between BCVI and gender,

Table 3. ASSOCIATION BETWEEN BCVI AND PREDICTORS IN

n BCVI Present

Gender

Male 304 24

Female 124 16

Age groups (yr)

13-30 133 7

31-50 156 21

51-70 111 9

71-90 28 3

Mechanism of trauma

Motor vehicle accident 199 23

Fall from height 86 9

Bicycle accident 35 1

Pedestrian traffic injuries 24 1

Fall on stairs 19 2

Assault 14 0

Other 51 4

Craniofacial fracture

Yes 75 14

No 353 26

Facial fracture 42 8

Skull fracture 19 4

Facial + skull fracture 14 2

Note: Significance level was set at .01.Abbreviation: BCVI, blunt cerebrovascular injury.

Varjonen et al. Blunt Cerebrovascular Injury. J Oral Maxillofac Surg 20


age group, mechanism of injury, and craniofacial frac-

tures. Analysis showed a 4-fold higher risk of BCVI in

patients with craniofacial fracture than in those with

other trauma (odds ratio [OR] = 4.096; 95% confi-

dence interval [CI], 1.866-8.993; P < .001). Patients

31 to 50 years old had a 3.4-fold higher risk than their

reference group (13 to 30 yr; OR = 3.426; 95% CI,

1.356-8.656; P = .009).Table 5 presents associations between craniofacial

fracture subgroups and BCVI. In the 56 patients with

facial fractures, BCVI most commonly occurred in

combined facial (20.0%) and midfacial (20.0%)

fractures. None with exclusively upper or lower facial

fractures showed BCVI. No statistically relevant differ-

ences appeared between BCVI and facial fracture

subgroups. Of the 33 patients with skull fractures,BCVI occurred most frequently in those with complex

skull fractures (37.5%), followed by basilar skull

fractures (14.3%), but in no other types of skull

fracture. The correlation between BCVI and complex

skull fractures was almost significant (P = .033).

Table 6 presents specific facial fractures and

fractures extending into the carotid canal and foramen

magnum. Further analysis showed that all BCVIs infacial fractures occurred in isolated zygomatico-

orbital fractures (35.7%), combined facial fractures

428 PATIENTS WITH TRAUMA

% BCVI in 40 Patients, % P Value

.110

7.9 60.0

12.9 40.0

.110

5.3 17.5

13.5 52.5

8.1 22.5

10.7 7.5

.500

11.6 57.5

10.5 22.5

2.9 2.5

4.2 2.5

10.5 5

0 0

7.8 10

18.6 35.0 .002

7.4 65.0

19.0 20 .882

21.1 10

14.3 5

18.

18 April 2018 � 2:37 pm � CE AH

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Table 4. MULTIVARIATE REGRESSION ANALYSIS FORBLUNT CEREBROVASCULAR INJURIES IN 428PATIENTS WITH TRAUMA

OR

95% CI for OR

P ValueLower Upper

Gender (ref, female) 0.460 0.223 0.946 .035

Age groups

(ref, 13-30 yr)

31-50 yr 3.426 1.356 8.656 .009

51-70 yr 2.179 0.746 6.370 .155

71-90 yr 2.432 0.531 11.145 .253

Mechanism of injury

(ref, MVA)

Fall from height 0.701 0.293 1.675 .424

Bicycle accident 0.110 0.013 0.908 .040

Pedestrian traffic

injuries

0.170 0.020 1.449 .105

Fall on stairs 0.491 0.092 2.622 .405

Assault 0.000 0.000 .998

Other 0.452 0.143 1.433 .178

Craniofacial fracture

(ref, yes)

4.096 1.866 8.993 <.001

Note: Significance level was set at .01.Abbreviations: CI, confidence interval; MVA, motor

vehicle accident; OR, odds ratio; ref, reference.


Surg 2018.

VARJONEN ET AL 1.e5

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(20.0%), and isolated orbital fractures (12.5%). The

number of specific facial fractures was insufficient

for statistical analysis. Only 1 patient with a skull

base fracture extending to the foramen magnum

Table 5. ASSOCIATION BETWEEN BCVI AND SUBGROUPS OFCRANIOFACIAL FRACTURE

n BCVI Present

Facial fracture

Any (n = 56) 56 10

Combined facial 20 4

Upper 1 0

Midfacial 30 6

Lower 5 0

Skull fracture

Any (n = 33) 33 6

Basilar skull fracture* 21 3

Other 4 0

Complex skull fracturey 8 3

Note: Significance level was set at .01.Abbreviation: BCVI, blunt cerebrovascular injury.* Fracture of the sphenoid, petrous, temporal, clivus, or occipity Basilar skull fracture plus other skull fracture.

Varjonen et al. Blunt Cerebrovascular Injury. J Oral Maxillofac Surg 20


(12.5%) had BCVI, and none of the 5 patients with a

fracture extending to the carotid canal had BCVI.

Discussion

The purpose of this study was to analyze possible

correlations between BCVI and craniofacial fractures

and to evaluate the incidence of BCVI in different

types of craniofacial fractures, with the hypothesis of

there being an association between craniofacial frac-

tures and BCVI. Furthermore, the authors investigated

a possible correlation of facial fracture subtypes

to BCVI.The present study of craniofacial fractures and BCVI

showed a strong correlation, with BCVI occurring 2.5

times more frequently in patients with craniofacial

fracture than in those with all other types of severe

trauma. Nearly 1 in 5 patients with craniofacial

fracture (18.6%) was diagnosed with BCVI. There

was no difference between facial fractures and skull

fractures with regard to BCVI. Logistic regressionshowed a 4-fold higher risk of BCVI for craniofacial

fractures compared with all other trauma.

Thus, the present results are in line with those of

Buch et al14 who stated that BCVI can occur in up to

11% of patients with blunt trauma injuries. However,

overall BCVI incidence was considerably higher

(9.3%) in the present study than in previous

studies.1-5 One possible explanation for the higherincidence of BCVI could be the authors’ institution

serving as a level 1 trauma center and a tertiary

hospital and therefore having a higher incidence of

severe trauma. Furthermore, the authors’ guidelines

CRANIOFACIAL FRACTURES IN 75 PATIENTS WITH

% BCVI in 14 Patients, % P Value

17.9 71.4 .757

20.0 28.6 .090

20.0 42.9

18.2 42.9 .924

14.3 21.4 .033

37.5 21.4

al condyle.

18.

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Table 6. SPECIFIC FACIAL FRACTURES ANDFRACTURES EXTENDING TO THE CAROTID CANALANDFORAMEN MAGNUM AND BCVI IN 75 PATIENTS

n

BCVI

Present %

P

Value

Facial fractures (n = 56) NA

Combined facial 20 4 20.0

Upper third 1 0

Multiple midfacial 4 0

Exclusively orbital 8 1 12.5

Exclusively

zygomatico-orbital

14 5 35.7

Exclusively maxillary 1 0

Exclusively nasal 3 0

Exclusively condylar 2 0

Exclusively

non-condylar

3 0

Skull fractures (n = 33) .084

Carotid canal 5 0

Foramen magnum 8 1 12.5

Fracture not involving

foramen

20 5 25.0

Note: Significance level was set at .01.Abbreviations: BCVI, blunt cerebrovascular injury; NA,

---.Q6


Surg 2018.


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for BCVI screening in patients with high-energy

trauma seem liberal; in addition to the Denver criteria,

the authors included thoracic and lower cervical spine

trauma. In the authors’ unit, even if the trauma alarm

protocol has not been triggered, the attending trauma

surgeon can order an aWBCT when clinical signs ormechanism of trauma indicate possible severe trauma.

Thus, the liberal screening protocol could have

increased the number of imaged patients and diag-

nosed BCVIs, especially among facial fracture cases.

Buch et al14 reported that 87% of their patients with

BCVI also had cervical or skull base fractures or a com-

bination of the 2, but concluded that isolated midface

fractures in the absence of cervical spine or skull basefractures were not associated with underlying BCVI.

However, the only facial injuries observed in their study

were complex facial fractures with midface instability.

The authors excluded cervical fractures to focus on

the effect of craniofacial fractures alone. Occurrence

was almost evenly divided among isolated facial frac-

tures, isolated cranial fractures, and combinations of

the 2 groups. Further analysis showed a high occur-rence of BCVI in combined facial fractures andmidfacial

fractures, especially in zygomatico-orbital fractures

(Figs 1, 2). Based on these results, facial fractures

should be considered an independent risk factor for

BCVI. For more accurate conclusions about different


types of craniofacial fractures, a larger number of

patients with specific fracture types is required.

Recent studies have emphasized the relevance of

facial fractures in BCVIs, such as mandibular and

especially extracapsular condylar fractures15,22 and

maxillary fractures involving pterygoid plates.15

Kang et al23 described the injury mechanism of the in-

ternal carotid artery (ICA) in conjunction with Le FortI osteotomy. Owing to the anatomic proximity of the

ICA to the foramen lacerum and the pterygoid plate,

the artery can be directly damaged if a sharp bony

edge causes shearing near the skull base. This is in

line with the findings of Mundinger et al15 who

concluded that in patients with facial fracture, risk

for BCVI without applying screening criteria was

higher in patients with Le Fort I fractures. The samestudy reported corresponding findings in patients

with mandibular subcondylar fractures. Vranis et al22

studied condyle fractures in more detail and found

that direct injury caused by bony fragments, especially

displaced extracapsular condyle fractures, increased

the risk for BCVI. According to these studies, Le Fort

I fractures and extracapsular mandibular condylar frac-

tures, in particular, can lead to localized ICA damage.The authors found no associations between BCVI

and these fracture subtypes. The present study

showed a high occurrence of BCVI, especially in

zygomatico-orbital fractures, indicating that a facial

fracture is a marker of substantial trauma energy,

which in turn increases the likelihood of BCVI, even

when the fracture does not cause direct mechanical

damage to a vessel.Others have reported an association between skull

base fractures and BCVI.1,14,15,18,19 In the present

study, the authors analyzed all types of cranial

fractures. BCVI occurred most frequently in complex

skull fractures (combination of basilar skull fractures

and other skull fractures; 37.5%) and basilar skull

fractures (14.2%), but none of the patients with

exclusively other skull fracture types showed BCVI.This differs from the findings of York et al21 who re-

ported a high BCVI rate in fractures in other parts of

the skull, with 29% of patients with non-basilar skull

fractures having ICA injury. Carotid canal fractures

also have been implicated as a risk factor for BCVI.

Petrous bone fractures and carotid canal involvement

can lacerate a blood vessel, especially in the intraosteal

segment.20 York et al21 also evaluated the incidence ofICA injury and skull fractures, establishing that in skull

fractures with carotid canal involvement (35%), injury

to the ICA was twice as frequent as without canal

involvement (15%). Interestingly, in the present study,

none of the 5 patients with carotid canal involvement

and only 1 of 8 patients with a fracture extending to

the foramen magnum had BCVI. The number of these

patients was small, and further investigation with a

18 April 2018 � 2:37 pm � CE AH

print&web4C=FPO

FIGURE1. A 25-year-old unconscious woman was admitted with an unclear injury mechanism. Radiologic imaging depicted a left zygomaticarch fracture (broad arrow), right mandibular parasymphyseal fracture (thin arrow), and dental injuries to the upper incisors (arrowhead).

Varjonen et al. Blunt Cerebrovascular Injury. J Oral Maxillofac Surg 2018.

VARJONEN ET AL 1.e7

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larger cohort of patients might clarify any associations

between skull fracture subtypes and BCVI.

The question arises as to whether BCVI correlates

with a certain type of injury or requires a certainamount of trauma energy. Even minor craniofacial

trauma has coincided with serious carotid injury.

One case study described a healthy young man with

a non-dislocated mandibular double fracture as a result

of a single punch, who was diagnosed with carotid

dissection and acute secondary embolic infarcts.24

Considering that report and the variation in craniofa-

cial fractures with BCVI in the present and previousstudies, the energy required to cause any craniofacial

fracture seems sufficient to cause an associated

BCVI. Interestingly, a previous study found that a

long styloid process of the temporal bone can

contribute to the pathogenesis of cervical carotid


dissection.25 Thus, taking into consideration that

hyperextension, rotation, and lateral flexion of the

neck predispose to BCVI, more detailed evaluation

of a local anatomic association is required. Furtherinvestigation of the level of BCVI and possible vectors

for trauma energy would probably shed some light on

these associations.

Controversy still exists concerning which patients

with trauma are at risk for BCVI and for whom

screening is thus indicated. Current BCVI screening

guidelines allow for BCVI being missed and risk for

stroke. Thus, more liberalized screening for BCVIduring initial CT in patients with trauma and signs of

typical mechanisms or high-energy trauma is war-

ranted.2 The overall incidence of BCVI has increased

during the past decade, in part because of the

increased availability and accuracy of cervical CTA in

18 April 2018 � 2:37 pm � CE AH

Q3

FIGURE 2. Cervical computed tomographic angiography displayed blunt cerebrovascular injury (Biffl grade 2) in the 2 internal carotidarteries (arrows).

Varjonen et al. Blunt Cerebrovascular Injury. J Oral Maxillofac Surg 2018.


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combinationwith an increasing index of suspicion and

increased experience among trauma surgeons treatingthese injuries.1,26

Despite greater academic interest in this topic,

unambiguous evidence of associations between

craniofacial injuries and BCVIs is lacking. The present

study found that craniofacial fractures are a notable

risk factor for BCVI, without relevant differences in

risk between fracture subtypes. Therefore, in all

patients with polytrauma and craniofacial fractures,BCVI should be excluded.

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Remember the Vessels! Craniofacial Fracture Predicts Risk