American Association for the Surgery of Trauma—World Society of Emergency Surgery Guidelines on the diagnosis and management of cervical vascular injuries
Year: 2026
Type: article
Abstract: 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 <50 years old Lefort II or III fracture Focal neurologic defect Cervical spine injury Stroke on CT or MRI Skull base fracture involving foramen lacerum Risk factors for BCVI Neck soft tissue injury (e.g., seatbelt or hanging) High energy mechanism Lefort II or III midface fracture Mandible fracture Complex skull fracture, basilar skull fracture, occipital condyle fracture Severe TBI with GCS <6 Cervical spine injury Near hanging with anoxic brain injury Clothesline type injury or seatbelt abrasion TBI with thoracic injuries Scalp degloving Thoracic vascular injuries Blunt cardiac rupture Upper rib fractures *Adapted from Kim, et al.9 CTA is the study of choice for patients with suspected cervical blunt and penetrating trauma and has high sensitivity and specificity for vascular injury.9,34–38 Computed tomography angiography also provides information on soft tissue and skeletal injuries, which are often associated with BCVI, and can provide information on the trajectory of penetrating injuries caused by gunshot or stab wounds. The injury trajectory seen on CTA can guide decision-making on whether more invasive diagnostic tests such as endoscopy, bronchoscopy, laryngoscopy, or contrast swallow evaluations are needed to further screen for aerodigestive injuries.6,28 In patients with equivocal findings on a CTA, or if there is a high index of suspicion for vascular injury with a negative CTA, digital subtraction angiography (DSA) should be performed.35,39 Importantly, artifacts from dental hardware or retained metallic fragments can interfere with CTA quality.40,41 In resource-limited settings, duplex ultrasound imaging may be considered if CTA or DSA is not readily available. Ultrasound is specific but has poor sensitivity and cannot adequately evaluate osseous segments of the carotid and vertebral arteries.42Figure 1 and Figure 2 demonstrate CTA images of vertebral and carotid BCVI.Figure 1: Blunt vertebral artery injury. Right vertebral artery occlusion with distal reconstitution from contralateral artery after BCVI following fall from height.Figure 2: Blunt carotid artery injury. (A) Right internal carotid artery dissection after motorcycle vs. auto collision. (B) Left internal carotid artery dissection in the same patient.Management What are the indications for emergent operative intervention? Statement: Patients with hemorrhage should undergo immediate operative In patients with penetrating trauma, those with hard signs of injury should also undergo immediate In selected patients with hard signs of injury but are CTA may be considered to if an or endovascular approach is GOR 1B of the mechanism, injuries with and hard signs of vascular injury should undergo immediate operative (Table Hard signs include external expanding or vascular bruit or bubbling at the injury and neurologic symptoms in the of other In selected penetrating trauma patients with hard signs of injury but are CTA may be to for the optimal In patients with blunt trauma, without clinical evidence of bleeding from a neck source may be due to bleeding in other may also be due to associated high injury. In patients, resuscitation and further clinical and may be to the optimal treatment in penetrating cervical trauma, an approach was used to immediate cervical by management protocols for of the of the with the high sensitivity and specificity of this approach has in in up to of patients and is In resource-limited or without access to patients with soft signs of injury, or subcutaneous or with injury mechanisms such as from should also be considered for patients with cervical vascular injury are best by Statement: to blunt carotid injuries should undergo with therapy endovascular intervention for III and carotid injuries is Blunt vertebral artery injuries are to GOR 2C BCVI is commonly using the Denver which management (Table to III carotid injuries can be with only which the risk of stroke and III injuries with large may from but this is injuries can be with although there is as to the of in those with neurological injuries or endovascular artery BCVIs have a lower rate of stroke and are more clearly to therapy injuries for hemorrhage selected injuries may be with when imaging or injury without contrast injuries, internal jugular injuries, can be if there is TABLE - BCVI Grading or dissection with II or hematoma with or III with *Adapted from et al.9 What is the optimal therapy for blunt cervical vascular What is the optimal for Statement: as as is the management of choice in patients with BCVI to or decrease the stroke The choice of therapy with should be considered for injuries. with injuries or with to should therapy with or initiation of in patients with concomitant TBI is in patients, but this should be with a of treatment for is in injuries by Figure GOR Cervical vascular injury management injuries with soft signs of vascular injury should imaging while those without can be can be with antithrombotic therapy of endovascular or intervention after stroke in the of dissection of or indications for intervention after BCVI has not been therapy is the of therapy for BCVI to reduce the risk of stroke and mortality and should be as as while the risks of in patients with concomitant TBI and the median to stroke after is 48 hours following injury, this is the optimal to therapy for stroke there have been randomized controlled in trauma the choice of several and studies in cervical artery dissection have that therapy is to In one large study of BCVI patients, therapy was also associated with a risk of hemorrhage compared with Importantly, when at patients therapy to have injuries and higher risks of several studies in trauma have a risk of stroke in patients the of experts with therapy for patients, such as those with or The of therapy depends on the clinical and or of injury on The American Association guidelines for carotid artery dissection of for at 3 to after not as penetrating injuries may be with to should patients and should be Statement: Patients with blunt injury may from early as with and further treatment and can be injuries should also undergo as may and management may It is if imaging in TBI patients is after initiation of therapy for BCVI in the of neurological GOR 2B BCVIs are the of a mechanism and are by other severe injuries such as patients are in an neurologic should be performed to identify signs of stroke in the is consensus on the of brain after for BCVI in TBI patients. early initiation of therapy in patients that the risk of is imaging should be performed if there is an change in neurologic are established guidelines for imaging after management of BCVI. the to evaluate for injury or imaging may be performed at 3 or if neurologic symptoms in those without injury vertebral BCVIs likely not The of imaging after management of penetrating vascular neck trauma has not been What is considered a of Statement: In BCVI, of the initial injury is common in to III the after injury. CTA in that is and may change management from therapy to an endovascular approach when indicated. GOR 2C BCVIs to higher In one large study, of BCVIs at a of after injury compared with of II injuries, of III injuries, and of injuries. In the same study, the of BCVI to a higher occurred in 10% of 1 injuries, of II injuries, and of III The of neurologic should an for stroke. if a stroke occurs in the of dissection, there definitive evidence that endovascular or intervention improve patient In one systematic of patients with or traumatic carotid or at a of neurologic symptoms occurred in only of What are the treatment and their indications in cervical vascular injury? Statement: and endovascular may be used to are used more often in BCVI but can also be used in penetrating trauma at The approach is used for penetrating cervical injuries the of the in patients with external bleeding or with a expanding cervical a stroke occurs from dissection, there is definitive evidence that intervention GOR 1C BCVI can be by and intervention may also be used in penetrating injuries, in vessels such as the distal vertebral artery and the internal carotid artery the of the is performed in the of penetrating vascular injury and is for BCVI in the of hard signs of injury. is clear consensus on the of in internal carotid BCVI. The guidelines endovascular for II and III The of for carotid BCVI has the due to with In a study of trauma of injuries in in in and in The best of the of was a than The of has also been proposed as an indication of but this is The stroke rate is higher or different in patients compared with which may be due to not the for in one large study, patients with neurologic after BCVI, was not associated with a decrease in mortality but was associated with of a intervention may be considered in patients with a large of BCVI, and/or in those neurologic symptoms following injuries should a discussion with vascular and/or comparative studies of and therapy have been in vertebral The of vertebral III and injuries, can be with is for injuries, patients, or those with are to penetrating cervical injuries. treatment is in patients with hard signs of vascular injury, hemorrhage and neurologic the immediate of a to flow may be in identifying the and for the The optimal approach depends on the injury site but an initial the of the with and as needed. this can be with a to the of the there is a for a injury or injury to the an can include a median or a distal or skull base injuries, the can be the of the and process the of the vertebral artery is through a vertebral artery injuries are to access in and should be considered for an endovascular In cases of significant bleeding from the vertebral of the vertebral artery at in the artery associated with the of a at the level of the hemorrhage in the vertebral provides of the which can be by an approach and of the neck for cervical vascular injury, the and should be for associated injuries. should be taken to important the and the carotid and are carotid artery injuries, primary may be used in injuries, while or are for more injuries. A carotid should be considered if of the or common carotid artery is to stroke. should also be considered for more injuries may to vertebral artery injuries to in the vertebral is common due to and the presence of collateral blood of patients may have a contralateral primary should be if should also be considered for patients with multiple life-threatening injuries, and this of the or and/or of The internal jugular can be if primary is not or a The external carotid artery may also be In circumstances, the or can be although this should be if due to the high risk of are consensus guidelines optimal after or endovascular for carotid or vertebral BCVI. The Society of Vascular Surgery recommends after carotid or which ultrasound studies at 3 by to 1 and most studies the and following for BCVI are What is the of patients with cervical vascular Statement: The presence of a neurologic deficit or an established stroke is associated with high mortality and poor in BCVI and penetrating injury after BCVI is by the presence of neurologic on In a study of BCVI cases in the United using the Trauma Quality from to the mortality was and the stroke rate was patients with neurologic due to BCVI at but those that higher mortality vs. higher risk of stroke vs. and were likely to be vs. than BCVI BCVI or is in the trauma and should be a of trauma In the study of cervical artery dissection, in which only a traumatic injury diagnosis, the risk of stroke was patients or was between patients with or without This should be with as BCVI patients may differ from those in the study, of patients with neurologic after penetrating are from and by airway and mortality of injuries are on which are mortality from penetrating cervical injuries is to be as high as mortality may increase to with vascular Blunt cerebrovascular injury is uncommon but has devastating if a stroke strokes occur or the initial 48 hours and this the Patients to stroke after are those likely most from The of management for most BCVI is and It is which injuries from but likely those with or injuries on injuries present with bleeding than and assessment and management to hemorrhage and cerebrovascular blood The trauma should be well in the approach to quickly and distal vascular and expeditious The vertebral and external carotid as well as most injuries, can be while common and internal carotid artery injuries should be or
Authors: Leslie Kobayashi, Louis Perkins, Will Johnston, Lisa Kurth, Kendra Black, Fikri Abu-Zidan, Goran Augustin, Zsolt J. Balogh, Walter L. Biffl, L. D. Britt, Fausto Catena, Ian Civil, Federico Coccolini, Dimitris Damaskos, Nicola De’Angelis, Belinda De Simone, Joseph M. Galante, Adenauer M. O. Góes, Jose Gustavo Parreira, Timothy Hardcastle, Kenji Inaba, Andrew Kirkpatrick, Yoran Kluger, Ari Leppäniemi, Ron Maier, Ernest E. Moore, Andrew B. Peitzman, Mauro Podda, Massimo Sartelli, Thomas M. Scalea, Philip Stahel, Edward Tan, Matti Tolonen, Dieter Weber, Raul Coimbra
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7124163043