Blunt Injuries to the Carotid and Vertebral Arteries

Robert Dragon, MD, New Britain, Connecticut
Harry Saranchak,

MD, New Britain, Connecticut

Paul Lakin, MD, New Britain, Connecticut
Gerald Strauch,

MD, New Britain, Connecticut

Although blunt injuries to the carotid and vertebral
arteries
are relatively
rare, they produce
major
morbidity
and, in perhaps as many as 40 percent of
the cases reported, permanent
neurologic deficit that
precludes gainful employment
[I]. No more than 130
cases of blunt carotid injury and 40 cases of vertebral
injury have been reported in the English literature
since 1952 [I-101. All reports, however, indicate that
the possibility
of injury to these vessels should be
considered in any patient who, after a latent interval
following injury, whether severe or minor, begins to
develop neurologic signs or symptoms. If investigated
and treated
aggressively,
permanent
neurologic
deficit or even mortality
may be avoided. Our experience with the following patients
serves to underscore the problems
associated
with diagnosis
and
management
of these lesions.
Case Reports
Case I. A 24 year old white man was admitted to another

institution after an auto accident with a primary complaint
of pain in the right side of the chest. Initial radiography
revealed pneumothorax and an undisplaced fracture of the
right first rib. The pneumothorax was treated with tube
thoracostomy, and the patient remained stable for the first
8 hours after the accident. Left hemiparesis then developed. Angiography showed occlusion of the right carotid
artery, which was interpreted as an artifact. Cranial perforator openings were made without improvement in the
neurologic status. The patient was transferred to our institution 10 days after the accident, and the carotid artery
was explored on the 14th day. Attempts at thrombectomy
were unsuccessful,
and the patient
paresis 10 years after the injury.

has persistent

hemi-

Case II. A 45 year old white woman experienced
a brief
flashing light in the left eye 2 days before admission.
On
hemiparesis
followed by difficulty with speech. Examination revealed a harsh left cervical bruit. Angiography
revealed a typical “string sign” indicative of carotid arterial
dissection
(Figure 1). The patient underwent
successful
exploration
and repair. She related that 2 days before
From the Depanments of Surgery and Radiology, New Britain General
Hospital, New Britain, Connecticut.
Requests for reprints should be addressed to Gerald Strauch. MD, New
Britain General Hosoital. New Britain. Connecticut 06050.
Presented at the Sk Annual Meeting of the New England Surgical Society,
Portsmouth, New Hampshire, September 26-28, 1980.

Volume 141, April 1981

hospitalization,
she had undergone chiropractic
manipulation and had had severe pain in the left side of the neck.
She has no neurologic deficit today.
Case III. A 21 year old woman was involved in an auto
accident and was thought to have incurred a left cervical
injury on the steering wheel of the vehicle. The patient was
neurologically
intact of the scene of the accident, but after
45 minutes of observation,
aphasia, paralysis in the right
arm and paresis developed in the right, leg. Angiography
done immediately
revealed
an apparent
5 mm pseudoaneurysm
with an intimal flap above the aneurysm in
the left internal carotid artery (Figure 2). Exploration
disclosed that the artery contained intraluminal
clot and
had been disrupted longitudinally
as well as transversely.
The disrupted
vessel was excised and a vein graft. interposed (Figure 3). Although improvement
was slow in the
immediate
postoperative
period, the patient has had excellent recovery of function over the past 14 months, and
the deficits are detectable
only with exhaustive
testing.
Case IV. A 14 year old boy was admitted to the hospital
after being struck by an automobile.
He complained
only
of discomfort
in the back. Clinical, laboratory
and radiologic examinations
revealed no evidence of serious injury.
He was discharged from the hospital after several days, in
good condition and with no neurologic signs or symptoms.
Two and one-half weeks after injury, he was brought to the
hospital dead after collapsing at home. Autopsy revealed
that the cause of death was delayed hemorrhage from
disruption of the left carotid artery in the neck. A massive
hematoma extended from the neck into the mediastinum,
where rupture into the right pleural cavity had occurred.
Case V. A 35 year old man flexed his neck suddenly
while scolding his son and felt something snap on the right
side of the neck. He felt weak, experienced diplopia and lost
his equilibrium.
One hour later he had a severe occipital
headache, weakness in the right arm and leg and impaired
swallowing. Angiography
suggested dissection of the right
vertebral artery (Figure 4). His condition stabilized while
he was under observation,
and he underwent
anticoagulation. He became asymptomatic
after a few days. Angiography 1 month later revealed the vessel to be normal
(Figure 5). He has no neurologic deficit at present.

Comments
Ninety percent of carotid injuries reported in the
literature
were caused by penetrating
injuries
[2].
Most vertebral
artery injuries, on the other hand,

497

Dragon et al

appear to be secondary
to blunt trauma [7]. About
60 percent of blunt carotid injuries are caused by
motor vehicle accidents. Direct blows and falls each
account for 15 percent of cases [l-6]. In most cases,
the injury to this vessel occurs in the area extending
from the common carotid bifurcation
to the skull
[1,5]. The mechanisms
of injury as outlined
by
Crissey and Bernstein
[8] are direct blows to the
vessel, hyperextension
and rotation, blunt intraoral
trauma and basilar skull fracture.
It appears that
hyperextension
and rotation
are by far the most
significant
modes of injury to the vertebral
arteries
[7,11]. Although produced by major traumatic events
such as motor vehicle accidents,
vertebral
arterial
occlusion or spasm has been documented
after chiropractic
manipulation,
Yoga exercises and other
mild traumatic events such as that in our fifth patient

events, impaired
perfusion
or abrupt cessation
of
perfusion.
Several clinical features aid in the recognition
of
such an injury. A bruit may be present in as many as
20 to 30 percent of cases. While some patients may
have a cervical hematoma,
50 percent of patients in
collected series had no objective evidence of cervical
injury. Horner’s syndrome,
present because of asso-

[71.
The angiographic
findings of arterial injury range
from slight irregularity
secondary to an intimal flap,
to more significant
dissections
associated
with the
string sign, as seen in our second and fifth patients
[12], to total occlusion of the vessel as seen in patient
I. Very severe injury to the vessels can produce
complete severance followed by false aneurysm
formation, as noted in patient III. The neurologic
defects observed can be attributed
to thromboembolic

Figure 2. Case Ill. Carotid angiogram reveailng a false aneurysm
of the Internal carotid artery with lntimal flaps above the aneurysm.

Figure 1. Case II. Subtraction views of the carotid artery with the
“string sign” of the internal carotid artery lndkatlve ot dissect/on.

Flgm, 3. Case Ill. Carotid ahry
graft.

after tspair

wllh interposition vein

The American Journal 01 Surgery

Blunt Injuries to Carotid and Vertebral Arteries

ciated injury to cervical sympathetic
ganglia, is
helpful in diagnosis if present. Ninety percent of
patients characteristically
display a lucid interval of
1 or more hours before the onset of neurologic deficits, whether transient ischemic attacks or stroke
[1,2,5]. Some injuries to the carotid arteries were not
detected at the time of insult and presented much
later as stenotic lesions or aneurysms producing
transient ischemic attacks [13].
These injuries do not always occur as isolated
events. They are frequently associated with other
injuries, and they can be difficult to distinguish from
intracranial injuries. Fortunately,
most of the patients are alert rather than obtunded on presentation.
Intracranial injury can be ruled out quickly and effectively with computed tomographic scanning. With
an obvious deficit and normal findings on computed
tomographic scanning, angiography is then indicated
to rule our significant cervical vascular injury.
Three basic methods of therapy have been described in the literature: anticoagulation, ligation of
the injured vessel and repair of the vessel. All three
methods have provided acceptable results. Our fifth
patient, for example, responded well to anticoagulation, which is the method advocated by some [14].
However, in patients with a large central neurologic
deficit or a large cervical hematoma, the hazard of
producing further hemorrhage is apparent. Ligation,
the first surgical approach used for carotid arterial
injury, is an acceptable means of controlling an ex-

panding hematoma in a hemodynamically unstable
patient with a large central deficit. The results of ligation with minimal deficit are far inferior to reconstruction.
Reconstruction,
whether by simple tacking of an
intimal flap, by reentry procedures for more complicated dissections [12], or by resection and grafting
of severely injured vessels, appears to yield the best
results in patients with transient ischemic attacks or
mild neurologic deficits [1,2]. Coma has ominous
prognostic significance when seen after injury. In one
collected series only 21 percent of comatose patients
left the hospital alive and well. That same analysis
of reported cases tends to support reconstruction
even in patients with severe central deficits, such as
our third patient [2]. The risk of producing hemorrhagic cerebral infarction must be appreciated in
these patients but may be less of a problem than reported in the earlier literature [4]. Most reported
deaths were caused by stroke or associated injuries.
We were unable to find another death similar to that
of our fourth patient.

Ftgure 4. Case V. Subtract&n fftm of “string stgn” veriebrat artery
suggestive of dlssectfon.

Figure 5. Case V. Anglogram of the same vertebral artery as In
Figure 4, 7 month later.

Volume 141, April 1991

Summary
A small series of patients with blunt injury to either a carotid or vertebral artery is presented. In
three patients the injury was recognized relatively
promptly. Two underwent surgery and one was observed with reasonably good results. In two patients
the injury was unrecognized, resulting in death in one
patient and in a severe, fixed, long-term neurologic
deficit in the other. It appears likely that recon-

499

Dragon et al

struction
may be the treatment
of choice in any patient
with angiographically
proven
injury
unless
coma or severe dense hemiplegia
is present.

References
1. Krajewski LP, Hertzer NR. Blunt carotid artery trauma: report
of two cases and review of the literature. Ann Surg 1980;
191:341-6.
2. Unger SW, Tucker WS Jr, Mrdeza MA, et al. Carotid arterial
trauma. Surgery 1980;87:477-87.
3. Hoffman TH, Richardson JD, Flint LM. lntimal disruption of major
cerebral vasculature
following blunt trauma. Surgery
1980;87:441-4.
4. Ledgerwood AM, Mullins RJ, Lucas CE. Primary repair versus
ligation for carotid artery injuries. Arch Surg 1980;115:
488-93.
5. Yamada S, Kindt GW, Youmans JR. ‘Carotid artery occlusion
due to nonpentrating injury. J Trauma 1967;7:333-42.
6. Rubio PA, Reul 61, Beall AC Jr, et al. Acute carotid injury:
twenty-five years’ experience. J Trauma 1974;14:96773.
7. Heros RC. Cerebellar infarction resulting from traumatic occlusion of a vertebral artery. J Neurosurg 1979;51:11 l-3.
8. Crissey MM, Bernstein EF. Delayed presentation of carotid intimal tear following blunt craniocervical trauma. Surgery
1974;75:543-9.
9. Davidson KC, Werford EC, Dixon GD. Traumatic veretebral
artery pseudoaneurysm following chiropractic manipulation.
Radiology 1975;115:651-2.
10. Avellanosa AM, Glasauer FE, Young OH. Traumatic vertebral
arteriovenous fistula associated with cervical spine fracture.
J Trauma 1977; 17:885-8.
11. Okasawa S, Nibblelink D. Vertebral artery occlusion following
hyperextension and rotation of the head. Stroke 1974;5:
640-2.
12. Ojemann RG, Fisher CM, Rich JC. Spontaneous dissecting
aneurysm of the internal carotid artery. Stroke 1972;3:
434-40.
13. Busuttil RW, Davidson RK, Foley KT, et al. Selective management of extracranial carotid arterial aneurysms. Am J Surg
1980;140:85-91.
14. Towne JB, Neiss DD, Smith JW. Thrombosis of the internal
carotid artery following blunt cervical trauma. Arch Surg
1972;104:565-8.

Discussion
John Davis (Burlington,
VT): I have personally
seen
only two cases of blunt trauma to the carotid artery, but
I think they substantiate
the authors’ major point. One
injury was a hematoma
that occurred after an auto accident. Because of its large size, exploration
was considered
mandatory.
Carotid arteriography
showed a tear in the
carotid artery, and repair was undertaken. This patient had
no neurologic deficit, and he might have done alright if
nothing had been done. I think he would have developed
a false aneurysm and needed surgery later, but he probably
would have survived without neurologic deficit.
The second case was probably a karate chop; some kind
of bare hand hit the side of the neck. The patient had some
slurring of speech. He was also inebriated,
making examination difficult. A house officer suggested that we perform
carotid arteriography,
which demonstrated
an intimal flap
that was then repaired. Again, the patient had no neuro-

500

logic deficit and probably would not have because I think
Sir Astley Cooper showed many years ago that in most
persons one can ligate a carotid artery without neurologic
deficit.
The situation is such that every surgeon is and should
be an angiographer.
I am concerned when surgeons will not
attempt to evaluate arteries by this method. In few hospitals can angiography
be performed
immediately
by the
radiologist. The surgeon can perform it immediately on the
operating table by placing the needle in the artery, injecting
dye and taking one or more pictures using a portable
roentgenographic
unit. I believe we should perform reconstruction
in all patients, based on the fact that many
of them will have associated head injures, particularly those
in auto accidents.
One cannot afford the possibility that
failure to improve the circulation
may be detrimental.
It is rare that a patient’s carotid artery cannot be repaired at the time of surgical intervention
for other injuries.
The neck incision and repair of the carotid artery carry a
very low morbidity and mortality. I think one should repair
the artery at that time. I do not know whether it will affect
the outcome, but I do not think there is any way to determine that in advance in most of these patients. My view is
that repair should be performed,
and unless it is a very
unusual situation it will not add to the morbidity
or the
mortality.
Anthony
S. Patton (Salem, MA): The extracranial
vessels may be the cause of what appears to be an intracranial problem. We had a similar experience
some years
ago. A 30 year old man who was left-handed
entered with
severe blunt chest trauma and seemed to be on the way to
recovery. He initially had a normal aortic arch study and
was stable without a respirator. Ten days later, he suddenly
had left hemiparesis
and stopped breathing.
Emergency
angiography
showed an occlusion to the right internal carotid artery. Operation disclosed the artery to be severely
damaged and the intima embolized into the distal stump.
This was removed, with great trepidation,
with a Fogarty
catheter, and the patient awoke immediately.
A vein graft
was needed for reconstruction,
and the patient eventually
did well. There was no evidence of any neck injury. I hope
more such cases will be recognized
and successfully
treated.
John B. Ballou (Salem, MA): The fifth case in which
the irate father scolded his son and had a thrombosis of the,
vertebral artery represents
a form of blunt trauma to the
vertebral arteries from just turning the neck. I would like
to bring to the Society’s attention
another case that just
occurred within the past week. An elderly women recovering from a bowel resection woke up with quadriplegia.
We found subluxation
of the third of fourth cervical vertebra, which we felt had been incurred by hyperextension
of the neck at the time of intubation
for anesthesia.
Robert Dragon (closing): I would like to thank Dr.
Davis for his comments and can only concur with him that
any injured patient who, after a latent interval, develops
any neurologic signs or symptoms should undergo immediate angiography.

The American Journal ol Surgery