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Traumatic Cerebrovascular Injury
Surjith Vattoth, MD, FRCR
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Abbreviations

                • Traumatic cerebrovascular injury (TCVI)
              • Definitions

                • TCVI is defined as extracranial or intracranial cerebrovascular structural defect caused by known injury to head, neck, &/or chest
                  • Blunt or penetrating TCVI, as per mechanism of injury
                • Defects solitary or multiple, 1 or more patterns of injury
                  • Classification scheme (types 1-5) devised using DSA
                • Dissection: Intramural hematoma extends along vessel wall
                • Intimal extension: Intimal flap, true & false lumen
                • Traumatic aneurysm is more precise & is preferable term
                  • True aneurysm/dissecting aneurysm: Elastic lamina disruption with preservation & stretching of adventitia
                    • Hematoma between media/adventitia common
                  • False aneurysm/pseudoaneurysm: Complete disruption of arterial wall; lumen contained only by thrombus outside vessel wall
                  • Mixed-type aneurysm: Initially starts as true aneurysm, later ruptures → contained hematoma & false aneurysm

              IMAGING

              • General Features

                • CT Findings

                  • MR Findings

                    • Angiographic Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              • Microscopic Features

                                • TCVI vs. Low-Energy Spontaneous Dissection

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Tunthanathip T et al: Traumatic cerebrovascular injury: prevalence and risk factors. Am J Emerg Med. ePub, 2019
                                              2. Griffin RL et al: Aspirin for primary prevention of stroke in traumatic cerebrovascular injury: association with increased risk of transfusion. J Neurosurg. 1-8, 2018
                                              3. Rajpal G et al: Management of intracranial arterial dissection. Neurol India. 66(1):40-2, 2018
                                              4. Foreman PM et al: Blunt traumatic extracranial cerebrovascular injury and ischemic stroke. Cerebrovasc Dis Extra. 7(1):72-83, 2017
                                              5. Kobata H: Diagnosis and treatment of traumatic cerebrovascular injury: pitfalls in the management of neurotrauma. Neurol Med Chir (Tokyo). 57(8):410-7, 2017
                                              6. Bhaisora KS et al: Traumatic aneurysms of the intracranial and cervical vessels: a review. Neurol India. 64 Suppl:S14-23, 2016
                                              7. Kansagra AP et al: Current trends in endovascular management of traumatic cerebrovascular injury. J Neurointerv Surg. 6(1):47-50, 2014
                                              8. Prasad V et al: Pipeline endovascular reconstruction of traumatic dissecting aneurysms of the intracranial internal carotid artery. J Neurointerv Surg. 6(10):e48, 2014
                                              9. Ro A et al: Pathomorphological differentiation between traumatic rupture and nontraumatic arterial dissection of the intracranial vertebral artery. Leg Med (Tokyo). 16(3):121-7, 2014
                                              10. Portanova A et al: Intracranial vasa vasorum: insights and implications for imaging. Radiology. 267(3):667-79, 2013
                                              11. Rahme RJ et al: Spontaneous cervical and cerebral arterial dissections: diagnosis and management. Neuroimaging Clin N Am. 23(4):661-71, 2013
                                              12. Cohen JE et al: Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections. J Trauma Acute Care Surg. 72(1):216-21, 2012
                                              13. Santos-Franco JA et al: Dissecting aneurysms of the vertebrobasilar system. a comprehensive review on natural history and treatment options. Neurosurg Rev. 31(2):131-40; discussion 140, 2008
                                              14. Chen CJ et al: Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol. 25(5):769-74, 2004
                                              15. O'Sullivan RM et al: Supraclinoid carotid artery dissection following unusual trauma. AJNR Am J Neuroradiol. 11(6):1150-2, 1990
                                              16. Deck JH: Pathology of spontaneous dissection of intracranial arteries. Can J Neurol Sci. 14(1):88-91, 1987
                                              17. Wilkinson IM: The vertebral artery. extracranial and intracranial structure. Arch Neurol. 27(5):392-6, 1972
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        • Diagnostic Checklist

                                                          TERMINOLOGY

                                                          • Abbreviations

                                                            • Traumatic cerebrovascular injury (TCVI)
                                                          • Definitions

                                                            • TCVI is defined as extracranial or intracranial cerebrovascular structural defect caused by known injury to head, neck, &/or chest
                                                              • Blunt or penetrating TCVI, as per mechanism of injury
                                                            • Defects solitary or multiple, 1 or more patterns of injury
                                                              • Classification scheme (types 1-5) devised using DSA
                                                            • Dissection: Intramural hematoma extends along vessel wall
                                                            • Intimal extension: Intimal flap, true & false lumen
                                                            • Traumatic aneurysm is more precise & is preferable term
                                                              • True aneurysm/dissecting aneurysm: Elastic lamina disruption with preservation & stretching of adventitia
                                                                • Hematoma between media/adventitia common
                                                              • False aneurysm/pseudoaneurysm: Complete disruption of arterial wall; lumen contained only by thrombus outside vessel wall
                                                              • Mixed-type aneurysm: Initially starts as true aneurysm, later ruptures → contained hematoma & false aneurysm

                                                          IMAGING

                                                          • General Features

                                                            • CT Findings

                                                              • MR Findings

                                                                • Angiographic Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Staging, Grading, & Classification

                                                                          • Microscopic Features

                                                                            • TCVI vs. Low-Energy Spontaneous Dissection

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Image Interpretation Pearls

                                                                                          Selected References

                                                                                          1. Tunthanathip T et al: Traumatic cerebrovascular injury: prevalence and risk factors. Am J Emerg Med. ePub, 2019
                                                                                          2. Griffin RL et al: Aspirin for primary prevention of stroke in traumatic cerebrovascular injury: association with increased risk of transfusion. J Neurosurg. 1-8, 2018
                                                                                          3. Rajpal G et al: Management of intracranial arterial dissection. Neurol India. 66(1):40-2, 2018
                                                                                          4. Foreman PM et al: Blunt traumatic extracranial cerebrovascular injury and ischemic stroke. Cerebrovasc Dis Extra. 7(1):72-83, 2017
                                                                                          5. Kobata H: Diagnosis and treatment of traumatic cerebrovascular injury: pitfalls in the management of neurotrauma. Neurol Med Chir (Tokyo). 57(8):410-7, 2017
                                                                                          6. Bhaisora KS et al: Traumatic aneurysms of the intracranial and cervical vessels: a review. Neurol India. 64 Suppl:S14-23, 2016
                                                                                          7. Kansagra AP et al: Current trends in endovascular management of traumatic cerebrovascular injury. J Neurointerv Surg. 6(1):47-50, 2014
                                                                                          8. Prasad V et al: Pipeline endovascular reconstruction of traumatic dissecting aneurysms of the intracranial internal carotid artery. J Neurointerv Surg. 6(10):e48, 2014
                                                                                          9. Ro A et al: Pathomorphological differentiation between traumatic rupture and nontraumatic arterial dissection of the intracranial vertebral artery. Leg Med (Tokyo). 16(3):121-7, 2014
                                                                                          10. Portanova A et al: Intracranial vasa vasorum: insights and implications for imaging. Radiology. 267(3):667-79, 2013
                                                                                          11. Rahme RJ et al: Spontaneous cervical and cerebral arterial dissections: diagnosis and management. Neuroimaging Clin N Am. 23(4):661-71, 2013
                                                                                          12. Cohen JE et al: Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections. J Trauma Acute Care Surg. 72(1):216-21, 2012
                                                                                          13. Santos-Franco JA et al: Dissecting aneurysms of the vertebrobasilar system. a comprehensive review on natural history and treatment options. Neurosurg Rev. 31(2):131-40; discussion 140, 2008
                                                                                          14. Chen CJ et al: Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol. 25(5):769-74, 2004
                                                                                          15. O'Sullivan RM et al: Supraclinoid carotid artery dissection following unusual trauma. AJNR Am J Neuroradiol. 11(6):1150-2, 1990
                                                                                          16. Deck JH: Pathology of spontaneous dissection of intracranial arteries. Can J Neurol Sci. 14(1):88-91, 1987
                                                                                          17. Wilkinson IM: The vertebral artery. extracranial and intracranial structure. Arch Neurol. 27(5):392-6, 1972