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Vascular Injuries of the Neck and Thoracic Inlet: Helical CT–Angiographic Correlation¹

¹ From the Department of Radiology, Hospital of Saint Raphael, Yale University School of Medicine, 1450 Chapel St, New Haven, CT 06511 (D.B.N., M.T.L.); and the Department of Radiology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, Fla (F.M.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 19, 2003; revision requested April 8; final revision received September 11; accepted September 12. All authors have no financial relationships to disclose. Address correspondence to D.B.N. (e-mail: dnunez@srhs.org).

View larger version (43K): [in a new window]   Figure 1.  Zones of the neck for classification of penetrating injuries. Zone I extends from the sternal notch to the cricoid cartilage. The thoracic inlet may be considered an inferior extension of this zone. Zone II extends from the cricoid cartilage to the angle of the mandible. Zone III extends from the angle of the mandible to the base of the skull.

View larger version (158K): [in a new window]   Figure 2a.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (163K): [in a new window]   Figure 2b.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (165K): [in a new window]   Figure 2c.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (84K): [in a new window]   Figure 2d.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (75K): [in a new window]   Figure 2e.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (79K): [in a new window]   Figure 2f.  Partial occlusion in a patient with a gunshot wound to the left side of the neck (zones II and III). (a) Axial CT image obtained proximal to the bifurcation of the left common carotid artery (arrow) shows obliteration of the perivascular fat planes with displacement and narrowing of the adjacent left jugular vein (arrowhead). (b) Axial CT image obtained just above the bifurcation of the left common carotid artery shows normal calibers of the left internal carotid (IC) and left external carotid (EC) arteries and cephalic extension of the hematoma. (c) Axial CT image obtained cephalad to b shows narrowing and posterior irregularity of the left internal carotid artery (arrow), findings consistent with a vascular wall injury. (d-f) Slab maximum intensity projection image (d), surface rendered reformatted angiogram (e), and selective angiogram (f) of the left common carotid artery show the marginal vascular injury and the partial occlusion. In f, the levels of the CT images (a, b, and c) are shown as lines A, B, and C, respectively.

View larger version (128K): [in a new window]   Figure 3a.  Total occlusion in a patient with a gunshot wound to zone II of the neck. (a) Axial CT image obtained above the bifurcation of the left common carotid artery shows a crescentic defect in the anterior aspect of the left internal carotid artery (arrow). (b) Axial CT image obtained cephalad to a shows absence of enhancement in the left internal carotid artery secondary to total occlusion (*) and compression of the adjacent left internal jugular vein (arrow). Note the normal caliber of the left external carotid artery (LEC) and the prevertebral subcutaneous emphysema, which indicates the trajectory of the bullet. (c) Digital subtraction angiogram shows the total occlusion of the left internal carotid artery (LIC). The levels of the CT images (a and b) are shown as lines A and B, respectively. Dashed line = expected location of the anterior vessel wall. (d) Slab maximum intensity projection image shows the abrupt cutoff of the left internal carotid artery (arrow), a finding consistent with occlusion.

View larger version (118K): [in a new window]   Figure 3b.  Total occlusion in a patient with a gunshot wound to zone II of the neck. (a) Axial CT image obtained above the bifurcation of the left common carotid artery shows a crescentic defect in the anterior aspect of the left internal carotid artery (arrow). (b) Axial CT image obtained cephalad to a shows absence of enhancement in the left internal carotid artery secondary to total occlusion (*) and compression of the adjacent left internal jugular vein (arrow). Note the normal caliber of the left external carotid artery (LEC) and the prevertebral subcutaneous emphysema, which indicates the trajectory of the bullet. (c) Digital subtraction angiogram shows the total occlusion of the left internal carotid artery (LIC). The levels of the CT images (a and b) are shown as lines A and B, respectively. Dashed line = expected location of the anterior vessel wall. (d) Slab maximum intensity projection image shows the abrupt cutoff of the left internal carotid artery (arrow), a finding consistent with occlusion.

View larger version (103K): [in a new window]   Figure 3c.  Total occlusion in a patient with a gunshot wound to zone II of the neck. (a) Axial CT image obtained above the bifurcation of the left common carotid artery shows a crescentic defect in the anterior aspect of the left internal carotid artery (arrow). (b) Axial CT image obtained cephalad to a shows absence of enhancement in the left internal carotid artery secondary to total occlusion (*) and compression of the adjacent left internal jugular vein (arrow). Note the normal caliber of the left external carotid artery (LEC) and the prevertebral subcutaneous emphysema, which indicates the trajectory of the bullet. (c) Digital subtraction angiogram shows the total occlusion of the left internal carotid artery (LIC). The levels of the CT images (a and b) are shown as lines A and B, respectively. Dashed line = expected location of the anterior vessel wall. (d) Slab maximum intensity projection image shows the abrupt cutoff of the left internal carotid artery (arrow), a finding consistent with occlusion.

View larger version (123K): [in a new window]   Figure 3d.  Total occlusion in a patient with a gunshot wound to zone II of the neck. (a) Axial CT image obtained above the bifurcation of the left common carotid artery shows a crescentic defect in the anterior aspect of the left internal carotid artery (arrow). (b) Axial CT image obtained cephalad to a shows absence of enhancement in the left internal carotid artery secondary to total occlusion (*) and compression of the adjacent left internal jugular vein (arrow). Note the normal caliber of the left external carotid artery (LEC) and the prevertebral subcutaneous emphysema, which indicates the trajectory of the bullet. (c) Digital subtraction angiogram shows the total occlusion of the left internal carotid artery (LIC). The levels of the CT images (a and b) are shown as lines A and B, respectively. Dashed line = expected location of the anterior vessel wall. (d) Slab maximum intensity projection image shows the abrupt cutoff of the left internal carotid artery (arrow), a finding consistent with occlusion.

View larger version (136K): [in a new window]   Figure 4a.  Pseudoaneurysm in a patient with a gunshot wound to the lower left side of the neck (zone I). (a) Digital subtraction angiogram shows a marginal defect in the proximal left subclavian artery (arrow). (b) Axial CT image, obtained at the level of the sternal manubrium 2 days after admission of the patient to the hospital, shows a small area of contained extravasated contrast material along the left lateral aspect of the left subclavian artery (arrow). The intimal defect seen in a has evolved into a small pseudoaneurysm. (c) Follow-up conventional angiogram shows the pseudoaneurysm. (d) Digital subtraction aortogram of the aortic arch, obtained after endovascular treatment with a Wallstent (Boston Scientific, Natick, Mass), shows occlusion of the lesion.

View larger version (110K): [in a new window]   Figure 4b.  Pseudoaneurysm in a patient with a gunshot wound to the lower left side of the neck (zone I). (a) Digital subtraction angiogram shows a marginal defect in the proximal left subclavian artery (arrow). (b) Axial CT image, obtained at the level of the sternal manubrium 2 days after admission of the patient to the hospital, shows a small area of contained extravasated contrast material along the left lateral aspect of the left subclavian artery (arrow). The intimal defect seen in a has evolved into a small pseudoaneurysm. (c) Follow-up conventional angiogram shows the pseudoaneurysm. (d) Digital subtraction aortogram of the aortic arch, obtained after endovascular treatment with a Wallstent (Boston Scientific, Natick, Mass), shows occlusion of the lesion.

View larger version (104K): [in a new window]   Figure 4c.  Pseudoaneurysm in a patient with a gunshot wound to the lower left side of the neck (zone I). (a) Digital subtraction angiogram shows a marginal defect in the proximal left subclavian artery (arrow). (b) Axial CT image, obtained at the level of the sternal manubrium 2 days after admission of the patient to the hospital, shows a small area of contained extravasated contrast material along the left lateral aspect of the left subclavian artery (arrow). The intimal defect seen in a has evolved into a small pseudoaneurysm. (c) Follow-up conventional angiogram shows the pseudoaneurysm. (d) Digital subtraction aortogram of the aortic arch, obtained after endovascular treatment with a Wallstent (Boston Scientific, Natick, Mass), shows occlusion of the lesion.

View larger version (162K): [in a new window]   Figure 4d.  Pseudoaneurysm in a patient with a gunshot wound to the lower left side of the neck (zone I). (a) Digital subtraction angiogram shows a marginal defect in the proximal left subclavian artery (arrow). (b) Axial CT image, obtained at the level of the sternal manubrium 2 days after admission of the patient to the hospital, shows a small area of contained extravasated contrast material along the left lateral aspect of the left subclavian artery (arrow). The intimal defect seen in a has evolved into a small pseudoaneurysm. (c) Follow-up conventional angiogram shows the pseudoaneurysm. (d) Digital subtraction aortogram of the aortic arch, obtained after endovascular treatment with a Wallstent (Boston Scientific, Natick, Mass), shows occlusion of the lesion.

View larger version (147K): [in a new window]   Figure 5a.  Pseudoaneurysm in a patient with a gunshot wound to zone II of the neck. (a) Axial contrast-enhanced CT image shows focal irregularity of the left vertebral artery and a change in its caliber (arrow). Note the well-defined contour and normal appearance of the right vertebral artery. (b) Selective left vertebral arteriogram shows segmental narrowing of the vessel with a pseudoaneurysm.

View larger version (120K): [in a new window]   Figure 5b.  Pseudoaneurysm in a patient with a gunshot wound to zone II of the neck. (a) Axial contrast-enhanced CT image shows focal irregularity of the left vertebral artery and a change in its caliber (arrow). Note the well-defined contour and normal appearance of the right vertebral artery. (b) Selective left vertebral arteriogram shows segmental narrowing of the vessel with a pseudoaneurysm.

View larger version (155K): [in a new window]   Figure 6a.  Pseudoaneurysm in a patient with a severe crushing injury to the lower neck. (a) Axial contrast-enhanced CT image obtained at the level of the thoracic inlet shows abnormal accumulation of contrast material posterior to the brachiocephalic artery (arrow). There is also a mediastinal hematoma and subcutaneous emphysema anterior to the manubrium. (b) Digital subtraction aortogram shows a small contrast material-filled lobule, which corresponds to a pseudoaneurysm, along the posteromedial aspect of the origin of the brachiocephalic artery (arrow).

View larger version (104K): [in a new window]   Figure 6b.  Pseudoaneurysm in a patient with a severe crushing injury to the lower neck. (a) Axial contrast-enhanced CT image obtained at the level of the thoracic inlet shows abnormal accumulation of contrast material posterior to the brachiocephalic artery (arrow). There is also a mediastinal hematoma and subcutaneous emphysema anterior to the manubrium. (b) Digital subtraction aortogram shows a small contrast material-filled lobule, which corresponds to a pseudoaneurysm, along the posteromedial aspect of the origin of the brachiocephalic artery (arrow).

View larger version (126K): [in a new window]   Figure 7a.  Pseudoaneurysm in a patient with a hematoma of the anterior neck after a transcervical gunshot wound to zone II of the neck. (a) Axial CT image shows a large area of extravasated contrast material (arrow) with a surrounding hematoma. Note the significant compression of the airway and the lateral displacement of the enhanced common carotid arteries and left jugular vein. (b) Axial CT image obtained caudad to a shows extension of the extravasated contrast material to the right of the midline. The extravasated contrast material is inseparable from the right common carotid artery (arrow). Streak artifacts in the shoulders are incidentally noted. (c, d) Aortogram (c) and selective common carotid arteriogram (d) show extravasated contrast material (ie, a pseudoaneurysm) encircling the common carotid artery.

View larger version (132K): [in a new window]   Figure 7b.  Pseudoaneurysm in a patient with a hematoma of the anterior neck after a transcervical gunshot wound to zone II of the neck. (a) Axial CT image shows a large area of extravasated contrast material (arrow) with a surrounding hematoma. Note the significant compression of the airway and the lateral displacement of the enhanced common carotid arteries and left jugular vein. (b) Axial CT image obtained caudad to a shows extension of the extravasated contrast material to the right of the midline. The extravasated contrast material is inseparable from the right common carotid artery (arrow). Streak artifacts in the shoulders are incidentally noted. (c, d) Aortogram (c) and selective common carotid arteriogram (d) show extravasated contrast material (ie, a pseudoaneurysm) encircling the common carotid artery.

View larger version (103K): [in a new window]   Figure 7c.  Pseudoaneurysm in a patient with a hematoma of the anterior neck after a transcervical gunshot wound to zone II of the neck. (a) Axial CT image shows a large area of extravasated contrast material (arrow) with a surrounding hematoma. Note the significant compression of the airway and the lateral displacement of the enhanced common carotid arteries and left jugular vein. (b) Axial CT image obtained caudad to a shows extension of the extravasated contrast material to the right of the midline. The extravasated contrast material is inseparable from the right common carotid artery (arrow). Streak artifacts in the shoulders are incidentally noted. (c, d) Aortogram (c) and selective common carotid arteriogram (d) show extravasated contrast material (ie, a pseudoaneurysm) encircling the common carotid artery.

View larger version (80K): [in a new window]   Figure 7d.  Pseudoaneurysm in a patient with a hematoma of the anterior neck after a transcervical gunshot wound to zone II of the neck. (a) Axial CT image shows a large area of extravasated contrast material (arrow) with a surrounding hematoma. Note the significant compression of the airway and the lateral displacement of the enhanced common carotid arteries and left jugular vein. (b) Axial CT image obtained caudad to a shows extension of the extravasated contrast material to the right of the midline. The extravasated contrast material is inseparable from the right common carotid artery (arrow). Streak artifacts in the shoulders are incidentally noted. (c, d) Aortogram (c) and selective common carotid arteriogram (d) show extravasated contrast material (ie, a pseudoaneurysm) encircling the common carotid artery.

View larger version (136K): [in a new window]   Figure 8a.  Pseudoaneurysm in a patient with oropharyngeal bleeding as a delayed complication of tracheal intubation. (a) Axial CT image shows prevertebral soft-tissue swelling with lateral displacement of the right common carotid artery (RCCA) and right jugular vein and displacement of the esophagus (E) to the left of the midline. (b) Axial CT image obtained just caudad to a shows a small rounded area of extravasated contrast material behind the trachea and to the right of the midline (arrow). A pseudoaneurysm was suspected. (c) Confirmatory selective conventional arteriogram shows a pseudoaneurysm of the right inferior thyroid artery (arrow). (d) Conventional angiogram obtained after endovascular treatment with coils (arrows) shows occlusion of the lesion.

View larger version (130K): [in a new window]   Figure 8b.  Pseudoaneurysm in a patient with oropharyngeal bleeding as a delayed complication of tracheal intubation. (a) Axial CT image shows prevertebral soft-tissue swelling with lateral displacement of the right common carotid artery (RCCA) and right jugular vein and displacement of the esophagus (E) to the left of the midline. (b) Axial CT image obtained just caudad to a shows a small rounded area of extravasated contrast material behind the trachea and to the right of the midline (arrow). A pseudoaneurysm was suspected. (c) Confirmatory selective conventional arteriogram shows a pseudoaneurysm of the right inferior thyroid artery (arrow). (d) Conventional angiogram obtained after endovascular treatment with coils (arrows) shows occlusion of the lesion.

View larger version (121K): [in a new window]   Figure 8c.  Pseudoaneurysm in a patient with oropharyngeal bleeding as a delayed complication of tracheal intubation. (a) Axial CT image shows prevertebral soft-tissue swelling with lateral displacement of the right common carotid artery (RCCA) and right jugular vein and displacement of the esophagus (E) to the left of the midline. (b) Axial CT image obtained just caudad to a shows a small rounded area of extravasated contrast material behind the trachea and to the right of the midline (arrow). A pseudoaneurysm was suspected. (c) Confirmatory selective conventional arteriogram shows a pseudoaneurysm of the right inferior thyroid artery (arrow). (d) Conventional angiogram obtained after endovascular treatment with coils (arrows) shows occlusion of the lesion.

View larger version (112K): [in a new window]   Figure 8d.  Pseudoaneurysm in a patient with oropharyngeal bleeding as a delayed complication of tracheal intubation. (a) Axial CT image shows prevertebral soft-tissue swelling with lateral displacement of the right common carotid artery (RCCA) and right jugular vein and displacement of the esophagus (E) to the left of the midline. (b) Axial CT image obtained just caudad to a shows a small rounded area of extravasated contrast material behind the trachea and to the right of the midline (arrow). A pseudoaneurysm was suspected. (c) Confirmatory selective conventional arteriogram shows a pseudoaneurysm of the right inferior thyroid artery (arrow). (d) Conventional angiogram obtained after endovascular treatment with coils (arrows) shows occlusion of the lesion.

View larger version (118K): [in a new window]   Figure 9a.  Pseudoaneurysm in a patient with severe crushing of the upper chest after a motor vehicle accident. The patient had fractures of the sternum and right clavicle. (a, b) Consecutive axial CT images (a obtained cephalad to b) show abnormal enhancement of a rounded structure in the upper right side of the chest just posterior to the right first rib (arrow), a finding consistent with contained extravasation of contrast material. Increased soft-tissue attenuation (ie, a hematoma) is seen surrounding the lesion. (c) Selective right internal mammary (IM) arteriogram shows active extravasation of contrast material (arrows), a finding consistent with a pseudoaneurysm. (d) Selective arteriogram obtained after endovascular treatment with coils (arrows) shows occlusion of the pseudoaneurysm.

View larger version (121K): [in a new window]   Figure 9b.  Pseudoaneurysm in a patient with severe crushing of the upper chest after a motor vehicle accident. The patient had fractures of the sternum and right clavicle. (a, b) Consecutive axial CT images (a obtained cephalad to b) show abnormal enhancement of a rounded structure in the upper right side of the chest just posterior to the right first rib (arrow), a finding consistent with contained extravasation of contrast material. Increased soft-tissue attenuation (ie, a hematoma) is seen surrounding the lesion. (c) Selective right internal mammary (IM) arteriogram shows active extravasation of contrast material (arrows), a finding consistent with a pseudoaneurysm. (d) Selective arteriogram obtained after endovascular treatment with coils (arrows) shows occlusion of the pseudoaneurysm.

View larger version (135K): [in a new window]   Figure 9c.  Pseudoaneurysm in a patient with severe crushing of the upper chest after a motor vehicle accident. The patient had fractures of the sternum and right clavicle. (a, b) Consecutive axial CT images (a obtained cephalad to b) show abnormal enhancement of a rounded structure in the upper right side of the chest just posterior to the right first rib (arrow), a finding consistent with contained extravasation of contrast material. Increased soft-tissue attenuation (ie, a hematoma) is seen surrounding the lesion. (c) Selective right internal mammary (IM) arteriogram shows active extravasation of contrast material (arrows), a finding consistent with a pseudoaneurysm. (d) Selective arteriogram obtained after endovascular treatment with coils (arrows) shows occlusion of the pseudoaneurysm.

View larger version (119K): [in a new window]   Figure 9d.  Pseudoaneurysm in a patient with severe crushing of the upper chest after a motor vehicle accident. The patient had fractures of the sternum and right clavicle. (a, b) Consecutive axial CT images (a obtained cephalad to b) show abnormal enhancement of a rounded structure in the upper right side of the chest just posterior to the right first rib (arrow), a finding consistent with contained extravasation of contrast material. Increased soft-tissue attenuation (ie, a hematoma) is seen surrounding the lesion. (c) Selective right internal mammary (IM) arteriogram shows active extravasation of contrast material (arrows), a finding consistent with a pseudoaneurysm. (d) Selective arteriogram obtained after endovascular treatment with coils (arrows) shows occlusion of the pseudoaneurysm.

View larger version (114K): [in a new window]   Figure 10a.  Dissection in a 28-year-old woman with a hyperextension injury to the neck. (a, b) Consecutive axial CT images (a obtained cephalad to b) show narrowing of the right internal carotid artery (arrow in a) with concentric soft-tissue swelling (arrow in b), which is consistent with a perivascular hematoma. (c, d) Axial fat-suppressed T1-weighted MR image (c) and cervical MR angiogram (d) show dissection of the right internal carotid artery (arrow).

View larger version (109K): [in a new window]   Figure 10b.  Dissection in a 28-year-old woman with a hyperextension injury to the neck. (a, b) Consecutive axial CT images (a obtained cephalad to b) show narrowing of the right internal carotid artery (arrow in a) with concentric soft-tissue swelling (arrow in b), which is consistent with a perivascular hematoma. (c, d) Axial fat-suppressed T1-weighted MR image (c) and cervical MR angiogram (d) show dissection of the right internal carotid artery (arrow).

View larger version (93K): [in a new window]   Figure 10c.  Dissection in a 28-year-old woman with a hyperextension injury to the neck. (a, b) Consecutive axial CT images (a obtained cephalad to b) show narrowing of the right internal carotid artery (arrow in a) with concentric soft-tissue swelling (arrow in b), which is consistent with a perivascular hematoma. (c, d) Axial fat-suppressed T1-weighted MR image (c) and cervical MR angiogram (d) show dissection of the right internal carotid artery (arrow).

View larger version (117K): [in a new window]   Figure 10d.  Dissection in a 28-year-old woman with a hyperextension injury to the neck. (a, b) Consecutive axial CT images (a obtained cephalad to b) show narrowing of the right internal carotid artery (arrow in a) with concentric soft-tissue swelling (arrow in b), which is consistent with a perivascular hematoma. (c, d) Axial fat-suppressed T1-weighted MR image (c) and cervical MR angiogram (d) show dissection of the right internal carotid artery (arrow).

View larger version (146K): [in a new window]   Figure 11a.  Total occlusion in a patient with a gunshot wound to the anterior left side of the neck (zone II). (a) Axial CT image obtained at the level of C6 shows multiple metallic fragments along the trajectory of the bullet. A hematoma and soft-tissue air are present in the anterior left side of the neck. Bullet fragments are seen in the left transverse foramen (arrow) and the spinal canal. An injury of the left vertebral artery was suspected but was not clearly demonstrated. (b) Selective digital subtraction angiogram of the left vertebral artery shows total occlusion (arrow).

View larger version (67K): [in a new window]   Figure 11b.  Total occlusion in a patient with a gunshot wound to the anterior left side of the neck (zone II). (a) Axial CT image obtained at the level of C6 shows multiple metallic fragments along the trajectory of the bullet. A hematoma and soft-tissue air are present in the anterior left side of the neck. Bullet fragments are seen in the left transverse foramen (arrow) and the spinal canal. An injury of the left vertebral artery was suspected but was not clearly demonstrated. (b) Selective digital subtraction angiogram of the left vertebral artery shows total occlusion (arrow).

View larger version (135K): [in a new window]   Figure 12a.  Pseudoaneurysm in a 21-year-old man with a gunshot wound to the left side of the neck (zone II). (a) Axial CT image obtained at the level of the hyoid bone shows a normal bifurcation of the right common carotid artery. The origin of the right internal carotid artery (RIC) is seen posterior to the origin of the right external carotid artery (REC). A similar but more medial change in vessel contour is seen in the left common carotid artery (arrow), a finding initially interpreted as a normal bifurcation. (b) Selective left common carotid arteriogram shows a small pseudoaneurysm just proximal to the bifurcation (arrow), a finding that corresponds to the focal change in the medial vessel wall on the CT image (a). A bullet is seen posterior to the left internal carotid artery. (Reprinted, with permission, from reference 28.)

View larger version (123K): [in a new window]   Figure 12b.  Pseudoaneurysm in a 21-year-old man with a gunshot wound to the left side of the neck (zone II). (a) Axial CT image obtained at the level of the hyoid bone shows a normal bifurcation of the right common carotid artery. The origin of the right internal carotid artery (RIC) is seen posterior to the origin of the right external carotid artery (REC). A similar but more medial change in vessel contour is seen in the left common carotid artery (arrow), a finding initially interpreted as a normal bifurcation. (b) Selective left common carotid arteriogram shows a small pseudoaneurysm just proximal to the bifurcation (arrow), a finding that corresponds to the focal change in the medial vessel wall on the CT image (a). A bullet is seen posterior to the left internal carotid artery. (Reprinted, with permission, from reference 28.)

View larger version (123K): [in a new window]   Figure 13a.  Pseudoaneurysm in a patient with a gunshot wound to the right side of the neck (zone II). (a) Axial CT image shows a large area of extravasated contrast material (arrow) adjacent to the right common carotid artery (CCA). (b) Oblique surface-rendered reformatted image (conventional angiographic view) shows the lesion. Confirmatory conventional angiography was not needed before surgical treatment.

View larger version (78K): [in a new window]   Figure 13b.  Pseudoaneurysm in a patient with a gunshot wound to the right side of the neck (zone II). (a) Axial CT image shows a large area of extravasated contrast material (arrow) adjacent to the right common carotid artery (CCA). (b) Oblique surface-rendered reformatted image (conventional angiographic view) shows the lesion. Confirmatory conventional angiography was not needed before surgical treatment.