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.

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: neuropub@chw.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • 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).

References

1

Aarabi BMcQueen JD: Traumatic internal carotid occlusion at the base of the skull. Surg Neurol 10:2332361978

2

Barrow DLSpector RHBraun IFLandman JATindall SCTindall GT: Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62:2482561985

3

Berne JDNorwood SHMcAuley CEVallina VLCreath RGMcLarty 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 192:3143212001

4

Berne JDNorwood SHMcAuley CEVillareal DH: Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury. J Trauma 57:11172004

5

Biffl WLMoore EEElliott JPRay COffner PJFranciose RJ: The devastating potential of blunt vertebral arterial injuries. Ann Surg 231:6726812000

6

Biffl WLMoore EEMestek M: Patients with blunt carotid and vertebral artery injuries. J Trauma 47:4384391999

7

Biffl WLMoore EEOffner PJBrega KEFranciose RJElliott JP: Optimizing screening for blunt cerebrovascular injuries. Am J Surg 178:5175221999

8

Bok APPeter JC: Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis. J Trauma 40:9689721996

9

Carrillo EHOsborne DLSpain DAMiller FBSenler SORichardson JD: Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event. J Trauma 46:112011251999

10

Cogbill THMoore EEMeissner MFischer RPHoyt DBMorris JA: The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma 37:4734791994

11

Coldwell DMNovak ZRyu RKBrega KEBiffl WLOffner PJ: Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents. J Trauma 48:4704722000

12

Cothren CCMoore EEBiffl WLCiesla DJRay CE JrJohnson JL: Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 139:5405452004

13

Cothren CCMoore EEBiffl WLCiesla DJRay CE JrJohnson JL: Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 55:8118132003

14

Davis JWHolbrook TLHoyt DBMackersie RCField TO JrShackford SR: Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma 30:151415171990

15

Fabian TCPatton JH JrCroce MAMinard GKudsk KAPritchard FE: Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 223:5135251996

16

Janon EA: Traumatic changes in the internal carotid artery associated with basal skull fractures. Radiology 96:55591970

17

Kerwin AJBynoe RPMurray JHudson ERClose TPGifford RR: Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 51:3083142001

18

Krajewski LPHertzer NR: Blunt carotid artery trauma: report of two cases and review of the literature. Ann Surg 191:3413461980

19

Mayberry JCBrown CVMullins RJVelmahos GC: Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg 139:6096132004

20

McKevitt ECKirkpatrick AWVertesi LGranger RSimons RK: Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury. J Trauma 53:4724762002

21

McKevitt ECKirkpatrick AWVertesi LGranger RSimons RK: Identifying patients at risk for intracranial and extracranial blunt carotid injuries. Am J Surg 183:5665702002

22

Miller PRFabian TCBee TKTimmons SChamsuddin AFinkle R: Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma 51:2792862001

23

Miller PRFabian TCCroce MACagiannos CWilliams JSVang M: Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 236:3863952002

24

Morgan MKBesser MJohnston IChaseling R: Intracranial carotid artery injury in closed head trauma. J Neurosurg 66:1921971987

25

Redekop GMarotta TWeill A: Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents. J Neurosurg 95:4124192001

26

Rogers FBBaker EFOsler TMShackford SRWald SLVieco P: Computed tomographic angiography as a screening modality for blunt cervical arterial injuries: preliminary results. J Trauma 46:3803851999

27

Rozycki GSTremblay LFeliciano DVTchorz KHattaway AFountain J: A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma 52:6186232002

28

Sedzimir CB: Head injury as a cause of internal carotid thrombosis. J Neurol Neurosurg Psychiatry 18:2932961955

29

Unger JMGentry LRGrossman JE: Sphenoid fractures: prevalence, sites, and significance. Radiology 175:1751801990

30

Wahl WLBrandt MMThompson BGTaheri PAGreenfield LJ: Antiplatelet therapy: an alternative to heparin for blunt carotid injury. J Trauma 52:8969012002

31

Weller SJRossitch E JrMalek AM: Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography. J Trauma 46:6606661999

32

West OCMirvis SEShanmuganathan K: Transsphenoid basilar skull fracture: CT patterns. Radiology 188:3293381993

33

Willis BKGreiner FOrrison WWBenzel EC: The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery 34:4354411994

34

Woodring JHLee CDuncan V: Transverse process fractures of the cervical vertebrae: are they insignificant?. J Trauma 34:7978021993

35

Yamada SKindt GWYoumans JR: Carotid artery occlusion due to nonpenetrating injury. J Trauma 7:3333421967

36

Young HAOlin MSSchmidek HH: Fractures of the sella turcica. Neurosurgery 7:23291980

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