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Biffl WL, Moore EE, Kansagra AP, Flores BCCR, Weiss JS. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00777. [PMID: 39093622 DOI: 10.1097/ta.0000000000004439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
ABSTRACT Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California Department of Surgery/Trauma (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado; Division of Neuroradiology, Department of Radiology (A.P.K.), Santa Clara Valley Medical Center, San Jose, California; Section of Neurosurgery and Neurointerventional Radiology (B.C.C.R.F.), Scripps Memorial Hospital La Jolla; and Division of Vascular Surgery (J.S.W.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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Chen S, Ma G, Zhang P, Kang Q. Isolated traumatic supraclinoid internal carotid artery dissection diagnosed by high-resolution vessel wall MRI. Br J Neurosurg 2023; 37:1801-1804. [PMID: 34585640 DOI: 10.1080/02688697.2021.1919861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 04/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Isolated traumatic supraclinoid internal carotid artery (ICA) dissection is a rare complication of blunt craniomaxillofacial trauma, and differentiation from atherosclerosis is the key factor for confirming the diagnosis. CASE DESCRIPTION A 53-year-old man was admitted because of blunt trauma to his head and face. His primary manifestations were disability of abduction of the left eye on day 2, recurrent epistaxis and a blowing murmur in the left ear on day 4. Neurological physical examination showed bilateral normal pupil diameter, a corrected visual acuity of 0.6 in the right eye and 0.3 in the left eye, and loss of abduction of the left eye. Craniofacial computed tomography scans revealed multiple craniomaxillofacial fractures mainly including a LeFort III injury of the left maxilla, fractures of the left ramus of the mandible, fractures of the left orbital apex, fractures of the sellar turcica, etc. Brain magnetic resonance (MR) findings showed multifocal lacunar infarcts in the left hemisphere. Cerebral angiography demonstrated severe intraluminal stenosis of the left supraclinoid ICA, which was highly suspicious of arterial dissection. A high-resolution vessel wall MR imaging performed on day 7 showed proximal intramural subacute haemorrhage and two distal intimal flaps at the injured region, both of which facilitated the exclusion of atherosclerosis and thus, confirmation of isolated arterial dissection. The patient underwent treatment with endovascular stent placement and antiplatelet agents two weeks later and had no ictus of symptomatic stroke during the next half-year duration. CONCLUSIONS HR vw-MRI is able to assist in the diagnosis of isolated traumatic supraclinoid dissection complicated with underlying atherosclerosis.
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Affiliation(s)
- Shanwen Chen
- Department of Neurosurgery, The Hospital of Shunyi District, Beijing, China
| | - Gengping Ma
- Department of Neurosurgery, The Hospital of Shunyi District, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuan Wu Hospital, Capital Medical University, Beijng, China
| | - Quanli Kang
- Department of Neurosurgery, The Hospital of Shunyi District, Beijing, China
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Buchholzer S, Aymon R, Becker M, Scolozzi P. Does the type of craniomaxillofacial fracture (CMF) differ between patients with intracranial hemorrhage (ICH) and those with blunt cerebrovascular injury (BCVI)? A retrospective study. J Craniomaxillofac Surg 2023; 51:740-745. [PMID: 37643933 DOI: 10.1016/j.jcms.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/31/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
The purpose of the present study was to investigate and compare craniomaxillofacial fracture (CMF) type in patients with intracranial hemorrhage (ICH) versus blunt cerebrovascular injury (BCVI). A retrospective cohort study was performed. The predictor variables were the types of CMF. The primary outcomes variables were ICH and BCVI. Secondary outcomes were death and survival with or without neurological sequelae. Descriptive, bivariate, and multiple logistic regression statistics were computed, and the significance level was set at P ≤ 0.05. The sample was composed of 1440 patients with a mean age of 46.6 years ±24 years, and 71% were men. Pure orbital wall (odds ratio [OR]), 3.62; 95% confidence interval [CI], 1.32-12.69; P < 0.022), Le Fort III (OR, 16.08; 95% CI, 5.89-43.50; P < 0.001), cranial vault (OR, 9.74; 95% CI, 3.83.24.32; P < 0.001), skull base (OR, 9.42; 95% CI, 3.86-24.02; P < 0.001) and cervical fractures (OR, 5.50; 95% CI, 1.65-15.97; P = 0.003) were significantly associated with BCVI. All of the CMFs (P < 0.001), except for Le Fort I (OR, 0.79; 95% CI, 0.18-2.63; P = 0.731), nasal (OR, 1.05; 95% CI, 0.77-1.42; P = 0.758), and mandibular (OR, 0.68; 95% CI, 0.45-1.01; P = 0.066) fractures, were significantly associated with ICH. Secondary outcomes were negatively influenced by ICH and BCVI (P < 0.001). Within the limitations of the study it seems that Le Fort I and nasal fractures could be protective of cerebrovascular injuries, by cushioning impact forces. On the other hand it seems that patients with pure orbital wall, Le Fort III and cranio-cervical fractures are more prone to having concomitant life-threatening cerebrovascular injuries. This category of patients should have an immediate and comprehensive neurological assessment and CT angiography to rule out BCVI and to determine its severity.
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Affiliation(s)
- Samanta Buchholzer
- Division of Oral and Maxillofacial Surgery, Department of Surgery, University of Geneva & University Hospitals of Geneva, Geneva, Switzerland
| | - Romain Aymon
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Faculty of Medicine, University of Geneva & University Hospitals of Geneva, Geneva, Switzerland
| | - Minerva Becker
- Division of Radiology, Department of Imaging and Medical Informatics, University of Geneva & University Hospitals of Geneva, Geneva, Switzerland
| | - Paolo Scolozzi
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Faculty of Medicine, University of Geneva & University Hospitals of Geneva, Geneva, Switzerland.
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Wood Matabele KL, Seitz AJ, Doan TC, Poore SO. Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures-A NSQIP Study. J Craniofac Surg 2023; 34:1181-1184. [PMID: 36991535 DOI: 10.1097/scs.0000000000009297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/27/2022] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Le Fort fractures comprise a pattern of complex midfacial fractures that arise secondarily to craniofacial trauma. Although management of these fractures has been detailed within the literature, there is a paucity of research examining postoperative outcomes after surgical repair. The primary aim of this study is to assess patient outcomes after operative management of Le Fort fractures, and examine factors influencing the risk for developing postoperative complications, through utilization of the ACS-NSQIP database. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases recorded between 2012 and 2019 with International Classification of Disease (ICD)-9 and ICD-10 codes corresponding to Le Fort fractures. Patient demographics, clinical variables, and postoperative variables were recorded. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications. RESULTS Identification of cases with appropriate ICD codes, and exclusion of those with missing data, yielded 562 patients for analysis. There were no cases of minor complications and 14 cases of severe complications (3 cases of wound dehiscence, 3 cases of transfusion requirement, 1 case of failure to wean from the ventilator for more than 48 h, 1 pulmonary embolism, and 8 cases of reoperation), corresponding to an overall complication rate of 2.49%. Logistic regression analysis revealed steroid use as an independent predictor of severe postoperative complications (OR =13.73, 95% CI: 1.08-128.02, P =0.02). CONCLUSION The present study is the first to conduct a risk factor analysis of patients with Le Fort fractures using the ACS-NSQIP national database. The overall postoperative complication rate was 2.49%, with 14 cases of complications recorded in 8 years. Although this may suggest that surgical management of Le Fort fractures is generally well-tolerated, it should be noted that this problem is frequently associated with other severe injuries of the head and neck that may influence patient prognosis. Given this, further analysis would benefit from a larger patient cohort and longer postoperative data as the ACS-NSQIP database only records outcomes within 30 days.
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Affiliation(s)
- Kasey Leigh Wood Matabele
- University of Wisconsin School of Medicine and Public Health, Division of Plastic Surgery, Madison, WI
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Azad TD, Raj D, Ahmed K, Ran K, Materi J, Dardick J, Olexa J, Musharbash F, Lubelski D, Witham T, Bydon A, Theodore N, Byrne JP, Haut E. Predictors of Blunt Cerebrovascular Injury, Stroke, and Mortality in Patients with Cervical Spine Trauma. World Neurosurg 2023; 169:e251-e259. [PMID: 36334717 DOI: 10.1016/j.wneu.2022.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI), defined as blunt traumatic injury to the carotid or vertebral arteries, is associated with significant risk of stroke and mortality. Cervical spine trauma is a recognized risk factor for BCVI. OBJECTIVE The objective of this study was to identify significant predictors of BCVI and its sequelae in patients with known cervical spine injury. METHODS Patients from 2007 to 2018 with blunt cervical spine injury diagnoses were identified in the National Trauma Data Bank. Multivariable logistic regression models were used to identify patient baseline and injury characteristics associated with BCVI, stroke, and mortality. RESULTS We identified 229,254 patients with cervical spine injury due to blunt trauma. The overall rate of BCVI was 1.6%. Factors associated with BCVI in patients with cervical spine injury included lower Glasgow Coma Scale, motor vehicle crash, higher Injury Severity Score, concomitant traumatic brain or spinal cord injury, and current smoking status. BCVI was a strong predictor of stroke (odds ratio, 8.2; 95% confidence interval, 5.7-12.0) and was associated with mortality (odds ratio, 1.7; 95% confidence interval, 1.3-2.2). Stroke occurred in 3.3% of patients with BCVI versus 0.02% for patients without BCVI. CONCLUSIONS While BCVI is rare following cervical spine injury due to blunt trauma, it is a significant predictor of stroke and mortality. The risk factors associated with BCVI, stroke, and mortality identified here should be used in the development of more effective predictive tools to improve care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kowsar Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph Dardick
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Farah Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elliott Haut
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Färkkilä EM, Kaban LB, Boos-Lima FBDJ, Peacock ZS. Association of craniomaxillofacial fractures and blunt cerebrovascular injuries. Int J Oral Maxillofac Surg 2022:S0901-5027(22)00485-4. [PMID: 36564270 DOI: 10.1016/j.ijom.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
High energy trauma has been considered a risk factor for blunt cerebrovascular injuries (BCVI). The purpose of this study was to determine the incidence and risk factors for BCVI specifically in patients with maxillofacial fractures in an urban level I trauma center. A retrospective cohort study of patients aged ≥ 18 years, admitted to Massachusetts General Hospital (MGH) between 2007 and 2017, was implemented. There were 23,394 patients treated and entered into the MGH Trauma Registry: 22,287 sustained blunt trauma. Of the total blunt trauma patients, 68 (0.3%) had BCVI. There were 2421 patients with CMF fractures from blunt trauma (mean ± standard deviation age, 53 ± 22 years; 29.9% female included as study subjects, of whom 24 (1.0%) had BCVI). In a multivariate model, all mandible fracture (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.6-11.6, P = 0.004), crush injury, defined as blunt compression injury (OR 11.1, 95% CI 2.1-58.1, P = 0.004), and cervical spine injury (OR 10.1, 95 CI 3.7-27.5, P < 0.001) were independent risk factors for BCVI. Mortality was 4.3 times higher in craniomaxillofacial fracture patients with BCVI versus those without BCVI; complications of BCVI (stroke) contributed to the majority of deaths. Appropriate screening and treatment of BCVI in patients with maxillofacial fractures is important.
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Affiliation(s)
- E M Färkkilä
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L B Kaban
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - F B D J Boos-Lima
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Z S Peacock
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, Massachusetts, USA.
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Larrabee KA, Kao AS, Barbetta BT, Jones LR. Midface Including Le Fort Level Injuries. Facial Plast Surg Clin North Am 2021; 30:63-70. [PMID: 34809887 DOI: 10.1016/j.fsc.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Le Fort fractures occur at uniform weak areas in the midface often due to blunt impact to the face. Sporting injuries are a common cause of facial trauma; however, use of protective equipment has reduced the number of sports-related injuries. All patients with traumatic injuries should be evaluated using Advanced Trauma Life Support protocol. Le Fort fractures can contribute to airway obstruction, and urgent intubation may be indicated. Surgery is indicated for most displaced Le Fort fractures to restore function and facial harmony. To facilitate reduction, the original occlusive relationship should be restored by placing the patient in MMF.
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Affiliation(s)
- Katherine A Larrabee
- Department of Otolaryngology HNS, DETC K8 Clinic, Henry Ford Hospital 2799 E Grand Boulevard, Detroit, MI 48202, USA.
| | - Andrew S Kao
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
| | - Benjamin T Barbetta
- Division of Oral & Maxillofacial Surgery, DETC K8 Clinic, Henry Ford Hospital 2799 E Grand Boulevard, Detroit, MI 48202, USA
| | - Lamont R Jones
- Department of Otolaryngology HNS, DETC K8 Clinic, Henry Ford Hospital 2799 E Grand Boulevard, Detroit, MI 48202, USA.
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Al Babtain I, Abdullah M Alsahly M, A Aba Alkhail AB, Almutib JT, Al Otaibi RAF, Alsalamah ASH, Asseri YM, Ahmed AO. The Relationship Between Cerebrovascular Injuries and Craniomaxillofacial Fractures: Findings From a Tertiary Hospital in Saudi Arabia. Cureus 2021; 13:e17959. [PMID: 34660147 PMCID: PMC8515776 DOI: 10.7759/cureus.17959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/08/2022] Open
Abstract
Background and objective Blunt cerebrovascular injuries (BCVIs) can lead to serious outcomes, particularly because they are difficult to detect in the acute phase. There are studies that have described the association between cerebrovascular injuries and craniomaxillofacial (CMF) fractures; however, no such study has been conducted among a Saudi population. In light of this, we conducted this study to evaluate the correlation between BCVI and CMF fractures among the local population in Saudi Arabia. In addition, the most common types of fractures associated with BCVI were identified. Methods This retrospective cohort study was conducted at the King Abdulaziz Medical City, a tertiary hospital in Riyadh, Saudi Arabia. All eligible patients with CMF fractures who were hospitalized at the King Abdulaziz Medical City were included. Consecutive patients were screened; no sampling or randomization was required. Patients with penetrating or avulsive mechanisms of injury were excluded. Results Out of a total of 1,560 patients included in the study, 1,537 (98.5%) had CMF fractures, while 23 (1.5%) had BCVIs. None of the patients with CMF fractures had BCVIs. Among the patients with BCVIs, 12 (52.2%) were men and 11 (47.8%) were women. The mean age of these patients was 46.91 ± 17.04 years. Among patients with CMF fractures, 1,071 (69.7%) were men and 466 (30.3%) were women. Their mean age was 23.93 ± 17.36 years. Conclusion The study did not identify any correlation between BCVI and CMF fractures; however, further studies with larger samples across multiple centers are needed to validate our findings and gain deeper insight into the relationship between BCVI and CMF fractures.
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Affiliation(s)
| | | | | | - Jehad T Almutib
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Rakan Ahmed F Al Otaibi
- Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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Lane W, Brar B, Mehra P. Utility of Routine Computed Tomography Angiogram Screening for Blunt Carotid Injury in Isolated Mandible Fractures. J Oral Maxillofac Surg 2020; 79:1105.e1-1105.e4. [PMID: 33421418 DOI: 10.1016/j.joms.2020.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Determine the incidence of blunt carotid injury (BCAI) in the blunt trauma induced isolated mandible fracture population and determine the utility of computed tomographic angiography (CTA) screening for BCAI in this population. METHODS A retrospective data review was performed on patients presenting to Boston Medical Center from January 2008 to January 2019 with a diagnosis of mandible fracture. Population selected utilizing ICD-9 and ICD-10 diagnosis codes for mandible fracture and BCAI. Excluded populations were pediatric (less than 18 years) and penetrating carotid injuries. RESULTS A total of 1,508 mandible fractures were identified, with 73% (n = 1,103) being isolated injuries. Five BCAIs were identified, and of these, 1 was associated with an isolated mandible fracture (incidence <0.01%). One of 110 isolated mandible fractures screened for BCAI with the use of CTA was positive (incidence 0.9%). CONCLUSIONS BCAI is a rare finding in isolated mandible fractures. The inclusion of this population as an independent risk factor for BCAI should be questioned. Routine screening with CTA is not warranted.
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Affiliation(s)
- William Lane
- Chief Resident, Department of Oral and Maxillofacial Surgery, Boston University Henry M. Goldman School of Dental Medicine & Boston Medical Center, Boston, MA
| | - Branden Brar
- Resident, Department of Oral and Maxillofacial Surgery, Boston University Henry M. Goldman School of Dental Medicine & Boston Medical Center, Boston, MA
| | - Pushkar Mehra
- Professor and Chair, Department of Oral and Maxillofacial Surgery, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA; and Chief, Oral and Maxillofacial Surgery, Boston Medical Center, Boston, MA.
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Puolakkainen T, Vähäsilta L, Bensch F, Narjus-Sterba M, Wilson ML, Thorén H, Snäll J. Blunt cerebrovascular injuries in the craniofacial fracture population-Are we screening the right patients? Int J Oral Maxillofac Surg 2020; 50:463-470. [PMID: 32994036 DOI: 10.1016/j.ijom.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
Current knowledge of blunt cerebrovascular injuries (BCVIs) in craniomaxillofacial fracture (CMF) patients is limited. The purpose of this study was to determine the occurrence of BCVIs in patients with all types of CMF. This retrospective study included CMF patients in a level 1 trauma centre during a 3-year period. Patients who were not imaged with computed tomography angiography and patients with mechanisms other than blunt injury were excluded. The primary outcome variable was BCVI. A total of 753 patients were included in the analysis. A BCVI was detected in 4.4% of the patients screened. BCVIs occurred in 8.7% of cranial fracture patients, 7.1% of combined craniofacial fracture patients, and 3.1% of facial fracture patients. The risk of BCVI was significantly increased in patients with isolated cranial fractures (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.18-5.50; P=0.017), those involved in motor vehicle accidents (OR 3.42, 95% CI 1.63-7.17; P=0.001), and those sustaining high-energy injuries (OR 3.17, 95% CI 1.57-6.40; P=0.001). BCVIs in CMF patients are relatively common in high-energy injuries. However, these injuries also occur in minor traumas. Imaging thresholds should be kept low in this patient population when BCVIs are suspected.
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Affiliation(s)
- T Puolakkainen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - L Vähäsilta
- Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Turku, Turku, Finland; Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland
| | - F Bensch
- Department of Radiology, HUS Medical Imaging Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Narjus-Sterba
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M L Wilson
- Injury Epidemiology and Prevention (IEP), Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland; Injury Epidemiology and Prevention Unit, Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - H Thorén
- Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Turku, Turku, Finland; Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland
| | - J Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Blitzer DN, Ottochian M, O'Connor JV, Feliciano DV, Morrison JJ, DuBose JJ, Scalea TM. Timing of intervention may influence outcomes in blunt injury to the carotid artery. J Vasc Surg 2020; 71:1323-1332.e5. [DOI: 10.1016/j.jvs.2019.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
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Identifying risk factors of cerebrovascular injuries following blunt mandible fracture; a retrospective study from a national data base. Eur J Trauma Emerg Surg 2019; 47:855-860. [PMID: 31786656 DOI: 10.1007/s00068-019-01272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to determine the risk factors of cerebrovascular injury (CVI) in patients with blunt mandible fractures. METHODS All patients who sustained a mandible fracture as a result of blunt force trauma from the 2012-2014 National Trauma Data Bank from the United State of America were included in the study. A CVI was noted as having occurred if there was an injury to the vertebral or carotid artery in the neck. Patients' demography, injury mechanism, and additional fractures were compared between the groups of patients with and without CVI using univariate analyses. In addition, a multivariate logistic regression model was fit to identify risk factors for CVI in this cohort. All two-sided p values < 0.05 were considered statistically significant. RESULTS Out of 29,398 patients who qualified for the study, only 398 (1.4%) patients sustained a CVI. There were significant differences (p < 0.001) identified between the groups regarding sex, race, mechanism of injury, occurrence of c-spine fracture, and of Le Fort II and III fractures in the univariate analysis. The risk factors identified by the multiple logistic regression model echoed these results and showed that female gender, injuries due to motorcycle, motor vehicle crashes and the presence of a cervical spine or Le Fort fracture were all associated with the occurrence of CVI (p < 0.05). CONCLUSION The patients with mandible fracture who were female and sustained a high impact blunt force mechanism had a significantly higher risk of CVI. These high-risk patients should be screened for CVI at the time of initial evaluation.
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Al Kindi ST, Bakathir A, Al Azri F, Al Wahaibi K. Dissecting Aneurysm of the Internal Carotid Artery as a Complication of Facial Bone Trauma. Oman Med J 2019; 34:70-73. [PMID: 30671188 PMCID: PMC6330184 DOI: 10.5001/omj.2019.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The involvement of the internal carotid artery in dissecting aneurysm is rarely reported in the literature and may occur as a complication of trauma, surgery, and other medical conditions. We report a case of a 22-year-old male who was involved in a motor vehicle accident with associated multiple orthopedic and maxillofacial fractures. During surgical management, the patient was incidentally diagnosed with a dissecting aneurysm involving the right internal carotid artery.
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Affiliation(s)
- Sami Tahir Al Kindi
- Oral and Maxillofacial Surgery Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | - Abdulaziz Bakathir
- Department of Dental and Maxillofacial Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Faisal Al Azri
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
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Varjonen EA, Bensch FV, Pyhältö TT, Koivikko MP, Snäll J. Remember the Vessels! Craniofacial Fracture Predicts Risk for Blunt Cerebrovascular Injury. J Oral Maxillofac Surg 2018; 76:1509.e1-1509.e9. [DOI: 10.1016/j.joms.2018.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 12/21/2022]
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Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria. Surgery 2018; 164:494-499. [PMID: 29884478 DOI: 10.1016/j.surg.2018.04.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/20/2018] [Accepted: 04/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Blunt carotid and vertebral artery injury, collectively termed blunt cerebrovascular injury occur in less than 1% of blunt traumas. Conventional indications for screening miss up to 20% of blunt cerebrovascular injuries. Therefore, the expanded Denver criteria were created in 2012. We hypothesized the introduction of the expanded Denver criteria would lead to an increase in the national detection of blunt cerebrovascular injury with a subsequent decrease in stroke rate. METHODS The National Trauma Data Bank was queried for blunt trauma admissions. Patients were divided into 2 groups: pre-expanded Denver criteria (2007-2011) or post-expanded Denver criteria era (2013-2015). The primary endpoint was the incidence of blunt cerebrovascular injury, which was used as a surrogate for detection. RESULTS There were 10,183 blunt cerebrovascular injuries with 5,364 blunt cerebrovascular injuries in the pre-expanded Denver criteria group (0.19%) and 4,819 blunt cerebrovascular injuries in the post-expanded Denver criteria group (0.22%; P < .001). The stroke-rate in the post-expanded Denver criteria was significantly higher (9.2% vs 5.5%; OR 2.73, CI 2.29-3.25, P < .001). The strongest associated injury with blunt cerebrovascular injury was skull-base fracture (OR 3.61, CI 3.46-3.77, P < .001). CONCLUSION The detection of blunt cerebrovascular injury has increased by 16% since the publication of the expanded Denver criteria. Skull-base fracture is the strongest traumatic risk factor for blunt cerebrovascular injury. Although detection may have increased, the stroke-rate nearly doubled in the post-eDC era. This warrants future research.
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Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures. Curr Opin Otolaryngol Head Neck Surg 2017; 25:527-532. [PMID: 28877048 DOI: 10.1097/moo.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The primary purpose of this chapter is to define current recommendations for vascular work-up of patients with craniomaxillofacial (CMF) trauma with emphasis on imaging to include intraoperative fluorescence, angiography, and surgical exploration. The second goal is to review current management recommendations for observation versus surgical exploration based on the neck zones of injury. RECENT FINDINGS Over the past two decades, endovascular techniques are increasingly utilized, particularly in zones I and III of the neck. Additionally, modern advances in radiographic technology have allowed for selective exploration of penetrating zone II injuries. A high suspicion for blunt cerebrovascular injury should be maintained for patients with high-speed deceleration mechanisms of injury, with a majority of patients managed with medical therapy or conservative monitoring over surgical intervention. SUMMARY CMF fractures are associated with vascular injuries to the intracranial carotid system, extracranial carotid system, or vertebral artery system. A thorough understanding of at risk patients, optimal work-up, and timely treatment algorithms is imperative given the devastating sequellae of stroke and death.
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