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The management of injuries to the neck can be a challenging dilemma. The various critical structures that course through the neck, particularly the esophagus, trachea, carotid and vertebral arteries, jugular veins, and spinal cord, carry a significant morbidity and mortality when injured and can be unforgiving when the diagnosis is delayed or missed. For the purposes of this chapter, we will focus our attention on injuries to the cervical vascular structures, namely the carotid and vertebral arteries and jugular veins. Penetrating cervical vascular injuries are usually secondary to gunshot wounds, stab wounds, or impalements, whereas blunt cervical vascular injuries, otherwise known as blunt cerebrovascular injuries (BCVI), are usually secondary to flexion-extension mechanisms. Approximately 20% to 25% of patients with penetrating neck trauma will have an associated cervical vascular injury and 1% to 3% of patients admitted with blunt trauma will have a BCVI with an associated stroke rate of about 20% for injuries not treated with antithrombotic agents. This underscores the potential morbidity if these injuries are left undiagnosed or untreated.


Carotid Artery

The left common carotid artery branches off the aortic arch in the thoracic cavity and courses superiorly through the neck before bifurcating into the external and internal carotid arteries. The right common carotid artery arises from the brachiocephalic trunk and courses superiorly through the neck, terminating at the carotid bifurcation. The carotid bifurcation, located at approximately the level of the fourth cervical vertebrae, is the origin of the internal and external carotid arteries. The internal carotid artery courses deep through the neck within the carotid sheath and terminates in the brain without branching, whereas the external carotid artery takes a more superficial course and has several branch points, including the superior thyroid artery, the superior laryngeal artery, the ascending pharyngeal artery, the lingual artery, the facial artery, the occipital artery, and the posterior auricular artery before terminating as the maxillary and superficial temporal arteries (Fig. 7-1).


Anatomy of the carotid and vertebral arteries. (Reproduced with permission from Lalwani AK: Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4th ed. New York, NY: McGraw Hill; 2020)

Vertebral Artery

The left and right vertebral arteries originate from the left and right subclavian arteries, respectively. They course through the transverse foramina of the vertebral bodies on either side of the neck, then across the posterior arch of the first cervical vertebrae, through the foramen magnum, and they terminate after merging as the basilar artery in the skull (Fig. 7-1). The vertebral arteries are further divided into four segments:

  • V1: from the origin at the subclavian artery to the transverse foramen of C6,

  • V2: from the transverse foramen of C6 to the transverse foramen of C2,

  • V3: from ...

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