Prior to popularization of the CT scan with the utilization of CT angiography (CTA), ultrasound imaging was an option for noninvasive imaging to detect carotid dissections in the neck and has a 86 % sensitivity [19] in detecting internal carotid artery injuries. Earlier studies advocated for this method and in one study, ultrasound was determined to be as good as arteriography with the added benefit of being faster and less expensive, but it was only ideal for Zone II injuries [20]. From experience, there are limitations with the ultrasound: patient size, body habitus, operator availability, and difficulty around bony structures such as the skullbase [3, 19]. Given these limitations, ultrasonography has had a limited role in primary assessment of vascular trauma ; however, some contend that it may be useful as a noninvasive follow-up imaging modality in patients to evaluate the rate of healing [21].

CT angiography (CTA) has become the primary initial imaging technique for evaluating head and neck vessel injuries. Earlier CT angiography had a sensitivity between 50 and 68 % [22, 23] however, with technological advances the sensitivity and specificity has improved to 90 and 100 %, respectively [24]. Advocates for CT over digital subtraction angiography (DSA or catheter-based angiography) argue that the major advantage is having the availability of CT scanners 24/7 in most of the hospitals in the US whereas having an angiography suite and an interventionalist on-call limits its utility. Furthermore, improved multidetector CT scanner and workstations that can postprocess the 2D and 3D data have been extremely useful in detecting dissections [6, 8, 25]. However, CTA may be suboptimal in patients with dental implants or severe atherosclerotic disease, improper bolus or timing of contrast, and motion artifact, which can affect the quality of image [6]. The requisite contrast bolus may also be undesirable in those patients with borderline renal function. Proponents for the use of CTA argue for diagnostic purposes, that CTA is less invasive and time-consuming when compared to DSA, and may allow for faster surgical intervention if warranted [26]. In general, the use of DSA can be reserved for definitive treatment or when diagnosis is equivocal in a case with a negative CTA despite having persistent clinical concerns [6].

Utilization of MRI with MR angiography (MRA) is another noninvasive method to evaluate for possible vessel injury. The advantages in using MRI/MRA for investigating possible neck vessel injury includes the ability to assess adjacent soft tissue injuries such as, ligamentous injuries, spine disc ruptures, and spinal cord injuries. When assessing the head, it can evaluate for diffuse axonal injury or detect early signs of a stroke. Levy et al. reported from their investigation that MRA for carotid artery dissection had a sensitivity of 95 % and specificity of 99 % [27], however they mentioned that this can be limited by the bony anatomy of the skullbase and/or metal artifacts such as dental implants. The use of contrast in MRA can be avoided in those individuals with impaired creatinine clearance, albeit with lower sensitivity for detecting dissections. As with any MRI, the disadvantages of its use depends on the medical stability of the patient (due to a longer duration in the MR scanner when compared to CT), difficulties of a ventilated patient, metal implant, aneurysm clip, pacemaker, etc. Despite these disadvantages, patients with transient ischemic attack or stroke symptoms with a normal CT should undergo a stroke protocol MRI. If the imaging shows scattered emboli, a heightened index of suspicion should lead the team to reassess the vessels of the neck.

Digital subtraction angiography (DSA) is still considered the gold standard in evaluating for head and neck vessel dissections [3, 6, 7, 28]. Compared to the prior three imaging modalities, it is an invasive procedure with associated procedural risks such as, pseudoaneurysm in the groin, iatrogenic vessel injury/dissection, stroke, cerebral hemorrhagic, and surrounding tissue injury. The literature has reported combined procedural risks of 0.5–15 % [29]. Despite the procedural risks, DSA information has the highest sensitivity and treatment can be implemented immediately, if required. In many instances, the patient’s overall stability is a priority before transporting a patient to the angiosuite [30]. Given these limitations, along with the labor-intensive nature of catheter-based angiography studies, CTA has remained the first-line vascular imaging treatment of choice for trauma patients.

Head and neck vessel injury or dissection without any signs of external injury during the initial trauma surveys occurs in approximately 50 % of all cases [31]. There is often a silent period [4, 32] where the patient remains asymptomatic from their injuries, however as the disease progresses, acute symptoms may appear within a four hour window, which we have seen, or they may appear in a delayed fashion by remaining silent for as long as 75 days [3]. It is important for trauma surgeons, emergency room physicians, neurosurgeons, and neurologist alike to consider head and neck vessel injuries when there is a sudden onset of symptoms that occur in patients with a remote trauma history. Delayed stroke-like symptoms or severe neck pain in a delayed fashion following trauma mandates immediate vascular imaging.

In the initial trauma scans, often the first head CT may be negative for stroke of hemorrhage, however associated chest injuries, skull base fractures [4] or other signs of external injury such as bruising around the neck, a broken collar bone, or skin abrasions may be an indicator to a possible vascular injury in the neck. Surrounding tissues of the neck may be tender to touch, and auscultation of the carotids with the stethoscope during the examination is very important when evaluating for a bruit to detect early signs of carotid injury [11]. The development of a delayed Horner’s syndrome also mandates further imaging. The presence of increasing headaches, nausea/vomiting, hemiparesis, facial paralysis, visual disturbances, and aphasia may be signs of anterior circulation stroke. Both the Denver criteria [33] and Memphis criteria [23] are two commonly used screening tools used in blunt trauma situations to help guide further evaluation of the head and neck vessels (Table 10.2).

Similarly, vertebral artery injuries may also generate neurological deficits related to the posterior circulation. These may include headaches, dizziness, nausea, vomiting, blurry vision, loss of central vision, hemiparesis/paralysis, and even coma or death, particularly with brainstem strokes seen in severe vertebral artery injuries.

As mentioned in Table 8.​1, the Biffl classification is used to stratify the severity of injury to vessels in the neck. In a follow-up publication by Biffl et al. in 2002, they were able to demonstrate the percentage of strokes associated with the different grades of injury [22] (Table 10.3).

The management of traumatic carotid or vertebral artery injuries varies widely amongst specialists. Dissection of the carotid artery is the most commonly seen injury resulting from blunt or whiplash injury [4], however other injuries such as a pseudoaneurysm can also occur (Fig. 10.1).