Imaging of traumatic arterial injuries in the neck with an emphasis on CTA

Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries

Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.

ACR Appropriateness Criteria® Penetrating Neck Injury

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Safety in selective surgical exploration in penetrating neck trauma

BACKGROUND

Selective management of penetrating neck injuries has been considered the standard of care with minimal risks to patient safety. In a previous non-randomized prospective study conducted at our center, selective management proved to be safe and reduced unnecessary exploratory cervicotomies. In the present study, the role of clinical examination and selective diagnostic tests were assessed by reviewing demographic and clinical data. A comparison of results between two groups (mandatory surgical exploration versus selective surgical exploration) was made to check the safety of selective management in terms of the rates of morbidity and mortality.

METHODS

A retrospective analysis at the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo was performed by a chart review of our trauma registry, identifying 161 penetrating neck trauma victims.

RESULTS

Of the 161 patients, 81.6 % were stabbed and 18.4 % had gunshot injuries. Stratifying the wound entry points by neck zones, we observed that zone I was penetrated in 32.8 %, zone II in 44.1 % and zone III in 23.1 % of all the cases. Thirty one patients (19.2 %) had immediate surgical exploration, which had a mean length of stay of 6 days, a complication rate of 12.9 % and a mortality rate of 9.4 %. Of the 130 who underwent selective surgical exploration 34 (26.1 %) required operative procedures after careful physical examination and diagnostic testing based on clinical indications. The mean length of stay for the selective surgical exploration group was 2 days with a complication rate of 17.6 % with no mortality, and virtually all of them were related to associated injuries in distant body segment. No statistical significance was found comparing mortality and complication rates between the two groups. Selective approach avoided 59 % of unnecessary exploratory cervicotomies.

CONCLUSION

Careful evaluation of asymptomatic and stable patients with minor signs of injury can safely avoid unnecessary neck explorations with low rates of morbidity. This should be the standard management of such patients.

Positive Outcome After a Small-Caliber Gunshot Fracture of the Upper Cervical Spine without Neurovascular Damage

BACKGROUND

Gunshot wounds to the cervical spine most frequently concur with serious injuries to the spinal cord and cervical vessels and often have a fatal outcome.

CASE REPORT

We describe the case of a 35-year-old male with a complex fracture of the C2 vertebra body and a mandibular fracture after a penetration gunshot to the cervical spine. Computed tomography (CT) at admission revealed the exact extent of the fractures and the small caliber bullet lodged next to the C2 vertebra. In this rare and extremely lucky case no collateral vascular or neurological damage was detected. Eighteen months after surgical bullet removal and posterior C1-C3 fusion complete bone healing of the C2 vertebra was achieved and there were no secondary neurovascular deficits.

CONCLUSIONS

Immediate surgical C1-C3 fixation resulted in an excellent outcome without secondary neurovascular deficits in this rare case of traumatic complex C2 vertebral fracture caused by a gunshot injury.

Imaging of penetrating injuries of the head and neck:current practice at a level I trauma center in the United States

Penetrating neck injuries are commonly related to stab wounds and gunshot wounds in the United States. 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 traditionally been 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 and minimally invasive imaging modality to evaluate penetrating injuries of the head and neck for stable patients. 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 and optimal treatment.

Contemporary management of combat-related vertebral artery injuries

BACKGROUND

Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations.

METHODS

A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected.

RESULTS

Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy.

CONCLUSION

VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Management of penetrating neck injuries

BACKGROUND

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

METHODS

Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations.

RESULTS

Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected.

CONCLUSION

FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only.

Imaging vascular trauma

Background

Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.

Methods

A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.

Results

Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.

Conclusion

Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.