Vertebral Artery Transection in Nonpenetrating Trauma: A Series of 4 Patients

The hidden aspect of carotid lesions in traffic accidents: A little-known phenomenon

Vascular injuries that occur during traffic accidents are a commonly neglected aspect that can add more detail to the framework of a case. In this study, we analysed a case series of 150 traffic accidents, 39 of which were marked by microscopically identifiable vascular lesions. The purpose was to identify the presence of carotid injuries in individuals who died due to traffic accidents and had nonpenetrating trauma of the neck. We focused on the discrepancies regarding the macroscopical aspect and the histology and demonstrated how histological analysis of the carotids in cases of trauma can reveal injuries that are attributable to the trauma itself. We conducted a histological analysis of the lesions to describe their distribution and type and investigate potential correlations. The study offers insight on how to examine road accidents that involve traumatic injury of the carotid arteries. Indeed the main task of the forensic pathologist in the case of death is to establish the existence of a causal relationship between the micro- or macroscopic alterations observed in the autopsy and the traumatic event that led to the death of the subject. Thus, further morphological elements were provided to the forensic practitioners that may reveal injuries attributable to the trauma itself and should be evaluated in cases of trauma in traffic accidents.

Vertebral artery dissection in acute cervical spine trauma

Objective:

The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).

Methods:

A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD.

Results:

Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified.

Conclusion:

There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

The Prevalence and Management of Stingers in College and Professional Collision Athletes

PURPOSE OF REVIEW

Particularly common in collision sports such as American football or rugby, stingers are a traumatic transient neuropraxia of a cervical nerve root(s) or brachial plexus that may last anywhere from minutes to hours. This review summarizes the knowledge on the diagnosis and management of stingers in college and professional collision athletes by providing an overview of their epidemiology and pathophysiology, followed by a discussion on current treatment guidelines and return-to-play recommendations.

RECENT FINDINGS

Despite modifications to tackling technique, increasing awareness, and various equipment options, American football continues to have a high rate of cervical spine injuries, the majority of which occur in preseason and regular season competition settings. The incidence of stingers has slowly increased among collision athletes, and nearly half of all players report sustaining at least one stinger in their career. Recent studies have shown certain anatomical changes in the cervical spine are related to acute and reoccurring stingers. Most players who experience stingers do not miss practices or games. Despite their prevalence, literature highlighting the impact of stingers on college and professional collision athletes is limited. Advances in imaging modalities and novel radiographic parameters have provided tools for screening athletes and can guide return-to-play decisions. Future research regarding appropriate screening practices for athletes with reoccurring stingers, use of protective equipment, and rehabilitation strategies are needed to identify predisposing factors, mitigate the risk of injury, and restore full functional strength and ability.

Bilateral vertebral artery transection following blunt trauma

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All documented blunt cerebrovascular artery transections have demonstrated a one hundred percent mortality rate to date.

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These injuries occur in patients with coexisting injuries, limiting the ability to attribute a given neurologic outcome to any one injury.

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These injuries must be distinguished from the better-studied blunt carotid artery injuries, as each responds to treatment differently.

Introduction

Blunt vertebral artery injury (BVI) is a potentially catastrophic event associated with a variety of trauma mechanisms, particularly in the setting of cervical spine injury. Early detection and treatment of BVI and blunt carotid artery injury (BCI) – collectively termed blunt cerebrovascular injuries (BCVI) – is a known determinant of favorable outcomes, except in the case of complete transection injuries. The limited existing reports of these injuries demonstrate a 100% mortality rate regardless of the management approach taken, and further investigation is essential in better understanding the nature of the injury and improving patient outcomes.

Presentation of case

A 55 year old previously healthy patient was brought to the Emergency Department following a motor vehicle collision. The patient was alert upon arrival to the ED and complained of neck pain. Initial assessment was significant for open fracture of the left upper extremity, swelling of the anterior neck, and no purposeful movements noted of the lower extremities. Shortly thereafter, the patient showed a sudden decline in mental status and became hemodynamically unstable. Focused Assessment with Sonography for Trauma was positive, and after remaining unstable despite resuscitation efforts, the patient was brought emergently to the operating room.

Discussion

Following exploratory laparotomy for bleeding control and washout of the open fracture, CT angiogram of the head and neck was obtained. This revealed significant C5–C6 dissociation as well as bilateral vertebral artery transection and large prevertebral hematoma. Prior to any further surgical intervention, the patient’s neurologic function continued to decline, and brain CT demonstrated infarcts in the posterior cerebral artery distribution. Brain death was confirmed the next day, and all care was subsequently withdrawn.

Conclusions

Analysis of outcomes in patients with BCVI suggests that BVI should be distinguished from the better-studied CVI. Each injury type has been found to possess its own distinct risk factors, likelihoods of progression, and surgical accessibility, all of which affect management. Data on complete vessel transections remains limited for all BCVIs, with no documented cases of bilateral BVI to date. Our case study supports the 100% mortality rate seen in previously reported BCVI transections. Furthermore, our findings suggest that BVI transections occur in patients with coexisting injuries, which challenges the ability to attribute a single neurologic outcome to any one injury.

The diagnostic accuracy of magnetic resonance angiography for blunt vertebral artery injury detection in trauma patients: A systematic review and meta-analysis

The role of magnetic resonance angiography (MRA) in the evaluation of patients with blunt vertebral artery has not been fully established. Our aim is to define the diagnostic accuracy of MRA in comparison to digital subtraction angiography (DSA) for the detection of blunt vertebral artery injury in trauma patients. A computer-assisted literature search of the PubMed, Scopus, Highwire, Web of Science, and LILACS was conducted, in order to identify studies reporting on the sensitivity and specificity of MRA in comparison to DSA for the detection of blunt vertebral artery injury in trauma patients. The Database search retrieved 91 studies. Five studies fulfilled our eligibility criteria. Two authors assessed the risk of bias and applicability concerns using QUADAS-2. Two-by-two contingency tables were constructed on a per-vessel level. Heterogeneity was tested by the statistical significance of Cochran's Q, and was quantified by the Higgins's I² metric. The pooled estimates of sensitivity and specificity for blunt vertebral artery injury detection with MRA in comparison to DSA were calculated based on the bivariate model. The meta-analysis was supplemented by subgroup and sensitivity analysis, as well as analysis for publication bias. There was significant clinical heterogeneity in the targeted population, inclusion criteria, and MRA related parameters. The reporting bias and applicability concerns were moderate and low, respectively. In the overall analysis, the sensitivity ranged from 25% to 85%, while the specificity varied from 65% to 99%, across studies. According to the bivariate model, the pooled sensitivity and specificity of MRA in the evaluation of patients with blunt vertebral artery was as high as 55% (95% CI 32.1%-76.7%), and 91% (95% CI 66.3%-98.2%), respectively. Subgroup analysis in terms of MRA sequence sensitivity of phase, the contrasted MRA (75% [95% CI 43%-92%]) seemed to be superior to the TOF MRA (46% [95%CI 20%-74%]). The addition of contrast enhancement did not seem to improve the diagnostic yield of MRA. The Egger's test did not identify any significant publication bias (p=0.2). An important limitation of the current meta-analysis is the small number of eligible studies, as well as the lack of studies on newer, high-field MR scanners. We concluded that MRA has a moderate diagnostic accuracy in the diagnosis of blunt vertebral artery injuries. Further studies on high-field magnetic resonance scanners are recommended.