Commentary on "A modern approach to cervical vascular injuries".

Abstract

Cervical vascular injuries, both penetrating and blunt, when not managed appropriately carry devastating consequences both in terms of mortality and debilitating neurologic sequelae. Drs Cox and O’Brien have provided an important update for those who care for patients with these injuries. We would like to focus on three specific aspects of diagnosis and treatment that are mentioned by the authors. First, the resurrection of the physical exam in diagnosis of penetrating cervical vascular injuries. As they detail, 3 major prospective studies encompassing more than 500 patients have validated the importance of a physical exam in guiding patient care. By moving from the traditional “zone”-based approach to a more logical exam-based approach, the rate of negative neck exploration has been dramatically reduced and the outcome of patients with injuries improved. In our opinion, the available data overwhelmingly support this approach. Second, the impact of computed tomography (CT) imaging on the overall diagnostic algorithm. This has been a real game changer. CT scans are now readily available in most major trauma centers. Patients can be rapidly and accurately evaluated for occult vascular injuries shortly after arrival to the emergency department. For patients with either a penetrating cervical injury or blunt trauma to the head and neck, the CT scan is invaluable in directing the next steps. With the current scanners the resolution of vascular structures is highly accurate and in most institutions, as the authors suggest, have made diagnostic angiography, the traditional gold standard, a rarely performed test in cervical vascular trauma. The impact of CT on our understanding of blunt carotid trauma and its management has been in our view its most significant contribution. Because of the rarity of these injuries, it has been difficult to establish evidence-based protocols for management. Because of the often high Injury Severity Scores and associated multisystem trauma, identification of blunt carotid injuries by physical exam alone is near impossible. Manifestation of ischemic cerebrovascular events can be immediate or delayed, masked by low Glasgow Coma Scale scores, or ignored in those patients deemed too unstable for evaluation/intervention. Based on what we have learned from CT imaging, Eastman et al 413138 PVS23210.1177/1531003511413138Moos and WeaverPerspectives in Vascular Surgery and Endovascular Therapy