When is a CT (Computed Tomography) angiogram of the neck vessels performed?

CT Angiography of Neck Vessels: Indications and Clinical Applications

CT angiography (CTA) of the neck vessels is primarily indicated for suspected vascular injuries, stroke evaluation, and assessment of cerebrovascular disease. This non-invasive imaging modality provides rapid and accurate visualization of the cervical vasculature to guide clinical decision-making.

Primary Indications for CT Angiography of Neck Vessels

• Suspected cervical vascular dissection or injury - CTA neck is the preferred initial screening examination due to its rapid acquisition and high spatial resolution (sensitivity and specificity approaching 98%) 1
• Penetrating neck trauma - CTA is the first-line imaging evaluation after clinical assessment, replacing conventional angiography with sensitivity 90-100% and specificity 98.6-100% 1, 2
• Acute ischemic stroke evaluation - CTA neck is essential for rapid assessment of extracranial vasculature and is useful for endovascular surgical planning 1
• Transient ischemic attack (TIA) - American Heart Association guidelines recommend noninvasive imaging of cervical carotid arteries within 48 hours for patients who are candidates for carotid endarterectomy or stenting 1
• Blunt cerebrovascular injuries (BCVI) - CTA is recommended over digital subtraction angiography for initial vascular evaluation due to short acquisition time and low complication rate 1

Clinical Scenarios Requiring CTA Neck

Trauma Evaluation

• Penetrating neck injuries - CTA has replaced conventional angiography as the preferred initial imaging modality 1
• High-velocity maxillofacial trauma - When clinical suspicion for vascular injury exists based on revised Denver criteria 1
• Blunt trauma with risk factors for BCVI (complex skull fractures, scalp degloving) 1

Stroke and Cerebrovascular Disease

• Acute stroke evaluation - CTA neck combined with CTA head provides comprehensive assessment of potential extracranial sources of thromboembolism 1
• Carotid territory TIA - CTA neck is useful in initial workup and triage 1
• Suspected cervical artery dissection - CTA neck allows detection of vessel irregularity, wall thickening/hematoma, pseudoaneurysm, and intimal flap 1

Vascular Pathology Assessment

• Extracranial atherosclerotic disease - CTA can accurately grade carotid stenosis with high negative predictive value 3
• Vascular anomalies - CTA provides detailed anatomic information for surgical planning 4

Advantages of CTA Neck

• Rapid acquisition - Critical in time-sensitive conditions like acute stroke 1
• High spatial resolution - Superior detail for detecting subtle vascular abnormalities 4
• Ability to visualize vessel calcification - Important for assessing atherosclerotic disease 4
• Simultaneous evaluation of surrounding soft tissue structures 1
• High sensitivity and specificity for vascular injuries (sensitivity 97%, specificity 99%) 2

Limitations and Considerations

• Iodinated contrast requirement - May be contraindicated in patients with severe renal impairment or contrast allergy 1
• Radiation exposure - A consideration especially for young patients or those requiring repeated imaging 1
• Heavy calcifications can lead to overestimation of stenosis 1
• Streak artifact from metallic foreign bodies may limit evaluation 1

Alternative Imaging Modalities

• MR angiography (MRA) - Alternative for patients with renal impairment or contrast allergy, but limited in acute trauma settings due to longer acquisition times and potential issues with metallic foreign bodies 1
• Ultrasound - Limited in neck trauma due to overlying soft tissue injury and limited evaluation of zones I and III 1
• Conventional angiography - Now primarily reserved for equivocal CTA findings or when endovascular therapy is planned 1

CTA of the neck vessels has revolutionized the evaluation of cervical vascular pathology, providing rapid, accurate, and non-invasive assessment that guides critical treatment decisions in both traumatic and non-traumatic conditions.