Cerebrovascular Injuries


Background

  1. Traumatic insults can lead to several vascular complications

Cavernous sinus thrombosis

  • May be due to trauma or secondary infection
    • Veins afferent to cavernous sinus drain many areas
      • Anterior face, oral cavity
      • Tonsils, pharynx, nasal cavity
      • Orbit, eye, paranasal sinuses
      • Middle ear, mastoid region
      • Cerebral cortex, pituitary
    • All eventually drain to internal jugular vein
  • Pathophysiology
    • Vessel walls are injured by trauma
    • Infection can enter area
      • Often by some form of trauma
      • Most frequent organism
        • S. aureus (92%)
        • Also S. pneumonia, S. pyogenes, pseudomonas, anaerobes
        • Peds: H. Flu, pneumococcus, other streptococci
    • Clots form due to endothelial damage
       
  • Symptoms
    • Nonspecific symptom
      • HA, fever, malaise
    • Eyes
      • Painful, red eye
      • Bloody chemosis
      • Exophthalmos
      • Ophthalmoplegia
        • 3, 4, 5 & 6th nerve palsies
        • Thrombosis of facial veins
      • May or may not have vision changes
        • Increased retrobulbar pressure
      • Pupils sluggish/fixed
        • Dilated (CN III parasympathetic)
        • Small & fixed (internal carotid sympathetic plexus)
      • Loss of corneal reflex (CN V)
    • Edema
      • Eyelid & bridge of nose
      • Overlying mastoid
      • Possible pharyngeal & tonsillar edema
         
  • Imaging
    • MRI is modality of choice
       
  • Treatment
    • Antibiotic treatment (gram positive & negative anaerobes)
      • Third generation cephalosporin PLUS
        • Nafcillin 2g IV q4h OR
        • Oxacillin 2 g IV q4h +
      • Consider substituting: Vancomycin
      • Unasyn
      • Chloramphenicol
      • Consider antifungals in immunocompromised pts
    • Anticoagulant
      • Heparin
        • Prevents extension & prevent septic emboli
    • Thrombolytic therapy
    • Corticosteroids
      • Especially in severe cases
    • Hypothermia to control fever & protect eye
       
  • Disposition
    • Admit to ICU

 

Carotid Cavernous Fistula

  1. Abnormal communications between carotid arterial system and venous cavernous sinus
  2. Pathophysiology
    • Traumatic - intracavernous portion of artery is torn
    • Spontaneous - usually from ruptured aneurysm
    • 4 angiographic types
      • Type A - (direct)
        • Direct communication between the internal carotid artery and cavernous sinus
      • Types B, C, D - (indirect)
        • Dural shunts
        • Fistulas to the cavernous sinus arise from dural arteries
  3. Symptoms (Direct CCFs)
    • History of closed head injury
      • Days or weeks before symptoms
    • Acute, sudden pain
    • "Classic triad"
      • Chemosis
      • Ocular bruit
      • Pulsating exophthalmos
        • Dilated ophthalmic veins
        • Swelling in orbit
    • Proptosis
    • Loss of vision / diplopia
  4. Imaging
    • CT or MRI are modalities of choice
  5. Treatment
    • Requires neurosurgery consult
    • Balloon embolization

 

Internal carotid aneurysm

  • Ophthalmic symptoms are presenting complaint in 50% of patients
  • Most dissections have at least some traumatic component

Symptoms

  • Pain
    • Unremitting pain
    • May localize
      • Head, Face
      • Eye
      • Jaw, Neck
  • Horner's syndrome (58%)
  • Transient monocular blindness
  • Photophobia
  • Possible meningismus
  • CN palsies
    • Lower cranial nerves
      • Tongue weakness
      • Dysarthria, dysphagia
      • Unpleasant metallic taste
    • Ocular motor palsies are rare

Imaging

  • MRI / MRA
  • Carotid doppler ultrasound
  • CT with contrast
  • Angiogram

Treatment

  • Neurosurgery consult
  • Admission
  • Treatment modalities
    • Bed rest and anticoagulation
    • Endovascular procedures
    • Surgical repair

 

Horner's syndrome

  • Group of symptoms seen when sympathetic innervation to eye is interrupted
    • Miosis, ptosis & anhydrosis
       

Pathophysiology

  • Interruption of 3-neuron sympathetic path
  • Causes
    • Lesion of the primary neuron
    • Brainstem stroke / tumor of preganglionic neuron
    • Brachial plexus trauma
    • Apex of lung tumors / infection
    • Lesion of postganglionic neuron
    • Dissecting carotid aneurysm
    • Carotid artery ischemia
    • Migraine headache
    • Middle cranial fossa neoplasm
       

Symptoms

  • Inability to completely open affected eye
    • May not sweat on same side of the face
  • Hemisensory loss
  • Dysarthria, dysphagia
  • Ataxia, vertigo, nystagmus
  • Pain
    • Face, neck
    • Axilla, shoulder, arm
    • Cough, hemoptysis
  • Facial flushing (harlequin effect)
    • Patients with preganglionic lesions
    • May occur when exercising
  • Ipsilateral orbit pain / migraine-like headache
    • Patients with postganglionic lesions
  • Ipsilateral head / neck / face pain
    • Carotid dissection
       

Diagnostic Tests

  • CXR
    • Lung tumors
  • Head CT
  • MRI / MRA of brain
    • Carotid dissection
       

Treatment

  • Care depends on etiology
  • Best course is to find cause, refer appropriately
    • Neurosurgery (dissections, tumors)
    • Surg/ pulmonary / Oncology (lung tumors)
    • Neurology