Carotid Artery Injuries in Traumatic Brain Injury

One of the most dangerous health issues in the world is traumatic brain injury (TBI), which is frequently brought on by falls, assaults, car crashes, or damage from sports. Trauma can harm the blood arteries supplying the brain, however the immediate worry is typically brain parenchymal injury (such as contusions, haemorrhages, or diffuse axonal injury). Because they can result in strokes, ischaemia, and even potentially fatal consequences, carotid artery injuries are the most serious of them. In the context of TBI, it is critical to identify, diagnose, and treat carotid artery damage in order to avoid detrimental neurological effects.

Carotid Artery Injuries: What Are They?

The main blood vessels in the neck that provide the brain with oxygen-rich blood are the carotid arteries. A carotid artery injury occurs when trauma damages the carotid artery wall. The extracranial or intracranial sections of the artery may sustain this damage, which might manifest in several ways:

• Intimal tears (damage to the artery’s innermost layer)
• Blood entering the artery wall and separating its layers is known as a dissection.
• False aneurysms caused by partial disruption of the vessel wall are known as pseudoeurysms.
• Thrombosis or occlusions (total obstruction of the artery)
• Abnormal connections between arteries and veins are known as arteriovenous fistulas.

Carotid Artery Injury Mechanisms in Traumatic Brain Injury

Although penetrating trauma can also cause carotid artery damage, blunt head or neck trauma is typically linked to them. Among the mechanisms are:

• Injuries from rapid deceleration, which are frequent in traffic accidents
• Neck rotation, hyperextension, or hyperflexion
• Fractures of the basilar skull that affect the carotid canal
• Direct hits to the jaw, neck, or face
• Penetrating wounds (such as gunshot or stabbing wounds)

The forces involved in severe TBI can strain or shear the carotid artery, resulting in modest but deadly vascular damage even in the absence of outward symptoms.

Clinical Display

Because the original brain injury may hide or delay the symptoms, carotid artery injuries frequently go unrecognised at first.

However, important clinical characteristics consist of:

• Neurological deficiencies (such as abrupt weakness, trouble speaking, or abnormalities in vision) that cannot be explained by brain imaging
• Following trauma, transient ischaemic attacks (TIAs) or delayed stroke
• Expanding haematoma in the neck
• Palsies of the cranial nerves, particularly the lower cranial nerves
• Massive epistaxis (when a skull base fracture occurs together with a carotid injury)

Carotid damage frequently doesn’t show up until days after the initial trauma, when the patient has a stroke.

Making a diagnosis

It’s critical to identify carotid artery damage early. Among the diagnostic instruments are:

• One of the most popular non-invasive, quick screening methods is CT angiography (CTA).
• MR Angiography (MRA): Beneficial for radiation-free follow-up and assessment.
• The gold standard for diagnosis is digital subtraction angiography (DSA), particularly if endovascular therapy is being considered.
• Duplex Ultrasound: Limited in cases of polytrauma, but helpful in certain extracranial injuries.

High-risk patients, those with severe facial fractures, cervical spine fractures, skull base fractures, or unexplained neurological findings-are identified with the aid of screening regimens like the Denver Criteria.

Classes for Carotid Artery Damage

The BIFFL classification is frequently used to grade carotid artery injuries:

• Grade I: Intimal irregularity with contraction of less than 25%
• Grade II: Intramural haematoma or dissection with more than 25% narrowing
• Grade III: Pseudoaneurysm
• Grade IV: Blockage
• Grade V: Extravasation and transection

  

This categorisation aids in directing therapeutic approaches.

Managment

The patient’s neurological condition, related injuries, and the extent (grade) of the injury all influence the course of treatment.

1. Health Care Administration

• For Grade I–II injuries, anticoagulation (heparin/warfarin) or antiplatelet medication (aspirin) is frequently used to avoid clot development and stroke.
• Anticoagulation choices are carefully weighed against the risk of cerebral haemorrhage in cases involving polytrauma or neurosurgery.

2. Treatment using Endovascular

• Inaccessible injuries, dissections, and pseudoaneurysms can all be treated with stenting or coiling.
• Because endovascular procedures are minimally invasive, they have emerged as the method of choice in many situations.

3. Surgical Fixing

• Penetrating injuries or excessive bleeding may necessitate an open surgical repair or bypass.
• Grafting, patch angioplasty, or direct vascular repair may be taken into consideration.

4. Neurocritical and Supportive Care

• Keeping an eye out for ischemic stroke
• Keeping the TBI patients’ cerebral perfusion pressure at its ideal level
• Multidisciplinary care involving interventional radiologists, trauma surgeons, and neurosurgeons

The outlook

The following factors determine how carotid artery damage turns out:

• Severity and grade of vascular injury
• The timing of the diagnosis and treatment
• The degree of related traumatic brain damage
• Ischaemic stroke presents before therapy

Neurological prognosis and survival are greatly enhanced by early identification and therapy. A delayed diagnosis frequently leads to death or irreversible disability.

Important Lessons for Patients and Families

• A dangerous but frequently unnoticed side effect of severe brain injury is carotid artery damage.
• Strokes can be avoided and recovery can be enhanced with early detection and treatment.
• To rule out vascular problems, doctors may advise specialised imaging if your loved one has experienced serious head or neck trauma.
• The best results are obtained through a multidisciplinary strategy that includes interventional radiologists, trauma specialists, and neurosurgeons.

In conclusion

A crucial point of interaction between vascular and neurological trauma is carotid artery damage in traumatic brain injury patients. Even though they are rare, missing them increases the risk of morbidity and death. Detection and treatment have significantly improved thanks to developments in imaging and endovascular therapy. For trauma doctors and neurosurgeons, keeping a high index of suspicion is essential to prompt diagnosis and life-saving treatment.

Sources:

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC5994847/
2. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0045-1809619.pdf
3. https://www.sciencedirect.com/science/article/pii/S2210261223010209
4. https://pubmed.ncbi.nlm.nih.gov/3806201/
5. https://www.sciencedirect.com/science/article/pii/S0741521495702431
6. https://ajronline.org/doi/10.2214/ajr.184.5.01841672#sec-4