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98
10 Injuries oftheNeck
10.2 Blunt andPenetrating
Injuries totheNeck
Blunt and penetrating neck injuries (PNI) have
been reported to comprise 5–10% of all trauma
cases (Meisel and Hom 1998). The fact that multiple vital structures are located in a small anatomic area and are not protected from bone makes
all penetrating wounds potentially dangerous
(Fig. 10.4). The in-hospital mortality rate in a
large patient series from South Africa (n=510)
was reported to be 2% (Madsen et al. 2016a).
Forner etal. (2021) reported that the crude mortality rate was lower in those sustaining blunt
neck injuries compared to penetrating injuries
(4.9% vs. 6.0%, p<0.01). Patients with gunshot
wounds have a worse outcome than those with
neck injuries secondary to stab wounds (Madsen
etal. 2016b).
The vital structures of the neck can be divided
into ve groups: the air passages (larynx, pharynx, trachea, lung); vascular (carotid, jugular,
subclavian); gastrointestinal (pharynx, esophagus); neurologic (brachial plexus, peripheral
nerves, cranial nerves); and solid organs (thyroid,
submandibular gland). The patient can present a
variety of signs and symptoms (Table 10.1),
which should alert the clinician that injury to any
of the above structures has occurred. Hard signs
occur in less than 10% of patients with
PNI.However, they are highly specic for serious injury, with a positive predictive value of
almost 90% for a vascular or aerodigestive tract
injury (Simpson etal. 2021). These injuries are
particularly difcult to manage in the resourcepoor, often austere and/or remote, prehospital
Fig. 10.4 Penetrating wound of the anterior neck. Injury
to vital cervical structures is probable
Table 10.1 Signs and symptoms of penetrating neck
trauma
Diagnosis Signs and symptoms
Laryngotracheal injury Subcutaneous emphysema
Airway obstruction
Sucking wound
Hemoptysis
Dyspnea, respiratory
distress
Stridor
Cyanosis
Hoarseness or dysphonia
Vascular injury Shock
Hemorrhage
Hematoma
Pulse decit
Neurologic decit
Bruit or thrill in neck
Pharynx/esophagus
injury
Subcutaneous emphysema
Hematemesis
Dysphagia or odynophagia
Subcutaneous crepitance
Retropharyngeal air
environment. To this day, there exists no consensus statement or agreed guidelines regarding the
prehospital management of these injuries
(Simpson etal. 2021). In a recent paper, Simpson
etal. (2021) reviewed the relevant literature and
proposed a management algorithm based on the
commonly used cABCD (catastrophic hemorrhage, Airway, Breathing, Circulation,
Disability). Control of c (gauze, packing), A (airway establishment on an individual basis performing rapid sequence intubation), B
(ventilation, mindful of chest complications), C
(circulatory resuscitation), and D prevention
(avoidance of cervical spine immobilization in all
cases of PNI unless there is evidence of severe
focal neurological decit or altered mental status) form the basis of this algorithm, from which
the authors plan to investigate a Delphi process to
develop a consensus statement on the prehospital
management of PNI.
As soon as a patient with a neck injury comes
to the accident and emergency department, rapid
assessment of the airway, breathing, and circulation is essential. Adherence to Advanced
Trauma Life Support (ATLS) principles is fun-
10.3 Injuries totheAir Passages
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damental with an emphasis on early assessment
of the airway (Shilston et al. 2021). Isolated
blunt trauma to the neck is unlikely to cause signicant hemorrhage. However, with overt symptoms and/or signs, immediate resuscitation and
an emergency operation are appropriate
(Feliciano 2015). Adequate venous access
should be secured, and blood should immediately be sent for crossmatch, coagulation prole, and full blood count. Physiological evidence
of hypovolemic shock should prompt activation
of the major hemorrhage protocol, resuscitation
with appropriate blood products, and treatment
with tranexamic acid (Shilston et al. 2021).
Sterile gauze and digital pressure should be
applied to any neck wound with ongoing bleeding. If this fails to achieve hemostasis, a Foley
catheter (20FG) can be used to stem the bleeding (Shilston etal. 2021).
Once the patient is stabilized, a secondary survey is carried out checking for external injuries,
nerve injuries (sympathetic chain, brachial
plexus), subcutaneous emphysema, and hoarseness (Varghese 2013; Shilston etal. 2021).
99
Fig. 10.5 Penetrating injury to the left lateral neck. A
vascular injury is probable
10.3 Injuries totheAir Passages
Penetrating laryngotracheal injuries are uncommon (Fig. 10.5). They represented ca 10% of
neck trauma cases examined during a 5-year
period at a level I trauma center (Cussack etal.
1986). Their incidence is estimated 1 per 5000 to
13,700 emergency room visits (de Mello-Filho
and Carrau 2000). However, these injuries are
associated with signicant morbidity and mortality (Grewal etal. 1995; Akhtar and Awan 2008;
Randall etal. 2014). The presence of respiratory
distress and hemoptysis is suggestive of a major
injury (Grewal et al. 1995; Akhtar and Awan
2008). In a series of 57 patients, the majority of
injuries were to the trachea (33–58%). Twentyfour patients (42%) had an injury to the larynx
(Grewal etal. 1995). In another study, the majority of injuries (>80%) were located in the cervical
airway, ca one-fth (18%) in the thoracic airway,
and a very small percentage (2%) in both (Madani
etal. 2016) (Fig.10.6).
Fig. 10.6 Deep penetrating laceration to the anterior part
of the neck of a 41-year-old male patient. The injury
extends to the upper chest (left side) and lateral neck
(right side). There was suspicion of a laryngotracheal
injury
The respiratory rate and signs of airway compromise, including dyspnea and stridor
(Table10.2), require immediate assessment, and
if necessary an endotracheal intubation or a tracheostomy should be established. In cases of
laryngotracheal separation, prompt airway control via routine intubation or emergency tracheostomy is of lifesaving importance (O’Neill
et al. 2009; Reeve et al. 2021). Patients with
penetrating neck injuries represent a heterogenous group; therefore, the airway management
should be based on the individual clinical sce-
100
10 Injuries oftheNeck
Table 10.2 Hard vs. soft neck injury signs
Hard signs Soft signs
Airway compromise Subcutaneous
emphysema
Air bubbling wound Dysphagia, dyspnea
Expanding or pulsatile
hematoma
Active bleeding Venous oozing
Shock, compromised
radial pulse
Hematemesis Minor hematemesis
Neurological decit/
paralysis/cerebral
ischemia
Neck thrill/bruit Stridor
Non-pulsatile, non-
expanding hematoma
Chest tube air leak
Paresthesia
Hoarseness
Unexplained bradycardia
without CNS injury
Tracheal deviation
nario (Tallon etal. 2007; Schaefer 2014; Herrera
et al. 2020). Awake ber-optic intubation, tracheostomy under local anesthetic, inhalation
induction anesthesia, and high-ow nasal oxygen are the options in a cooperative patient. A
exible ber-optic bronchoscope preloaded
with a snugly tting tracheal tube can be introduced through the glottis, facilitating direct
visualization of distal injuries. The well-lubricated tracheal tube can then be cautiously railroaded over the ber-optic scope, ensuring that
the cuff is inated distal to any injuries (Shilston
etal. 2021). Applying positive- pressure ventilation before securing a tracheal tube distal to the
injury should be avoided if possible. If bagmask ventilation is required, because of signicant hypoxia before placement of a tracheal
tube, minimizing of airway pressures as much
as possible is recommended (Shilston et al.
2021). Furthermore, patients should be assessed
for the presence of life-threatening thoracic
injury related to the neck trauma itself or independent of the neck injury. Any such lifethreatening injuries should be managed
according to the ATLS primary survey principle
(Shilston etal. 2021).
Vocal quality should be examined, and the
patient should be asked about changes in voice
(hoarseness or dysphonia; Table 10.1). The lar-
ynx and trachea should be palpated for tenderness and crepitus, and the neck and upper chest
should be palpated for subcutaneous emphysema.
Endoscopy and CT scan are done and will aid in
the differentiation between the patients who need
only observation and those who need an operative procedure (Lupetin etal. 1998; Meisel and
that Gonzalez etal. (2003), based on the results
of a prospective blinded study, concluded that
dynamic CT contributes minimally to the sensitivity of physical examination in the diagnosis of
surgically signicant penetrating zone II neck
injury.
Laryngeal injuries are classied by location
(supraglottic, transglottic, cricoid, or tracheal)
and type (hematoma, mucosal tears or lacerations, cartilage fractures and/or dislocations, or
laryngotracheal disruption). Trone and Schaefer
(1980) and later Fuhrman etal. (1990) proposed
the following classication of laryngotracheal
injury:
1. Minor endotracheal hematoma without
detectable fracture
2. Edema, hematoma, minor mucosal disruption
without exposed cartilage, nondisplaced fracture noted on CT scan
3. Massive edema, mucosal tears, exposed carti-
lage, cord immobility
4. A group III with more than two fracture lines
or massive trauma to the laryngeal mucosa
5. Complete laryngotracheal separation
With the advancement of diagnostic imaging
and endoscopy, modications to the original
Schaefer classication combine clinical presentation and diagnostic ndings from computed
tomography (CT) and endoscopy to guide management (Verschueren etal. 2006).
Small lacerations, shallow lacerations, and
nondisplaced fractures usually need only observation. These represented roughly 2/3 (64.3%) in
a series of 56 patients, from the Massachusetts
Eye and Ear, the results of which were recently
published (Wang etal. 2022). Conservative treatment of group I and II injuries was reported to be
100% effective (Bent etal. 1993). Mucosal tears
10.3 Injuries totheAir Passages
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101
require approximation. A soft laryngeal stent
may be needed for badly macerated mucosa
(Meisel and Hom 1998; Schaefer 2014). Simple
tracheal lacerations that do not detach a tracheal
ring or encroach on the airway can be repaired
without a tracheostomy (Meisel and Hom 1998).
More severe disruptions imply more extensive
soft-tissue injury, and a 6-week tracheostomy
either below or through the tracheal injury is considered to be the safest procedure (Meisel and
Hom 1998). Later, the stenosis may require
sleeve resection.
Optimal repair of a laryngeal fracture should
restore the primary functions of the larynx (protection of the lower respiratory tract, airway,
and voice). There is lack of consensus as to the
optimal method of repair. Simple xation using
sutures, stainless wire, or wire-tube batten xation has been used by various authors. De
Mello- Filho and Carrau (2000) have used adaptation plate xation to xate laryngeal fractures
with good results. The authors considered plate
xation superior to the other methods because
stability of the laryngeal skeleton is immediate
and three-dimensional; furthermore, plates (or
mesh) can be used to bridge large defects.
Surgical management of the 19 surgically
treated patients included open reduction internal xation (n=13) or open reduction internal
xation and suspension microlaryngoscopy
(n=6) (Wang etal. 2022). Earlier experimental
studies in a rabbit model had shown similar
results (Dray et al. 1999). Comminuted fractures will probably require endolaryngeal stenting (Schaefer 2014). In cases of tracheal
injuries, prompt intubation below the site of the
injury and early laryngo- or bronchoscopic
examination have been recommended (Rieth
etal. 2021). A primary anastomosis is required
with minimal resection during an urgent intervention. A better outcome is to be expected
when extubation is done early after surgery
(Rieth etal. 2021).
Grewal et al. (1995) reported two early
deaths in a group of 57 patients (3.5%) with
penetrating laryngotracheal injury, due to associated major vascular injury. Randall et al.
(2014), in a recent publication, reported the
results of a review of 89 patients (equating to
1/1042 admissions and 1/2478 emergency presentations) with laryngotracheal injuries from
Canada. Nineteen percent of injuries were
severe (Schaefer-Fuhrman score ≥4). Airway
intervention was performed at presentation in
65% of patients, with 13.5% necessitating emergent surgical airway; 52% underwent investigative or interventional airway surgery. Nine
patients (16%) had long-term moderate or
severe dysphonia; 14.5% had dysphagia. Odds
ratio for death and long-term dysphonia among
severe, compared to minor laryngotracheal injuries, were 7.1 (95% CI = 1.4–35.4) and 17.2
(95% CI=3.3–91.1), respectively. Delayed surgical intervention was associated with poor
results (Akhtar and Awan 2008).
Laryngotracheal injury is a rare occurrence in
the pediatric population. The low incidence is
mainly attributed to anatomical differences
between the adult and pediatric airway (Merritt
et al. 1998). Despite its infrequency, pediatric
anterior neck trauma poses considerable clinical
challenges and can have signicant morbidity.
Immediate evaluation with appropriate diagnostic imaging and endoscopy is indicated
(McCormick etal. 2014). Closed fracture of the
larynx and trachea was reported to be the most
common primary diagnosis (McCormick et al.
2014). In a series of 106 young patients, 60.2%
underwent a major operative procedure during
hospitalization (laryngoscopy and other tracheoscopy, operative repair of the larynx/trachea,
and tracheostomy). Thirty-seven patients
required mechanical ventilation (McCormick
etal. 2014). Cheng etal. (2017) conducted a literature search on blunt pediatric laryngotracheal
trauma and identied 66 children with a majority
of males and an average age of 9.5± 4.4 years
(range 2–17). CT was employed in 66.7% of
cases (false negative in 29.5% of cases).
Treatment consisted of observation (9.1%),
endoscopy alone (31.8%), endoscopic repair
(7.6%), and open neck exploration with repair/
open reduction internal xation (51.5%).
Tracheotomy was utilized in 33.3% of the cases.
Mortality was rare, with only one (1.5%)
reported (Cheng etal. 2017).
102
10 Injuries oftheNeck
10.4 Vascular Injuries
Vascular injuries are the most common injuries
associated with penetrating neck trauma. They
are estimated to occur in up to 40% of patients
(Bagheri etal. 2008). Arterial injuries seem to be
the most frequent vascular injuries (26.7%), as
was reported in a study from 14 level I and II
American College of Surgeons-veried centers.
Major venous injuries occurred in ca 20% of
these patients (DuBose et al. 2015). Of arterial
injuries, 80% involve the carotid vessels and up
to 43% involve the vertebral arteries (Ofah and
Hall 2012). Lee etal. (2014) reported that penetrating carotid artery injury occurs in 4.9–6% of
penetrating trauma. Blunt external carotid artery
injury seems to be present in approximately 1%
of all blunt trauma cases (Bif etal. 1998).
The mortality of penetrating neck injuries
(PNI) reported currently by most civilian centers
is 3–6% (Brennan etal. 1990). The leading cause
of death is hemorrhage from vascular structures,
but also complicating neurological decits as a
result of stroke (Ofah and Hall 2012). In a study
by Stone and Callahan (1963), vascular injuries
in the neck accounted for 50% of deaths.
However, not all vascular injuries are lethal.
Differentiation into two basic presentations,
depending on whether or not the injury is immediately life threatening, is crucial. The signs of
immediate life-threatening injuries include massive bleeding, expanding hematoma, nonexpanding hematoma in the presence of
hemodynamic instability, hemomediastinum,
hemothorax, and hypovolemic shock (Table10.2).
In all of the above situations, immediate surgical
exploration is mandatory. On the other hand,
hemodynamically stable patients who present
with nonlife-threatening features can undergo
thorough investigations to determine the extent
of the injury and the necessity of surgical
intervention.
The traditional classication of neck injuries
proposed by Monson et al. (1969) and later by
Roon and Christiansen (1979) uses an anatomic
description of zones I through III (Fig. 10.7).
Zone I is below the cricoid and represents a dangerous area because of the close proximity of the
vessels to the thorax. The bony thorax and clavicle on the one hand protect zone I from injury; on
a b
Zone 3
Zone 2
Zone 1
Fig. 10.7 (a) Schematic representation of the neck showing zones I–III. (b) CT angiography showing zones I–III
10.4 Vascular Injuries
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103
the other hand, however, they make surgical
exploration of the root of the neck difcult. Zone
I has a fairly high mortality rate (12.12%; Rao
etal. 1983).
Zone III is located above the angle of the mandible. This area, too, is protected by skeletal
structures and is difcult to explore because of
the skull base and the mandible. Due to the close
proximity of cranial nerves (VII, IX, X, XI, and
XII) to vessels in this area, an abnormal neurologic examination may be indicative of injury to
the great vessels. For zone III injuries, frequent
intraoral examination should be performed to
observe for edema or expanding hematoma
within the parapharyngeal or retropharyngeal
spaces.
Zone II injuries are the most frequently occurring (47–75%, Table 10.3) (Demetriades et al.
1997; Cruvinet Neto and Dedivitis 2011). In zone
II, isolated venous injuries and isolated pharyngoesophageal injuries are the most common
structures missed clinically in the preoperative
evaluation (Meisel and Hom 1998).
Low etal. (2014) investigated the association
between external wounds and corresponding
internal injuries after PNI to identify the clinical
use of the anatomic zones of the neck. In total,
146 patients sustaining a PNI were analyzed.
Thirty-seven (25%) patients had a total of 50
internal injuries. There was a high incidence of
noncorrelation between the location of the external injury and the internal structures that were
damaged in patients with hard signs of vascular
or aerodigestive injury. Therefore, the authors
concluded that the use of anatomical zones and
their role in the workup of penetrating neck injury
are questionable (Low etal. 2014). Madsen etal.
(2020), in a more recent study on the same subject, reached the same conclusion, as in 41% of
patients (122/298), there was no correlation
Table 10.3 Neck zones; frequency of injuries
Zone I 18%
Zone II 47%
Zone III 19%
More than one zone 16%
From Demetriades D, Theodorou D 1997, World J Surg
21: 41–7
between the site of the internal injury and the
external wound or the correlation could not be
determined. These authors stated that an approach
to PNI based on zones is questionable, and this
study supports a no-zone approach based on
imaging guided by clinical examination (Madsen
etal. 2020). Nevertheless, Ofah and Hall (2012)
still favor the use of such a descriptive classication to assist the treating trauma surgeon and recommend familiarity with the classication by
any reporting radiologist. Other authors favor a
classication by compartment (retropharyngeal,
parapharyngeal, submandibular, etc.), considering it more relevant than the classication by anatomical zone, especially in cases of an expanding
hematoma (de Regloix etal. 2016; Shuker 2016).
A proportion of patients with penetrating neck
injury will require immediate surgical intervention without radiological assessment; current
indications for such an immediate intervention,
as already mentioned, include patients with an
expanding hematoma, hemorrhagic exsanguination, shock, airway compromise, and massive
subcutaneous emphysema (Demetriades et al.
1997; Bagheri etal. 2008).
Hemodynamically stable patients can be
assessed with CT angiography (multi-detector
CTA), magnetic resonance angiography (MRA),
conventional angiography, and Doppler ultrasonography, depending on the resource prole of a
given center. CTA should be the rst-line investigation for all patients with suspected vascular
trauma and no indication for immediate operative
intervention, as was reported by Patterson etal.
(2012), who conducted a systematic literature
review relating to radiological diagnosis of vascular trauma over the past decade (2000–2010).
A more recent literature review (2000–2017)
conducted by Ibraheem et al. (2020) also concluded that CTA demonstrated a reliable high
sensitivity (83–100%) and specicity (61–100%)
for detecting injuries in penetrating neck trauma
in stable patients with soft signs of injury and
select patients with hard signs of injury. Digital
subtraction angiography (DSA) offers the clinician the ability to denitively rule out the presence of blunt carotid injury (BCI) and can also
permit intervention via endovascular techniques
104
10 Injuries oftheNeck
when indicated. However, it is an invasive method
with a complication rate of approximately 1%, it
is resource intensive, and it is not readily available at many hospitals. Several authors recommend the use of CTA followed by DSA (Lee
etal. 2014).
CTA allows detection of direct and indirect
signs of vascular injury not only in zone II but
also in zone I and zone III; it has been shown to
signicantly reduce the number of surgical neck
explorations (Ofah and Hall 2012). A comprehensive physical examination, combined with
CTA, is adequate for triage to effectively identify
or exclude vascular and aerodigestive injury after
penetrating neck trauma (Demetriades et al.
1997; Burgess et al. 2012; Shiroff et al. 2013;
Texeira et al. 2016; Hundersmarck et al. 2019;
Ibraheem et al. 2020). In a large series of 203
patients with PNI from Cape Town, a vascular
injury was identied in 27 (13.3%) patients and
only 25 (12.3%) required surgical intervention.
One hundred fty-eight (77.8%) patients, either
asymptomatic or with negative workup, were
managed expectantly (Thoma etal. 2008). CTA
is considered by experienced authors as the denitive vascular imaging modality for penetrating
neck injury (Madsen etal. 2018a, b).
Patients with active bleeding are more likely
to have a vessel laceration; an expanding hematoma is often associated with a false aneurysm
and a pulsatile mass with an arteriovenous stula
(Ssenyonga etal. 2015). There was a statistical
correlation between the presenting clinical feature and the underlying angiographic lesion
(Ssenyonga etal. 2015).
Routine surgical exploration of the neck leads
to a large number of negative explorations and
potential iatrogenic injury. As mentioned before,
the routine use of CTA has led to an increased
number of patients being managed expectantly.
Selective nonoperative management (SNOM) of
PNI is gaining favor (Thoma et al. 2008; Van
Waes etal. 2012; Madsen etal. 2016a). A stabilizing measure that has been reported to be useful in
hemodynamically unstable patients involves the
placement of a Foley catheter balloon tamponade
(FCBT), followed by CTA and other ancillary
testing to guide the use of operative management
(Van Waes etal. 2012). The use of an FCBT seems
to be more effective than the traditional use of
external pressure. It signicantly reduces mortality through its effect on preventing delayed bleeding. In some centers, it has been advocated as a
denitive treatment of venous injuries (Ball etal.
2011). In a large series (311 patients from Groote
Schuur Hospital in Cape Town, South Africa), 47
patients (15.1%) required FCBT. The authors
(Scriba etal. 2017) noticed an increasing use of
FCBT for PNI compared to an older study from
the same hospital (Thoma etal. 2008).
Carotid artery injuries are the most common
and also pose one of the most immediate lifethreatening situations. Surgical care aims at
arresting hemorrhage, yet maintaining cerebral
blood ow and preserving neurologic function.
Arteriography, vein patch, or segmental repair
with an autologous reversed saphenous vein graft
can be performed to repair the injury. The presence of neurologic decits, coma, and shock,
especially preoperatively, are poor prognostic
signs but are not absolute contraindications for
carotid artery repair. Carotid ligation has signicantly higher morbidity and mortality rates. It is
advocated in comatose patients with no evidence
of antegrade ow in the internal carotid artery. It
can also be considered in cases of an uncontrollable hemorrhage, when a temporary shunt is
technically difcult.
Vertebral artery injuries have been diagnosed
with increasing frequency. The treatment of
choice in the well-perfused patient is expectant
management. Surgical intervention is indicated if
a pseudoaneurysm, an arteriovenous stula, or
persistent bleeding is documented. Surgical
repair can be performed, but if the circle of Willis
is patent, ligation is an option. Angiographic
embolization has advantages for this difcult-toaccess artery, but distal control is still a problem.
Jugular vein repair depends on the condition
of the patient. Repair can be performed by simple
venography, resection, and reanastomosis, or
saphenous vein reconstruction, particularly of the
internal jugular vein (IJV). Repair of one side is
imperative in cases of bilateral IJV injury. The
external jugular vein can be ligated without
adverse effects.
10.4 Vascular Injuries
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105
In a study from Alabama, USA, Simmons
etal. (2012) retrospectively reviewed 25 patients
with vascular injuries to the neck treated at a
level I trauma center. There were 13 carotid artery
injuries, ve internal jugular vein injuries, and 13
external jugular vein injuries. Of the carotid injuries, six (50%) underwent operative repair (four
primary repairs, two bypasses), ve (38%) were
managed nonoperatively, and one was treated by
endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale
(GLS) score. Four of the venous injuries were
repaired, and the remaining 13 were ligated. A
much larger patient rate was successfully managed conservatively, as reported in two other
reports from South Africa. A total of 401 (79%)
and 158 (77.8%) were managed expectantly by
Madsen etal. (2016a) and Thoma etal. (2008),
respectively. Only ve (1.2%) patients in the
series of Madsen et al. (2016a) failed a trial of
selective nonoperative management and required
surgery. The in-hospital mortality rate has been
reported to be 17% in an earlier report (Ramadan
et al. 1995), whereas in the recent study of
Madsen etal. (2016a), it was reported to be 2%.
Penetrating neck injuries (PNI) are infrequent
in the pediatric population. Most patients presented with minor physical examination ndings
and did not require exploration or diagnostic
studies. In a retrospective study from Florida,
25% of patients underwent surgical exploration
for platysma penetration (Abujamra and Joseph
2003). A total of three patients (9%) died, all of
which had major physical examination ndings
(Abujamra and Joseph 2003). The mortality rate
was similar (7%) to that reported earlier by
Mutabagani etal. (1995). Observation of the stable child has been found to be an acceptable
choice of management of PNI (Abujamra and
Joseph 2003). Mandatory exploration of the neck
in children should not be performed unless clinically indicated (Mutabagani etal. 1995; Vick and
Islam 2008). Currently, management of penetrating neck trauma in children includes selective
neck exploration based on physical examination
and use of computed tomography angiography
(CTA) in stable patients, similar to current adult
recommendations (Tessler etal. 2017).
Patients presenting with coma or shock have a
particularly bad prognosis, with a mortality rate
reaching 50% and 41%, respectively (Ramadan
etal. 1995). Zone II had the highest mortality, but
was also the most commonly affected area,
whereas zone I was associated with the highest
morbidity in survivors, as was reported by Breeze
etal. (2012), who analyzed all hospital and postmortem records of all UK servicemen sustaining
battle injuries to the neck.
10.4.1 Blunt Extracranial Carotid
Injuries
Blunt trauma of the extracranial carotid (blunt
carotid injury, BCI) is less frequently encountered
than penetrating trauma. In the 61 patients with
carotid trauma reviewed by Ssenyonga et al.
(2015), the mechanism of injury was blunt in nine
(14.8%) patients and penetrating in 52 (85.2%).
BCI patients may present with an ischemic event
(transient ischemic attack (TIA), stroke) at the
time of initial examination. The onset of ischemic
events can range from a few minutes to 31days
after injury with the majority (82%) occurring
within the rst 7 days (Lee et al. 2014). Other
associated presenting signs and symptoms include
ipsilateral headache (58–92%), Horner syndrome
(9–75%), neck pain (18–46%), bruit (12–39%),
and tinnitus (13%) (Biousse etal. 1995; Lee etal.
2014). Patients who presented with only localized
symptoms (neck pain, Horner, tinnitus) developed
TIA (30%) and stroke (43%). Patients who presented with TIA developed stroke 6h to 31days
after injury. The total stroke rate was 52% despite
antithrombotic treatment in the series by Biousse
et al. (1995). The majority of ischemic strokes
appear to be embolic in nature (Scheid etal. 2006).
It is widely accepted that early, aggressive
medical therapy can reduce the incidence of ischemic events (Cothren etal. 2004). Nonetheless,
despite medical intervention, Bif etal. (1999a,
b) demonstrated that BCI can progress in severity.
In light of rapid progression of blunt carotid
injury, there are a large number of clinicians who
advocate for early screening in select trauma
patients (Lee etal. 2014).
106
10 Injuries oftheNeck
Patients who present with signs and symptoms
highly suspicious for BCI should undergo immediate screening to denitively rule out vascular
injury. The indicators include arterial bleeding
from the neck, nose, or mouth; cervical bruit;
expanding cervical hematoma; focal neurologic
decits (TIA, hemiparesis, vertebrobasilar symptoms, Horner syndrome); stroke identied on CT
or MRI; and neurologic ndings inconsistent
with head CT. Furthermore, patients presenting
with risk factors associated with blunt cerebrovascular injuries (Le Fort II/III fractures, skull
base fractures, occipital condyle fractures, carotid
canal fractures, cervical spine injuries, anoxic
brain injuries from hanging, a clothesline-type
injury, or a seat belt sign) should be screened
(Burlew etal. 2012).
Four imaging modalities have been used to
investigate BCI in the literature: CTA, magnetic
resonance angiography (MRA), conventional
angiography (DSA), and Doppler ultrasonography. Most authors advocate the use of CTA as an
initial screening method. DSA offers the clinician the ability to denitively rule out the presence of BCI and can also permit intervention via
endovascular techniques when indicated.
Therefore, several authors recommend the use of
CTA followed by DSA (Lee etal. 2014).
Goals of BCI treatment include minimizing
the progression of vessel injury, decreasing the
incidence of ischemic events in asymptomatic
patients, and improving overall neurologic and
survival outcomes. In the literature, there appears
to be a growing consensus for using antiplatelet
or anticoagulant agents for Bif Grade I and II
lesions (Table 10.4) with greater agreement on
the use of concurrent anticoagulant therapy due
to lower rates of CVA in the rst 6months postdischarge (Hanna et al. 2020; Catapano et al.
2020). Grade III injuries and higher are managed
by endovascular intervention. Simple observation is no longer recommended (Lee etal. 2014).
Both heparin and antiplatelet therapies appear
equally effective in minimizing the risk of stroke
in asymptomatic patients and improving neurologic outcomes in symptomatic patients (Colella
and Diamond 1996; Wahl et al. 2002; Cothren
etal. 2004). In a prospective, observational study
by Cothren etal. (2004), 19% of asymptomatic
BCI patients who were observed developed ischemic neurologic events, while no patients in the
anticoagulation group developed an ischemic
event. Several retrospective case series reported
similar efcacy and safety proles with heparin
or antiplatelet drugs (325 mg aspirin daily or
75mg clopidogrel daily) (Colella and Diamond
1996; Wahl et al. 2002; Cothren et al. 2004).
When using heparin, aggressive anticoagulation
is not recommended. A partial thromboplastin
time (PTT) of 40–50 is recommended and should
be achieved without using an initial bolus
(Bromberg etal. 2010). This protocol was found
to be well tolerated with a low (4%) rate of bleeding complications (Bif etal. 2002). In contrast,
more aggressive anticoagulation therapy with
higher PTT of 60–80, in conjunction with a
70unit/kg heparin bolus, demonstrated a signicantly higher rate of bleeding complications
(43%; Bif et al. 2002). Scott et al. (2015a)
recently reported the results of a 10-year retrospective review of 100 patients with Grade I and
II BCIs. After a grade mean follow-up of 60days,
nal radiographic imaging demonstrated that
64% of cases had resolved, 13% were radiographically stable, 9% were improved, whereas
14% worsened. Sixty-nine percent of patients
had received acetylsalicylic acid (ASA) or other
medication. There was one cerebral infarction
(1%). In another report by the same authors
(Scott etal. 2015b), the results of 44 patients with
Grade III and ve patients with Grade IV BCIs
(followed for 113days and 78days, respectively)
were as follows: 11% had resolved, 53% were
radiographically stable, 11% were improved, and
25% had radiographically worsened. Eighty percent of patients had received ASA or other medication. There were three (7%) and one (20%)
cases of cerebral infarction in Grade III and IV
patients, respectively. Regarding Grades I and II,
the authors concluded that the use of ASA or
other antiplatelet or anticoagulant medications
did not appear to correlate with radiographic
injury stability, nor with a decreased rate of cerebral infarction (Scott etal. 2015a, b).
Several retrospective case series on endovas-
cular intervention report success with treating
10.4 Vascular Injuries
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Table 10.4 Classication of blunt extracranial carotid injury and associated rates of stroke and mortality (adopted
from Bif etal., J Trauma, 47: 845–53, 1999)
Grade Distribution (%) Stroke rate (%) Mortality rate (%)
I Luminal irregularity with
<25% luminal narrowing
II
III Pseudoaneurysm 23.7 33 11
IV Occlusion 11.8 44 22
V Vessel transection 5.2 100 100
≥25% luminal narrowing
intraluminal thrombus, or
raised intimal ap
47.3 3 11
11.8 11 11
107
traumatic carotid injuries with low complications
(Lee etal. 2014). Pham etal. (2011) analyzed the
safety and efcacy of endovascular intervention
in a meta-analysis. The authors identied 153 ext.
carotid artery injuries in 140 patients who were
treated with endovascular techniques. Of the 153
carotid injuries, 48% were traumatic in origin.
The technical success rate was 99% (152/153).
The most commonly used stents were wall stents
followed by SMART stents. Out of 61, 60 (98.4%)
vessels of pseudoaneurysm (hematoma in communication with the true vessel lumen through a
vessel wall defect that transverses all three tissue
layers) cases were either successfully stented or
occluded when appropriate. Only 2 of the 138
patients with a mean follow- up of 17.7 months
(1–72 months) developed neurologic sequelae,
consisting of TIAs, one at 2.7 months and the
other at 12months following the procedure. All
other patients demonstrated either unchanged or
improved neurologic status. Procedural complications were seen in 2 of the 153 vessels (1.3%)
(Pham et al. 2011). Another meta-analysis of
endovascular management of a combination of
blunt (77%) and penetrating (23%) int. carotid
artery injuries involving 113 patients identied
successful stent placement in 76.1% of cases,
with stent patency achieved in 79.6%. New postoperative neurologic decits occurred in 3.5%
with one observed mortality (99.1% survival)
(DuBose et al. 2008). Blitzer et al. (2020) suggested that, if possible, intervention should be
delayed for at least 24 h. This was based on an
increased mortality for early intervention (early
16% vs. delayed 6.3%; p< 0.0001), which was
predominantly driven by the endovascular cohort
(early 19.2% vs. delayed 2.5%; p<0.001) (9190
patients studied, 812 of whom underwent operative intervention; open=288, endovascular=481,
both=43) (Blitzer etal. 2020).
Grade IV lesions (Table 10.4) pose a challenge for the endovascular technique and may be
complemented by open surgical intervention.
Passing a catheter in a Grade IV lesion (total vessel occlusion) may be technically impossible.
Cohen etal. (2012) reported successful endovascular reconstruction of critically stenotic (>90%)
or occluded (Grade IV) traumatic internal carotid
lesions in 16 patients with the use of coaxial
microcatheters and soft-tip micro-guide wires to
navigate across dissected segments, identifying
the true vessel lumen. In the occluded traumatized ICA, these authors used a delayed doublecontrast road map and ap fenestration to achieve
recanalization (Cohen etal. 2012).
Blunt carotid injuries Grade V with vessel
transection and frame extravasation are highly
lethal, with a mortality rate approaching 100%.
They require immediate surgical intervention
whenever possible. Due to rare survival of these
patients, there is limited clinical data. The
urgency of adequate surgical management of
Grade V BCI mirrors that of penetrating carotid
injuries.
10.4.2 Penetrating Extracranial
Carotid Injuries
Penetrating carotid artery injury can be highly
lethal if left untreated, approaching a mortality
rate of 100% (Lee etal. 2014). Penetrating inju-
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