American Association for the Surgery of Trauma—World Society of Emergency Surgery Guidelines on the diagnosis and management of cervical vascular injuries

Cervical vascular injuries comprise 10% of all vascular trauma, equally affecting adult and pediatric patients. Approximately 65% occur after penetrating trauma and 35% after blunt trauma.1,2 Untreated, blunt cerebrovascular injury (BCVI) results in stroke in up to 20% of patients, causing devastating neurologic consequences.3,4 In one multicenter study, 37% of strokes were present on initial evaluation; the rest occurred at a median of 48 hours after admission.5 This underscores the importance of adopting evidence-based screening protocols for blunt trauma patients for expeditious assessment of at-risk patients and early initiation of antithrombotic therapy (AT). Arterial injury occurs in up to 25% of penetrating neck trauma and has a mortality rate of up to 20% due to stroke and hemorrhage.6,7 Rapid assessment, bleeding control, and restoration of cerebrovascular blood flow are critical to minimize morbidity and mortality. The purpose of this article is to provide the American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) recommendations for the diagnosis and management of cervical vascular injuries (CVI). METHODS A computerized search of different databases (MEDLINE, EMBASE, COCHRANE) was performed. Citations were included for the period between January 2013 and September 2024 using the primary search strategy: trauma, traumatic, blunt, penetrating, blood vessel, vascular injury, supraclavicular, cervical, neck, carotid artery, vertebral artery, internal carotid artery, external carotid artery, internal jugular vein, external jugular vein, injury, surgery, diagnosis, operative, nonoperative, endovascular management, anticoagulant, antiplatelet, blunt cerebrovascular injury, BCVI, stent, combined with and/or as well as the MeSH terms: carotid artery Injuries, cerebrovascular trauma, vascular system injuries, vertebral artery dissection, endovascular procedures, neck injuries, cervical injuries. No search restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conferences, comparative studies, congresses, guidelines, government publications, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials. Selected older articles were also included as landmark papers in the field. Three authors independently reviewed abstracts chosen for relevance, and any discrepancy between reviewers was settled after discussion. The level of evidence was evaluated using a modified form of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system (Table 1).8 A group of experts in the field, coordinated by a central coordinator, was contacted to express their evidence-based opinion on several issues about cervical vascular trauma. Based on the evidence available, the central coordinator assembled the different answers derived from a round of discussion and created a set of recommendations. The recommendations were submitted for comments multiple times using an online modified Delphi process until complete consensus was achieved. The definitive version reported herein represents the position of the expert group from both the AAST and the WSES. An Executive Summary of the guidelines can be found in Supplemental Digital Content https://links.lww.com/TA/E997 as well as a list of abbreviations used in this manuscript https://links.lww.com/TA/E998. TABLE 1 - Modified System for GoR8 GoR Clarity of Risks/Benefit Quality of Supporting Evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses or imprecise conclusions) or exceptionally strong evidence from observational studies Strong recommendation, applies to most patients in most circumstances without reservation 1C Strong recommendation, low-quality or very low-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but subject to change when higher quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values 2C Weak recommendation, low-quality or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendation; alternative treatments may be equally reasonable and merit consideration GoR, Grading of Recommendations. TABLE 2 - Signs of Cervical Vascular Injury Hard Signs Soft Signs Active hemorrhage Venous oozing Expanding hematoma Nonexpanding hematoma Bruit or thrill in area of injury Dysphonia Shock unresponsive to fluids Dysphagia Massive hemoptysis or hematemesis Minor hemoptysis Air bubbling through the injury site Subcutaneous emphysema Evolving stroke Massive subcutaneous emphysema RESULTS Epidemiology What is the incidence of vascular injury in blunt neck trauma? What are the most common mechanisms of injury? Statement: Blunt cerebrovascular injury is reported as infrequent (1–3%), but it is likely underdiagnosed unless broad screening protocols are used. Stroke is the most devastating sequelae occurring in about 12% of carotid and 7% of vertebral artery injuries. The most common mechanisms causing blunt cerebrovascular injury are motor vehicle accidents and falls. The incidence of BCVI is approximately 1% to 3% of trauma patients, but the rate of detection depends on institutional screening protocols.9–12 The vertebral artery is more commonly injured than the carotid but has a lower risk of stroke, likely due to collateral flow through the Circle of Willis.13,14 In one large multicenter study, 53% of BCVIs involved the vertebral artery (VA), and 47% involved the internal carotid artery (ICA). Stroke was more common in injuries to the ICA, occurring in 11.7% of injuries compared with 6.7% of injuries to the VA.14 It is not uncommon for a patient to have more than one vessel injured.15–17 Motor vehicle accidents are the most common injury mechanism, accounting for half of BCVI cases.14,18 Other common causes include falls (18%), motorcycle collisions (10%), and pedestrians struck by motor vehicles (10%).14 Less common mechanisms of injury include assaults, bicycle accidents, skiing accidents, and hanging attempts.19–22 What is the incidence of vascular injury in penetrating neck trauma? Statement: Injuries to the carotid and vertebral artery occur in approximately 25% of patients sustaining a penetrating neck Injury. The presence of associated aerodigestive injuries is common and must be investigated. GOR 1C The common and internal carotid arteries are injured in 6% to 20% of cases of penetrating neck trauma and carry a mortality rate of up to 20%. Concomitant vascular injuries to the internal jugular (25%), external carotid (6%), and vertebral artery (6%) are common.23 In the United States, two-thirds of penetrating cervical vascular injuries occur after gunshot wounds (GSWs) and the other third after stab wounds, while in South Africa, stab wounds are more common.7,23 In combat-related trauma, shrapnel from explosive devices is a significant source of injury.24,25 Importantly, penetrating injuries to the vessels in the neck are commonly associated with injuries to the aerodigestive tracts.7,23,26 Clinical Presentation, Initial Assessment, and Diagnosis What is the optimal approach for the initial evaluation of a patient with suspected cervical vascular injury? Statement: Blunt trauma patients without a clear indication for an emergent operation should be broadly screened for vascular injury with computed tomography angiography (CTA) to decrease the incidence of stroke. In penetrating trauma without hard signs of vascular injury (see Table 2), CTA is indicated. Other diagnostic modalities, such as airway and digestive endoscopy and an esophagogram, may also be needed. GOR 1B The initial evaluation is the same as with any trauma patient and begins with the assessment of airway, breathing, and circulation. Vascular access should be established quickly to allow for immediate resuscitation and transfusions if needed. Identification of immediate life-threatening associated injuries, such as tension pneumo/hemothorax or cardiac tamponade, is critical. In blunt injuries, there should be a high suspicion of concomitant traumatic brain injury (TBI), and a careful neurological examination is warranted. In penetrating injuries, careful examination should identify all external wounds to assess for potential concomitant injuries to the thorax, abdomen, or extremities. Adjunct imaging with a chest x-ray (CXR) with or without Extended Focused Assessment with Sonography in Trauma (eFAST) should be performed to assist with identifying associated injuries.27 Patients with clear indications for operative intervention (Table 2) should be immediately taken to the operating room. In penetrating neck trauma, patients with soft signs (Table 2) should undergo screening, whereas those without hard or soft signs of injury may forgo imaging and undergo only close observation.28,29 Various screening criteria have been proposed for BCVI, although most are based on the Denver or Memphis criteria with variation across institutions (Table 3). The Eastern Association for the Surgery of Trauma (EAST) recommends adopting a screening protocol to improve detection and reduce the risk of stroke.9,10,30,31 Protocols are centered on the physical examination and the presence of specific concomitant injuries that increase the risk of BCVI. Direct signs or symptoms of BCVI are uncommon. The most common findings in patients with BCVI are cervical spine injuries and traumatic brain injury (TBI).32 BCVI is present in 9% of patients with severe TBI.33 Other important associated injuries include upper rib fractures, mandibular, midface, and skull base fractures, thoracic vascular injuries, and cervical soft tissue injuries, such as a seatbelt sign or ligature marks from hanging.10,30,31 TABLE 3 - Screening Criteria for BCVI* Denver Criteria Memphis Criteria Signs/symptoms of BCVI Unexplained neurologic deficit Arterial hemorrhage or expanding hematoma Horner's syndrome Cervical bruit in patient