High-risk mechanism of injury: A new indication for screening for blunt cerebrovascular injury?

Blunt cerebrovascular injury is a rare but catastrophic injury. Screening for blunt cerebrovascular injury after high-impact mechanism remains ill-defined but several associated lesions have been identified as high risk for concomitant blunt cerebrovascular injury and are used to prompt further investigation for early identification and intervention. We describe a case of a large cerebral infarction caused by a high cervical internal carotid dissection after a motorcycle collision. Upon presentation, the patient had a Glasgow coma scale of 14 and an open pelvic fracture, which was immediately addressed in the operating room. His subsequent imaging revealed a nasal fracture, bilateral rib fractures, bilateral pubic rami fractures and left acetabular fracture without evidence of traumatic brain injury, cervical spine injury or extensive facial fractures. After 48 h, he displayed a depressed sensorium and an abnormal pupillary exam. He was diagnosed by computed tomography angiogram with a carotid dissection resulting in a large infarct of the right hemisphere with herniation requiring emergent craniectomy. This case suggests screening for blunt cerebrovascular injury beyond the current recommendations especially in patients with high-impact mechanism.