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

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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.


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.


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).


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.

Article Information

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

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 1. A: Axial MR image showing contusions of the right temporal lobe and brain stem. B: Sagittal bone window CT reconstruction revealing a clival fracture (arrow). C: Digital subtraction angiogram demonstrating an indirect CCF (arrow) draining into the inferior petrosal sinus.

  • View in gallery

    Case 3. A: Head CT scan revealing bilateral temporal lobe contusions. B: Bone window CT showing left petrous and clival fractures. C: Computed tomography angiogram showing a patent right petrous ICA (arrow) and absent left petrous ICA (arrowhead).


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