Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base

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Object

Skull base fractures are often associated with potentially devastating injuries to major neural arteries in the head and neck, but the incidence and pattern of this association are unknown.

Methods

Between April and September 2002, 1738 Level 1 trauma patients were admitted to St. Joseph's Hospital and Medical Center in Phoenix, Arizona. Among them, a skull base fracture was diagnosed in 78 patients following computed tomography (CT) scans. Seven patients had no neurovascular imaging performed and were excluded. Altogether, 71 patients who received a diagnosis of skull base fractures after CT and who also underwent a neurovascular imaging study were included (54 men and 17 women, mean age 29 years, range 1–83 years). Patients underwent CT angiography, magnetic resonance angiography, or digital subtraction angiography of the head and craniovertebral junction, or combinations thereof.

Results

Nine neurovascular injuries were identified in six (8.5%) of the 71 patients. Fractures of the clivus were very likely to be associated with neurovascular injury (p < 0.001). A high risk of neurovascular injury showed a strong tendency to be associated with fractures of the sella turcica–sphenoid sinus complex (p = 0.07).

Conclusions

The risk of associated blunt neurovascular injury appears to be significant in Level 1 trauma patients in whom a diagnosis of skull base fracture has been made using CT. The incidence of neurovascular trauma is particularly high in patients with clival fractures. The authors recommend neurovascular imaging for Level 1 trauma patients with a high-risk fracture pattern of the central skull base to rule out cerebrovascular injuries.

Abbreviations used in this paper:AVF = arteriovenous fistula; CCF = carotid–cavernous fistula; CT = computed tomography; DSA = digital subtraction angiography; GCS = Glasgow Coma Scale; ICA = internal carotid artery; MR = magnetic resonance; MVA = motor vehicle accident; VA = vertebral artery.

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Contributor Notes

Address reprint requests to: Nicholas Theodore, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.
  • 1

    Aarabi B, & McQueen JD: Traumatic internal carotid occlusion at the base of the skull. Surg Neurol 10:233236, 1978

  • 2

    Barrow DL, , Spector RH, , Braun IF, , Landman JA, , Tindall SC, & Tindall GT: Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62:248256, 1985

    • Search Google Scholar
    • Export Citation
  • 3

    Berne JD, , Norwood SH, , McAuley CE, , Vallina VL, , Creath RG, & McLarty J: The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols. J Am Coll Surg 192:314321, 2001

    • Search Google Scholar
    • Export Citation
  • 4

    Berne JD, , Norwood SH, , McAuley CE, & Villareal DH: Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury. J Trauma 57:1117, 2004

    • Search Google Scholar
    • Export Citation
  • 5

    Biffl WL, , Moore EE, , Elliott JP, , Ray C, , Offner PJ, & Franciose RJ, : The devastating potential of blunt vertebral arterial injuries. Ann Surg 231:672681, 2000

    • Search Google Scholar
    • Export Citation
  • 6

    Biffl WL, , Moore EE, & Mestek M: Patients with blunt carotid and vertebral artery injuries. J Trauma 47:438439, 1999

  • 7

    Biffl WL, , Moore EE, , Offner PJ, , Brega KE, , Franciose RJ, & Elliott JP, : Optimizing screening for blunt cerebrovascular injuries. Am J Surg 178:517522, 1999

    • Search Google Scholar
    • Export Citation
  • 8

    Bok AP, & Peter JC: Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis. J Trauma 40:968972, 1996

    • Search Google Scholar
    • Export Citation
  • 9

    Carrillo EH, , Osborne DL, , Spain DA, , Miller FB, , Senler SO, & Richardson JD: Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event. J Trauma 46:11201125, 1999

    • Search Google Scholar
    • Export Citation
  • 10

    Cogbill TH, , Moore EE, , Meissner M, , Fischer RP, , Hoyt DB, & Morris JA, : The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma 37:473479, 1994

    • Search Google Scholar
    • Export Citation
  • 11

    Coldwell DM, , Novak Z, , Ryu RK, , Brega KE, , Biffl WL, & Offner PJ, : Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents. J Trauma 48:470472, 2000

    • Search Google Scholar
    • Export Citation
  • 12

    Cothren CC, , Moore EE, , Biffl WL, , Ciesla DJ, , Ray CE Jr, & Johnson JL, : Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 139:540545, 2004

    • Search Google Scholar
    • Export Citation
  • 13

    Cothren CC, , Moore EE, , Biffl WL, , Ciesla DJ, , Ray CE Jr, & Johnson JL, : Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 55:811813, 2003

    • Search Google Scholar
    • Export Citation
  • 14

    Davis JW, , Holbrook TL, , Hoyt DB, , Mackersie RC, , Field TO Jr, & Shackford SR: Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma 30:15141517, 1990

    • Search Google Scholar
    • Export Citation
  • 15

    Fabian TC, , Patton JH Jr, , Croce MA, , Minard G, , Kudsk KA, & Pritchard FE: Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 223:513525, 1996

    • Search Google Scholar
    • Export Citation
  • 16

    Janon EA: Traumatic changes in the internal carotid artery associated with basal skull fractures. Radiology 96:5559, 1970

  • 17

    Kerwin AJ, , Bynoe RP, , Murray J, , Hudson ER, , Close TP, & Gifford RR, : Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 51:308314, 2001

    • Search Google Scholar
    • Export Citation
  • 18

    Krajewski LP, & Hertzer NR: Blunt carotid artery trauma: report of two cases and review of the literature. Ann Surg 191:341346, 1980

  • 19

    Mayberry JC, , Brown CV, , Mullins RJ, & Velmahos GC: Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg 139:609613, 2004

    • Search Google Scholar
    • Export Citation
  • 20

    McKevitt EC, , Kirkpatrick AW, , Vertesi L, , Granger R, & Simons RK: Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury. J Trauma 53:472476, 2002

    • Search Google Scholar
    • Export Citation
  • 21

    McKevitt EC, , Kirkpatrick AW, , Vertesi L, , Granger R, & Simons RK: Identifying patients at risk for intracranial and extracranial blunt carotid injuries. Am J Surg 183:566570, 2002

    • Search Google Scholar
    • Export Citation
  • 22

    Miller PR, , Fabian TC, , Bee TK, , Timmons S, , Chamsuddin A, & Finkle R, : Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma 51:279286, 2001

    • Search Google Scholar
    • Export Citation
  • 23

    Miller PR, , Fabian TC, , Croce MA, , Cagiannos C, , Williams JS, & Vang M, : Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 236:386395, 2002

    • Search Google Scholar
    • Export Citation
  • 24

    Morgan MK, , Besser M, , Johnston I, & Chaseling R: Intracranial carotid artery injury in closed head trauma. J Neurosurg 66:192197, 1987

  • 25

    Redekop G, , Marotta T, & Weill A: Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents. J Neurosurg 95:412419, 2001

    • Search Google Scholar
    • Export Citation
  • 26

    Rogers FB, , Baker EF, , Osler TM, , Shackford SR, , Wald SL, & Vieco P: Computed tomographic angiography as a screening modality for blunt cervical arterial injuries: preliminary results. J Trauma 46:380385, 1999

    • Search Google Scholar
    • Export Citation
  • 27

    Rozycki GS, , Tremblay L, , Feliciano DV, , Tchorz K, , Hattaway A, & Fountain J, : A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma 52:618623, 2002

    • Search Google Scholar
    • Export Citation
  • 28

    Sedzimir CB: Head injury as a cause of internal carotid thrombosis. J Neurol Neurosurg Psychiatry 18:293296, 1955

  • 29

    Unger JM, , Gentry LR, & Grossman JE: Sphenoid fractures: prevalence, sites, and significance. Radiology 175:175180, 1990

  • 30

    Wahl WL, , Brandt MM, , Thompson BG, , Taheri PA, & Greenfield LJ: Antiplatelet therapy: an alternative to heparin for blunt carotid injury. J Trauma 52:896901, 2002

    • Search Google Scholar
    • Export Citation
  • 31

    Weller SJ, , Rossitch E Jr, & Malek AM: Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography. J Trauma 46:660666, 1999

    • Search Google Scholar
    • Export Citation
  • 32

    West OC, , Mirvis SE, & Shanmuganathan K: Transsphenoid basilar skull fracture: CT patterns. Radiology 188:329338, 1993

  • 33

    Willis BK, , Greiner F, , Orrison WW, & Benzel EC: The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery 34:435441, 1994

    • Search Google Scholar
    • Export Citation
  • 34

    Woodring JH, , Lee C, & Duncan V: Transverse process fractures of the cervical vertebrae: are they insignificant?. J Trauma 34:797802, 1993

    • Search Google Scholar
    • Export Citation
  • 35

    Yamada S, , Kindt GW, & Youmans JR: Carotid artery occlusion due to nonpenetrating injury. J Trauma 7:333342, 1967

  • 36

    Young HA, , Olin MS, & Schmidek HH: Fractures of the sella turcica. Neurosurgery 7:2329, 1980

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