Elsevier

Injury

Volume 41, Issue 9, September 2010, Pages 929-934
Injury

The epidemiology of BCVI at a single state trauma centre

https://doi.org/10.1016/j.injury.2010.03.006Get rights and content

Abstract

Background

Blunt carotid and vertebral artery injury (BCVI) is a relatively uncommon but potentially devastating injury. The aim of our study was to highlight the incidence, patterns, presentation and associations of BCVI at our institution.

Methods

Retrospective data between 1st January 2003 and 31st December 2006 was obtained from The Alfred Hospital's health information system, patient medical records and the Department of Neurosurgery's database. Injuries were graded using the Denver grading scale.

Results

67 patients (0.64%) out of 10,417 minor and major trauma admissions, were diagnosed with BCVI. 33 (49%) sustained blunt carotid and 34 (51%) sustained blunt vertebral injuries. Motor vehicle accident (MVA) was the cause in 43 out of 67. 35% had associated head injury whilst 57% had concurrent cervical spine fractures. Odds ratio analysis showed that MVA victims with concomitant upper cervical spine injury were 22.9 times more likely to suffer BCVI than those without such risk factors. Approximately 50% of patients had a Glasgow coma score of 14 or less (GCS  14). Grade 4 BCVI was most common. Stroke occurred in 22 (32%) and mortality in 14 (20%).

Conclusion

BCVI although infrequent, is a serious injury. Our study suggests that MVA patients with cervical spine fractures especially of the upper C-spine are at much higher risk of BCVI than those without such injuries.

Introduction

Blunt carotid artery injury (BCI) has been reported with an overall incidence ranging from 0.08% to 0.38%.1, 13, 23, 7, 15, 25, 12, 21, 17, 14, 19, 4, 6, 5. The majority of patients with BCI have no signs of cervical trauma nor neurological deficits at presentation.1, 13, 23, 7, 15, 25, 12, 21, 17, 14, 19, 4, 6, 5 The BCI is usually detected when delayed focal neurological deficits become apparent.

In Cogbill's multicentre study, more than half of the patients who presented with a Glasgow coma score (GCS) above 12 developed focal neurological deficits more than 12 h later.7 Similarly, Parikh et al. reported that almost 60% of patients who presented without focal deficits developed them later under observation.21 Fabian's group reported that 43% of patients were diagnosed with BCI subsequent to the onset of neurological deficits, after initially presenting with normal findings.12 In these patients, an average delay of 53 h from injury to definitive diagnosis was seen.12

Other significant findings which may herald the presence of BCI include Horner's syndrome, cranial nerve deficits, direct neck trauma, significant cervical spine injury and significant cervical soft tissue injuries such as contusions or haematomas.1, 21

Blunt vertebral artery injury (BVI) is also uncommon, with increased use of four vessel angiography after craniocervical trauma possibly contributing to its increased detection despite the absence of neurological symptoms.26, 11, 16, 24 BVI is usually suspected and confirmed on the basis of associated injuries to the cervical spine, spinal cord and nerve root rather than from vertebrobasilar insufficiency due to the arterial injury itself.

Yee's series on 16 patients who were diagnosed with BVI over a 9-year period, demonstrated that 75% of their patients with BVI presented with normal GCS, and the majority of those with neurological deficits were not due to the vertebral artery injury causing ischaemia or thomboembolic events, but rather attributed to the concomitant intracranial, cervical cord or nerve root lesions.27 Biffl's series also showed that cervical spine injuries were present in 71% of patients with BVI.3

BCVI is potentially devastating, particularly in patients who present with neurological deficits or stroke. Studies specifically targeting BCI report mortality rates of 5–43%, and good neurological outcomes in only 20–63% of survivors.7, 15, 25, 12, 21, 17, 14, 19, 4, 6, 5

BVI was reported with a death rate of 8% that was directly attributable to the arterial trauma in Biffl's series.3 However, other series also seem to suggest that BVI has relatively fewer serious consequences compared to BCI.26, 11, 16, 27

Biffl et al.4 have published an important series, comprising a 9-year study. Their incidence of blunt carotid injury (BCI) was 0.38% overall, with incidence rising to 1.07% during the screening phase of 2.5 years. They also found an incidence of 0.53% for blunt vertebral injury (BVI) over a 3-year period. Miller et al.19 found incidence of 0.33% and 0.5% for BCI during two different study periods. A number of trauma patients at our institution, manifesting unexplained neurological deficits and being subsequently diagnosed with BCVI, prompted us to undertake this study.

Section snippets

Methods

The Alfred Hospital is the level one trauma centre serving the state of Victoria, Australia. The hospital's health information system, medical records, as well as the Department of Neurosurgery's database were searched to retrospectively identify patients with BCVI over the period between 1st of January 2003 and 31st of December 2006. The diagnosis was based on imaging (CT angiography, MR angiography or formal digital subtraction angiography) in all cases. These had been performed based on

Results

10,417 patients were admitted to The Alfred hospital over the 4-year study period. 67 patients (0.64%) were diagnosed as having BCVI. Of these, 33 had carotid and 34 had vertebral artery injuries. Thirteen had bilateral injuries, of which eight were bilateral carotid, and five were bilateral vertebral artery injuries. None had both carotid and vertebral artery injuries.

The median age was 32 years in the BCVI group as opposed to 39 years in the trauma patients without BCVI. The difference was

Discussion

There are varied reported figures in the literature for incidence of BCVI. We found an incidence of 0.64% at our centre, whereas other series quote figures between 0.08% and 0.50% without screening protocols.19, 20, 10 This rate can rise up to 2.5% with screening.22 It is therefore likely that a lack of screening protocols in the past has resulted in BCVI being an under-reported phenomenon.

MVA remains the most common cause of BCVI contributing to 70% of our cases. This concurs with reported

Conclusion

In conclusion, BCVI is an often under-diagnosed injury with potentially devastating consequences, despite its relative infrequency. MVA still remains the most common cause. Glasgow coma score is not a predictor of the severity of injury; lower grades of injury tend to progress and the risk of stroke concurrently increases. Certain patterns of injury and clinical signs raise the suspicion of BCVI and produce a high yield when applied in screening protocols, as evidenced by the literature.

Our

Conflict of interest statement

The authors have no conflicts of interest to declare.

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