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Lamanna JJ, Gutierrez J, Alawieh A, Funk C, Rindler RS, Ahmad F, Howard BM, Gupta SK, Gimbel DA, Smith RN, Pradilla G, Grossberg JA. Association of Cerebrovascular Injury and Secondary Vascular Insult With Poor Outcomes After Gunshot Wound to the Head in a Large Civilian Population. Neurosurgery 2024; 94:240-250. [PMID: 37796002 DOI: 10.1227/neu.0000000000002700] [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: 01/25/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cerebrovascular injury (CVI) after civilian gunshot wound to the head (GSWH) likely contributes to poor outcomes, but little supporting evidence exists. The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or rehemorrhage) were associated with poor outcomes in a large civilian population. METHODS This was a single-institution, retrospective cohort study on patients admitted between January 2014 and July 2022 at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used. RESULTS A total of 512 civilian patients presented with GSWH, and a cohort of 172 (33.5%) met inclusion criteria, with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), and that of secondary vascular insult was 32.2% (28/172 patients). Bifrontal trajectories (adjusted odds ratio [aOR] 13.11; 95% CI 2.45-70.25; P = .003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; P < .001) were associated with increased odds of resultant CVI. Patients with CVI suffered higher rate of mortality (34% vs 20%; odds ratio [OR] 2.1; CI 0.78-5.85; P = .015) and were less likely to achieve a good functional outcome with a Glasgow Outcome Score of 4-5 (34% vs 68%; OR 0.24; CI 0.1-0.6; P = .004) at follow-up. Furthermore, patients with CVI and resultant secondary vascular insult had even worse functional outcomes (Glasgow Outcome Score 4-5, 16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, P = .001). CONCLUSION Intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying CVI may prove to be critical to improve outcomes by reducing stroke and rehemorrhage incidence.
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Affiliation(s)
- Jason J Lamanna
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Juanmarco Gutierrez
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Chadd Funk
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
- Sierra Neurosurgery Group, Reno , Nevada , USA
| | - Faiz Ahmad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Sanjay K Gupta
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - David A Gimbel
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta , Georgia , USA
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Mehta TI, Arun A, Heiberger C, Cognetti D, Ray TR, Amans MR, Fargen K, Huisman TAGM, Hui F. Venous Pathologies and Interventions of the Head. Semin Neurol 2023; 43:439-453. [PMID: 37562454 DOI: 10.1055/s-0043-1771512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.
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Affiliation(s)
- Tej Ishaan Mehta
- The United States Air Force Medical Corps, Falls Church, Virginia
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Anirudh Arun
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caleb Heiberger
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David Cognetti
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Ray
- Department of Mechanical Engineering, University of Hawai'i at Mānoa, Honolulu, Hawaii
- Department of Cellular and Molecular Biology, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii
| | - Matthew R Amans
- Department of Radiology, University of California San Francisco, San Francisco, California
- Department of Neurosurgery, University of California San Francisco, San Francisco, California
| | - Kyle Fargen
- Department of Neurosurgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Thierry A G M Huisman
- Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Ferdinand Hui
- Department of Radiology, The Queen's Medical Center, Honolulu, Hawaii
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Zheng B, Luo X, Zhou J, Huang X, Li M, Zheng H, Yuan Y, Wang J. Case report: Acute ischemic stroke caused by intracranial artery dissection in a patient with skull fractures. Front Neurol 2022; 13:963396. [DOI: 10.3389/fneur.2022.963396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
The intracranial artery dissection (IAD) is an uncommon but life-threatening disease. The IAD would develop a significant cerebral infarction due to unrecognized contrecoup brain injury. We report a 53-year-old man fell to develop blunt cerebrovascular injuries (BCVIs) more than 2 months ago. During his rehabilitation, he often had a transient left headache and underwent short-term right limb weakness twice, but he did not care. He was hospitalized again because of suffering right limb weakness for more than 4 h. The brain computed tomography angiography (CTA) showed subtotal occlusion of the left middle cerebral artery M1 segment, and the vascular morphology displayed the IAD. The patient was then treated with balloon dilation and a self-expanding stent. This case highlights that IAD may show delayed onset with no initial typical symptom. By early detecting of abnormal signs and symptoms, serious traumatic brain injury may be avoided.
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Golomb MR, Tejada JG, Ducis KA, Martinez ML. Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic. Pediatr Neurol 2022; 130:1-3. [PMID: 35245820 PMCID: PMC8830928 DOI: 10.1016/j.pediatrneurol.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/16/2022] [Accepted: 02/05/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Meredith R Golomb
- Division of Child Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
| | - Juan G Tejada
- Division of Pediatric Neuroradiology, Department of Radiology and Imaging Sciences, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Katrina A Ducis
- Division of Neurosurgery, Department of Surgery, University of Vermont, Burlington, Vermont
| | - Mesha L Martinez
- Division of Pediatric Neuroradiology, Department of Radiology and Imaging Sciences, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
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Civilian Firearm-Inflicted Brain Injury: Coagulopathy, Vascular Injuries, and Triage. Curr Neurol Neurosci Rep 2021; 21:47. [PMID: 34244864 DOI: 10.1007/s11910-021-01131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making. RECENT FINDINGS The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias.
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