Blunt Intracranial Cerebrovascular Injury

Intracranial cerebrovascular injury is more common in penetrating trauma than in blunt trauma, but it carries a high morbidity and mortality when left undiagnosed. The vessels are at highest risk of injury at transition points from a fixed segment to a mobile segment (e.g., along the skull base); therefore, patients presenting with skull base fractures should undergo an intracranial vascular imaging study. The gold standard imaging study is digital subtraction angiography (DSA) but can be supplanted with CT or MR angiography for expediency. Any patient with a traumatic head injury who develops a delayed neurological decline should undergo cerebrovascular imaging. Injuries to the cerebral vasculature are graded I–V. The modalities of treatment include endovascular therapy, open surgical intervention, or antiplatelet/anticoagulant therapy. The treatment strategy should be individualized to the patient and the location of the injury. Overall, patients presenting with skull base fractures should undergo cerebrovascular imaging, with treatment dependent on presentation; additionally, the patient should undergo surveillance imaging thereafter to assess for progression.