REVIEW

Imaging of Penetrating Injuries of the Head and Neck:
Current Practice at a Level I Trauma Center in the United States
Naoko Saito,1* Rania Hito,1** Peter A. Burke3 and Osamu Sakai1,2

Departments of 1Radiology and 2Otolaryngology − Head and Neck Surgery, and3Division of Acute Care & Trauma Surgery/Surgical Critical Care, Boston Medical Center,
Boston University School of Medicine, Massachuesetts, USA(Received for publication on October 9, 2013)(Revised for publication on January 10, 2014)(Accepted for publication on March 17, 2014)(Published online in advance on June 10, 2014)

Penetrating neck injuries are commonly related to stab wounds and gunshot wounds in the UnitedStates. The injuries are classified by penetration site in terms of the three anatomical zones of the neck.
Based on this zonal classification system, penetrating injuries to the head and neck have traditionallybeen evaluated by conventional angiography and/or surgical exploration. In recent years, multidetector-row computed tomography (CT) angiography has significantly improved detectability of vascular
injuries and extravascular injuries in the setting of penetrating injuries. CT angiography is a fast andminimally invasive imaging modality to evaluate penetrating injuries of the head and neck for stablepatients. The spectrum of penetrating neck injuries includes vascular injury (extravasation, pseudoaneurysm, dissection, occlusion, and arteriovenous fistula), aerodigestive injury (esophageal and tracheal
injuries), salivary gland injury, neurologic injury (spinal canal and cerebral injuries), and osseous injury, all of which can be evaluated using CT angiography. Familiarity with the complications and imaging characteristics of penetrating injuries of the head and neck is essential for accurate diagnosis andoptimal treatment. (doi: 10.2302/kjm.2013-0009-RE; Keio J Med 63 (2) : 23–33, June 2014)

Keywords: penetrating injury, head and neck, CT angiography, vascular injury,
aerodigestive injury

Introduction

cy services in the Greater Boston area with over 130,000
emergency encounters each year. The trauma service
treats and evaluates 3,000 and admits over 2,000 injured
patients annually. We see approximately 80% blunt injuries and 20% penetrating injuries, and these are broken
down evenly between gunshot and stab wounds.
The mortality rates for penetrating neck injuries canbe as high as 10%.1 Therefore, these injuries require immediate medical attention by surgeons and radiologists.
The imaging modalities for penetrating neck injury patients are radiography, endoscopy, ultrasound, computed tomography (CT), and magnetic resonance imaging

Penetrating trauma to the head and neck accounts for
5–10% of all trauma cases that present to emergency
departments in the United States.1 Significant penetrating neck injury violates the platysma by definition. Most
commonly these injuries are secondary to stab wounds
or gunshot wounds (Fig. 1) in the United States, whereas
penetrating neck injuries are rare in Japan and the mostcommon causes of such injuries in Japan are self-harmand stab wounds from accidents. Boston Medical Centeris the largest and busiest provider of trauma and emergen-

Current addresses: *Department of Radiology, Saitama International Medical Center, Saitama Medical University, Saitama, Japan (NS) and**Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Massachuesetts, USA (RH)
Reprint requests to:Osamu Sakai, MD, PhD, Department of Radiology and Otolaryngology − Head and Neck Surgery,
Boston Medical Center, Boston University School of Medicine, FGH Building, 3rd Floor, 820 Harrison Avenue, Boston, MA 02118, USA
E-mail: osamu.sakai@bmc.org
Copyright © 2014 by The Keio Journal of Medicine
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Saito N, et al: Penetrating Head and Neck Injuries in the US

Fig. 1 Gunshot injury.
(A) Axial CTA image shows a large bullet fragment resulting in a metallic artifact. (B) Scout image from CTA demonstrates multiple
gunshot fragments in the head, neck, and left shoulder.

(MRI). Of these, CT angiography (CTA) is increasingly
used in the workup of penetrating injury patients without
indications for immediate surgical exploration. CTA candelineate vascular injury, which is seen in up to 25% of
penetrating wounds.1–3 CT and CTA can also reveal nonvascular injuries and the trajectory of the wound.
The aims of this article are to review common penetrating injuries to the head and neck, the anatomic classification of the neck zone, and CTA findings of vascular/
extravascular injuries and to describe the traditional diagnostic algorithm and the impact of CTA on the diagnostic algorithm and injury management.
Definition of Penetrating Injury of the Headand Neck

Fig. 2 Zones of the neck.
Lateral neck radiograph shows the three anatomical zones of theneck. Zone I extends from the clavicles to the inferior border ofthe cricoid cartilage. Zone II extends from the inferior border ofthe cricoid cartilage to the angle of the mandible. Zone III extends
from the angle of the mandible to the skull base.

By definition, a penetrating neck injury violates the fullthickness of the platysma: if the platysma is intact, thewound is considered superficial. Penetrating neck injuries
are classified by penetration site into the three anatomicalzones of the neck (Fig. 2) as described by Monson et al.4
and Roon et al.5
Zone I extends from the clavicles to the inferior border of the cricoid cartilage. Important structures in zone
I include segments of the innominate artery and brachiocephalic veins, segments of the subclavian arteries andveins, the common carotid and vertebral arteries, esophagus, trachea, and thyroid.
Zone II extends from the inferior border of the cricoid
cartilage to the angle of the mandible. It is the most common area affected by penetrating injuries. Important
structures in zone II include the common, internal, andexternal carotid arteries and jugular veins, larynx, upper
esophagus, and pharynx.
Zone III extends from the angle of the mandible to theskull base. Important structures in zone III include theKeio J Med 2014; 63 (2): 23–33

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internal carotid and vertebral arteries, external carotid
artery branches, internal jugular vein, and pharynx.
Imaging Techniques and Practical Tips for Assessing
Penetrating Injury of the Head and Neck
CTA is increasingly used in the workup of patients withpenetrating injury who do not require immediate surgical
exploration.6–12 At most institutions, CTA has replaced
angiography as the initial method of diagnosis in patientswith penetrating head and neck injuries. At Boston Medical Center, CTA is performed using a 64-multidetectorrow CT scanner with a 0.625-mm configuration from theaortic arch to the skull base for neck CTA or to the vertexof the skull for head and neck CTA. The patient is injected intravenously with 100 mL of iodinated contrast material (350–370 mgI/ml) at 5 mL/s through an 18-gauge
catheter located in an antecubital fossa vein. Right-sided
injection is preferred to improve the bolus of contrast
agent by limiting venous regurgitation from compressionof the brachiocephalic vein by the aortic arch. We use
an automated triggering device with a region of interest
placed in the carotid bifurcation. Scanning parameters
common to the examinations are tube potential of 120
kVp and a use of automatic exposure control systems(max 660 mA). Axial, sagittal, and coronal multiplanarreformation (MPR) and maximum intensity projection(MIP) reformats with 5-mm slice thickness at 2-mm intervals are generated. Additional three-dimensional (3D)reconstructions with volume renderings are performed
in a 3D Lab or by attending radiologists at independentworkstations.
It has been shown that utilization of CTA decreases theneed for surgical exploration.11 Some studies have shown
100% sensitivity in detecting arterial lesions using direct
signs and indirect signs.1,2,13 The direct signs are wall
irregularity, contrast extravasation, lack of vascular enhancement, and caliber changes; the indirect signs arebone and bullet fragments less than 5 mm from a major
vessel or in the path of injury through a vessel and hematoma in the carotid sheath.13
CTA has many advantages over conventional catheter
angiography. CTA is a rapid, non-invasive, and relatively
inexpensive modality. CTA also reveals the trajectory of
the wound track and non-vascular injuries. Determination of the trajectory is important because the organs lying along the wound track have a high likelihood of injury.2 However, there are some limitations of CTA. Streak
artifact from shoulders, retained metallic fragments, anddental fillings can prevent adequate visualization of vessels (Fig. 3). Also, suboptimal timing of contrast or failed
intravenous injection may lead to decreased opacificationof vessels, which can impair the detection of vascular injury (Fig. 4).
Other imaging modalities for evaluating penetrating
injuries include ultrasound and MRI.2,14 Ultrasound is a

Fig. 3 Limitations of CTA: streak artifact.
Axial CTA image demonstrates a streak artifact from a bullet
fragment obscuring the adjacent right vertebral artery.

quick, non-invasive, and readily available tool; however,
the technique is highly operator-dependent, and air fromthe injury, artifacts from retained metallic fragments, andhematoma can limit evaluation of vital structures. MRI
provides superior soft tissue contrast and is performed inpatients with suspected spinal injury, cerebral injury, orsoft tissue injuries including those of the salivary glands.
MR angiography has also been proposed in the evaluation of vascular injury.15 Although MRI has many advantages, it is unlikely to become a first-line imaging modality in the emergency setting because it is time consuming
and also because metallic foreign bodies can preclude thepatient from safely entering the MRI suite.
Management of Penetrating Headand Neck Injuries
Surgical access to zone I and zone III injuries is challenging because of the inherent difficulties in accessing
the thoracic or intracranial cavity. Zone II, on the other
hand, is readily surgically accessible. Traditionally, in theevaluation of hemodynamically stable patients with penetrating neck trauma, patients with zone I and zone III
injuries were evaluated with conventional angiography,
whereas zone II patients were explored surgically.1–3,14,16
Patients with hemodynamic instability who present withclinically detectable signs of injury such as expanding
hematomas, active hemorrhage, neurologic symptoms,
bruit, thrill, hematemesis, hemoptysis, stridor, or air leakundergo immediate surgical exploration.3,14,16
In recent years, with evolution of CT, CTA has become
increasingly used for the initial evaluation of penetrating

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Fig. 4 Limitations of CTA: suboptimal timing of contrast.
(A) Axial CTA image demonstrates suboptimal opacification of the arteries (thin arrow) secondary to poor
timing of the contrast bolus. (B) Repeat CTA exam shows adequate opacification of the vessels (thin arrow).
Extravasation in the pre-auricular soft tissues is now visualized (thick arrow).

Fig. 5 Recent recommendations from the literature for the management of penetrating head and neck injuries.

neck injuries in all zones; this approach allows for highly
selective surgical interventions and decreases the needfor surgical exploration.6–12,14 Recent recommendationsin the literature for the management of penetrating neckinjury are summarized in Fig. 5. 1–3,6–12,14,16,17 Our current diagnostic and management algorithm of penetratingneck injury at Boston Medical Center is summarized inFig. 6.

Imaging of Penetrating Head and Neck Injuries
Vascular injury
Arterial injuries are seen in about 25% of patients withpenetrating neck injuries.1–3 Carotid artery injuries areseen in 80% of vascular injuries, and vertebral artery injuries are seen in 43%.18,19 Approximately 20% of vascular injuries involve venous structures.3 Venous injuries
are more commonly clinically silent when compared witharterial injuries, and injuries of peripheral branches of thecervical veins are often treated conservatively. Therefore,

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Fig. 6 The diagnostic and management algorithm for penetrating head and neck injuries at Boston Medical Center.
CTA, CT angiography; NL, nasolaryngoscopy; BS, barium swallow.

Fig. 7 Vascular injury: extravasation.
Arterial extravasation with zone II gunshot injury. (A) Axial CTA
image shows a focal region of extravasated contrast (arrow) inferior to the right mandible likely from the right facial artery. (B)
Sagittal MIP image demonstrates bullet fragments (arrow) in theregion of the right facial artery, likely the source of extravasation.

imaging should be focused on the identification of moreclinically significant injuries. The optimal imaging strategy for diagnosis of cervical venous injuries has not yet
been determined; however, CTA has been shown to demonstrate these injuries well.2 Vascular injuries seen on
CTA include extravasation, pseudoaneurysm, dissection,
occlusion, and arteriovenous (AV) fistula.1–3

Fig. 8 Vascular injury: pseudoaneurysm.
Pseudoaneurysm with zone I gunshot injury. (A) Axial CTA image demonstrates small outpouching (arrow) at the proximal leftcommon carotid artery, confirmed on conventional angiography(B: 3D, C: lateral projection) where multiple pseudoaneurysms(arrows) are visualized. A stent was placed in the left common
carotid artery.

Extravasation
CTA demonstrates extravasation (Fig. 7) as contrast
pooling outside the vascular lumen.2 Proximity to known
vasculature can help identify the injured vessel. Lack ofvascular enhancement in the parent vessel can also beseen in the setting of extravasation.
Pseudoaneurysm
Pseudoaneurysm formation (Fig. 8) results from partial
or complete disruption of the vessel wall. It is a relatively
common type of vascular injury and accounts for 33%

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Fig. 9 Vascular injury: dissection.
Arterial dissection with zone II gunshot injury. (A and B) Axial
CTA images (B: magnified image) demonstrate a filling defect in
the right lingual artery secondary to dissection (arrow).

Saito N, et al: Penetrating Head and Neck Injuries in the US

Fig. 10 Vascular injury: dissection.
Arterial dissection with zone II gunshot injury. Axial (A) and sagittal (B) CTA images demonstrate a filling defect and intimal flap
(arrow) in the left distal common carotid artery.

Fig. 11 Vascular injury: occlusion.
Occlusion with zone II gunshot wound. Axial (A) and coronal (B) CTA images demonstrate lack of opacification of the left vertebral
artery (arrows) from its origin with retained bullet in vertebral body of C6. (C) Conventional angiogram confirmed the occlusion (arrow) of the left vertebral artery at C7 level with patency of its origin.

of internal carotid artery lesions after penetrating trauma.18,20 CTA shows an outpouching of contrast from thelumen with widening of the vessel contour.2,6–12,20 Treatment consists of ligation, embolization, or bypass surgery. Occasionally conservative management is utilized.

sists of anticoagulation; however, in the setting of otherinjuries such as hematoma and solid organ lacerations,heparin may be contraindicated. Aspirin is used in thissetting at Boston Medical Center. Endarterectomy, bypass, interposition graft, and ligation are surgical options.

Dissection
Dissection (Figs. 9 and 10) is rare in penetrating
trauma, affecting less than 2% of patients.20 CTA demonstrates an enlarged vessel diameter with narrowed
eccentric lumen secondary to an intramural hematoma.
Non-occlusive dissection can appear as focal intraluminal filling defects.2,6–12,20 Conservative treatment con-Occlusion
Partial or complete occlusion (Fig. 11) is the most common type of vascular injury in penetrating trauma.20 CTA
reveals the absence of vascular enhancement. Proximal
dissection may or may not be present.2,6–12,20 Treatment
consists of anticoagulation or revascularization.

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Fig. 12 Vascular injury: AV fistula.
AV fistula with zone III gunshot injury. (A) Axial CTA image demonstrates pooling of contrast (arrow) at the C1 level, which could
indicate a pseudoaneurysm. (B) Conventional angiogram shows rupture of the right vertebral artery at the C1 level, with rapid fillingof a high right cervical venous pouch (arrow) and a draining vein. The AV fistula was successfully embolized.

Fig. 13 Esophageal injury.
Esophageal injury with zone I gunshot injury. (A) Axial CTA
image demonstrates hematoma (arrow) anterior to the esophagus as well as thickening of the esophagus. (B) Barium swallow confirms esophageal tear (arrow) anteriorly at the level of theclavicles. Surgical repair was performed successfully.

AV fistula
Patients with a bruit typically undergo conventional angiography because the likelihood of an AV fistula is highand conventional angiography allows the opportunity oftreatment. Direct communication can be demonstrated on
CTA with the enhancement of venous structures being
equal to that of the arteries2,6–12,20 (Fig. 12). Treatment
is typically surgical; however, embolization can be performed.

Fig. 14 Tracheal injury.
Tracheal injury with zone I gunshot injury. (A) Axial CTA image
in lung window shows massive pneumomediastinum (thin arrows)
and subcutaneous air (thick arrows). (B) Chest CT demonstrates
irregularity at the right lateral trachea (arrow), which was confirmed surgically and successfully repaired.

Aerodigestive injury
Esophageal injury
Traumatic injury to the esophagus is rare, being seen
in 0.9–6.6% of penetrating neck injuries.2 It has beenshown that a delay in diagnosis and surgical intervention
increases the number of complications resulting frommediastinitis, abscess, and sepsis.21 Early detection ofesophageal injuries is imperative as mortality is estimated to be up to 20%.2,21,22
CT findings of esophageal injury (Fig. 13) include
esophageal wall thickening, periesophageal gas andfluid collection, mediastinal fluid collection, mediastinal inflammation, and focal esophageal wall defect.2,23
MPR images provide a better appreciation of the extent

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Fig. 15 Tracheal diverticulum.
Axial CTA image shows outpouching of air at the posterolateral
trachea that indicates a tracheal diverticulum (arrow), not a tracheal injury. This is the typical location for a tracheal diverticulum.

Fig. 16 Salivary gland injury.
Parotid gland injury with zone III stab wound. (A) Axial CTA image demonstrates left parotid gland hematoma with small focus ofair (arrow) adjacent to the wound. (B) Coronal MIP image demonstrates small foci of extravasation (arrow) at the superior aspect of
the left parotid gland.

Fig. 17 Salivary gland injury.
Parotid gland injury with zone III stab wound. CT sialogram (A: axial, B: axial
MIP, C: 3D) demonstrates parotid duct injury and contrast leakage through thefistula (arrows).

of esophageal injuries and the relation to adjacent structures.23 If esophageal injury is suspected, fluoroscopic
esophagography and endoscopy are indicated.

Tracheal injury
Tracheal injuries are uncommon in penetrating neck injury, occurring in 1–7% of patients.2,21 If a wound track
crosses the trachea or larynx, tracheal injury must be
considered. CT reveals a focal defect or contour deformity of the tracheal wall, which are direct signs of tra-

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cheal injury (Fig. 14). Other findings of tracheal injury
are paratracheal air, pneumomediastinum, and soft tissue
emphysema in the neck.2,21 Using MPR images with lungand soft tissue window settings is helpful to detect direct
and indirect signs of tracheal injury on CT.24 It should
be kept in mind that a tracheal diverticulum25 (Fig. 15)
may be mistaken for tracheal injury in the trauma setting; however, knowing the common location of tracheal
diverticula at the right posterolateral tracheal wall can assist in differentiating the two diagnoses.
Salivary gland injury

Fig. 18 Epidural hematoma in spinal canal.
Epidural hematoma with gunshot wound. CTA axial image demonstrates a high-density epidural hematoma (arrow) at the rightlateral spinal canal deforming the thecal sac.

Salivary gland injury is a soft tissue injury of the neck,and salivary glandular damage (Figs. 16 and 17) can occur in penetrating neck trauma. Injury of Stenson’s andWarthin’s ducts can result in post-traumatic sialoceles
and fistulas that may require surgery. Facial nerve injury
may occur in cases of parotid gland injury.

Fig. 19 Cerebral injury.
Cerebral injury caused by an arrow. (A) Axial unenhanced CT demonstrates parenchymal hemorrhage (arrow) around the arrow in theleft parietal lobe. CTA images (B: sagittal MIP, C: 3D VR (volume rendering)) demonstrate an arrow entering the nasal cavity andexiting posteriorly through the parietal skull. (D) Conventional angiogram demonstrates a left distal posterior cerebral artery pseudoaneurysm (arrow) after removal of the projectile. (E) The pseudoaneurysm was successfully coiled (arrow).

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Saito N, et al: Penetrating Head and Neck Injuries in the US

Fig. 21 Temporal bone fracture.
Temporal bone fracture (arrow) resulting from gunshot wound.
The fracture extends to the glenoid fossa and is demonstrated
with multiple retained bullet fragments.
Fig. 20 Spinal fracture.
Spinal fracture with gunshot wound. Sagittal CT image in bonewindow demonstrates a bullet fragment within the vertebral bodyof C6, as well as fractures of the C6 body with posterior displacement (thick arrow), and a small minimally displaced fracture atthe vertebral superior endplate of C7 (thin arrow).

Neurogenic injury
Injury to the central nervous systems including spinal
cord injury (Fig. 18) and cerebral injury (Fig. 19) can
occur with penetrating trauma to the head and neck. Approximately 11–14% of spinal cord injuries are penetrating injuries to the cervical spine.2,13 Spinal cord injury is
implied when a wound track extends through the canal.
Gas, bone fragments, or foreign bodies in the spinal canalsignify dural violation. MRI can be performed to confirm
or further investigate neurogenic injury if there is no metallic foreign body present that precludes MRI.
Osseous injury
Fractures of the skull, facial bone, and cervical spine(Fig. 20) may be present in penetrating injuries to thehead and neck. Temporal bone fracture (Fig. 21) is frequently associated with various complications such as
nerve injury, ossicular chain injury, vascular injury, andcerebral injury.

Unstable cervical spine injuries are rare after penetrating trauma to the head and neck; however, thorough investigation of the cervical spine is needed. Cervical collars are not recommended in this setting as other injuries
may be masked.
Conclusion
Stab wounds and gunshot wounds are the most common causes of penetrating trauma to the head and neckin the United States. For patients without indications for
immediate surgical exploration, CTA has been demonstrated to have high sensitivity and negative predictive
value for vascular injuries. CTA can also delineate extravascular injuries that may or may not be suspected on
physical examination. Knowledge of management of penetrating neck injuries and their imaging characteristics isessential for making an accurate diagnosis and facilitating prompt treatment.
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